Maitland's Peripheral Manipulation

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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.

This product is appropriate for:

ELSEVIER BUTTERWORTH HEINEMANN

www.elsevierhealth.com

•

manual therapists

• •

physiotherapists undergraduates and lecturers

•

osteopaths

•

chiropractors

9

Maitland's Peripheral Manipulation

For Butterworth-Heinemann

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

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 BlTTTERWORTI-1 HEINEMANN

EDINBURGH LONDON NEW YORK OXFORD PHILADELPHIA ST LOUIS SYDNEY TORONTO

2005

ELSEVIER BUTTER\\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

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v

Contents

Foreword

vii

9. Recording

Preface to the fourth edition Preface to the first edition

ix

xi

Companion texts to this edition

xiii

1.

The Maitland Concept - an introduction

2.

Mobilization and manipulation - definitions, desired effects, role in rehabilitation and evidence base

25

4. Contemporary perspectives in physiotherapy 71

6. Principles of examination

249

11.

275

The shoulder and shoulder girdle complex

12. The elbow complex

357

13. The wrist and hand complex 14. The hip region

89

399

445 487

16. The ankle and foot complex

relationship 39

5. Principles of assessment

10. Peripheral neuromusculoskeletal disorders

15. The knee complex

3. Communication and the therapeutic

practice

237

525

17. The temporomandibular joints, larynx and hyoid (the craniomandibular complex)

577

Appendix 1 Movement diagram theory and compiling a movement diagram

125

599

Appendix 2 Self-management strategies: compliance 7. Principles and method of mobilization/ manipulation techniques

and behavioural change 617

165

8. Principles of selection and progression of mobilization/manipulation techniques

179

Index

625

vii

Foreword

It is not difficult to see why this book has stood the test of time and critical appraisal to reacl1 its 4th edition. Like its companion volume, Vertebral Manipulation, it was, in its slimmer original version published in 1970, a landmark publication. Other books on the 'why's and how's of manipulation existed but they were written by doctors, essentially for doctors. Physiotherapists were the 'also rans'. Not trained as primary medical diag nosticians, unable to prescribe medication or inject or carry out manipulations under anaesthetic, they and their skills were usually relegated to a secondary, tech nicians role in the assessment and treatment of mus culo-skeletal conditions. This approach was inevitably centred exclusively on the medical model of examina tion, diagnosis, and treatment but incorporated tech niques of manual skill commonly viewed as 'fringe' or 'alternative'. Some of these stemmed from osteopathy. Whilst the skills of passive movement used in treat ment of a wide range of disorders such as those within orthopaedics and neurology, had always been an essential part of the work of physiotherapists, a com prehensive text of sufficient substance and originality, written by a physiotherapist for physiotherapists was lacking. Maitland's Vertebral Manipulation changed all of that and Peripheral Manipulation (1970) followed on in the same vein. The development of aspects of 'the Maitland con cept' as it became known, was fascinating to follow. Numerous ideas, such as 'movement diagrams' and the 'grading' of each technique to define its force and amplitude and mode of application, became valuable teaching tools for communication and were an attempt at accurate recording, both in the clinical setting and in the process of teaching and learning. The conceptualiza tion of an imaginary (permeable!) 'brick wall' separat ing, but not mutually excluding, scientific knowledge

and clinical presentations, was illuminating and it is still, contrary to the views of a few who seem entirely to have missed the point, a valuable idea. Sound clinical reasoning, long before that term was on everybody's lips, was the foundation of the pio neering work of Geoffrey Maitland, as recorded in his books and articles. This was not only what he preached but also very much seen in what he prac tised, as those privileged to watch him treating patients, can confirm. His saying that 'technique is the brainchild of inge nuity' was demonstrated on one occasion when an observer, watching him on a course treating a patient, enquired what was the technique he was using. "I don't know" came the reply "I've never done it before"! this was not, of course, a facetious remark, but an enjoinder to "go thou and do likewise". The process of ongoing, continuous re-assessment at all stages of treatment and its follow-on, using pre cise, detailed questioning and retesting has remained as a fundamental strength of this approach. This process exemplifies the enormous contribution made by Geoffrey Maitland in his emphasis on the impor tance of subtle communication as a fundamental skill to be mastered in the process of "proving clinically" the value or otherwise of particular passive movement strategies and other associated techniques. This is well documented in Chapter 3, essential reading for all medical personnel of whatever profession. Another great strength of the approach described in this book is that it is non-dogmatic. Consequently, an evolving knowledge base has been incorporated, over the years. It is not a 'method' or 'school' in the narrow 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 possible to add to and develop the work. Compare the size and content of this edition with the first. The authors are to be congratulated on their success in developing the contents of this third edition to incor porate, apparently seamlessly, the advances made in, for example, the pain sciences, in the last fifteen years or so. An osteo-arthritic knee is no longer viewed as simply a painful, stiff joint, but a problem having, like low back pain, a bio-psychosocial construct, and this is right. Peripheral nociceptive, peripheral neurogenic, central and sympathetically maintained pain are exam ples highlighting variations within nervous system pain physiology which must help guide and modify our use of manipulative therapy. However the brilliance and originality of so many of Geoffrey Maitland's ideas have not been lost. For example, the concept of 'irritability' as distinct from 'severity', whilst it has been criticised from a narrow academic viewpoint, remains a valuable insight help ing the clinician make crucial decisions about the for mulation of their day to day treatments. Likewise the perceptive subdivision of 'overuse', 'misuse', 'abuse', 'new use' and 'disuse' to illuminate clinical states is as useful as ever in gaining further insight into the nature of the great array of musculo skeletal problems. Even terms such as 'unstable insta bility' and 'stable instability' which have thrown some moderate people into a rage, are supported by an underlying wisdom coupled with a wealth of clinical experience.

The expansion of the text to incorporate referenced research and other material, case studies, physiothera pists thoughts and hypotheses, clinical profiles, pho tography of techniques and much else adds greatly to the work as a standard reference and a course text, as well as a rich source of clinical guidance and illumination. It must surely have been an inspiration to the authors that a growing amount of research across a wide spectrum of expertise in physiotherapy and the field of manipulation has stemmed from the teaching summarized in this book and its previous editions. The foundation of the International Maitland Teacher's Association (IMTA) in Switzerland was due to the foresight and determination of a remarkable physiotherapist, Gisela Rolf. This organization has overseen the training of teachers who attempt to satisfy the demand in Europe and elsewhere for regulated, high standard, post-graduate courses in this field. They will, without doubt, be encouraged by this new edition. The pioneering work of Geoffrey Maitland, reflected in these pages has, over the years, generated some heat in discussion but, most importantly, great light. This present edition will illuminate further its subject. Most importantly it presents us with an absorbing and comprehensive text helping to define a crucial part of the work of physiotherapists. Peter Wells, London 2005

ix

Preface to the fourth ed ition

The preface to the first edition of this book was written 35 years ago and is as relevant to today's physiother apy profession as it was in 1970. The advancement of orthopaedic medical imaging and diagnostics, and the advent of extended scope physiotherapy practice have distracted the profession from the detail of joint pain and the ability to deal with it at face value. The mes sage in the preface to the first edition, therefore, could be applied to contemporary physiotherapy practice in 2005. Read it and see. 'The Maitland Concept', as it has come to be known, appears to be contradictory, exhibiting both the quali ties of stability and flexibility. The clinical basis and the Concept's fundamental elements have remained the same throughout its evolution. At the same time it has changed with the times and accepted contemporary manipulative physiotherapy methods. The Concept has maintained an unassuming, non-judgemental and open-minded approach, which perpetuates a patient centred model of clinical practice. This is its backbone and the strengtl1, stability and flexibility of the symbolic permeable 'brick wall' analogy. The fourth edition of Maitland's PeripheraL Manipula tion presents an integrated, contemporary and evidence based model of manipulative physiotherapy. Such a model is placed within the context of 'best practice' for movement-related neuromusculoskeletal disorders of the upper and lower limb. Each chapter of this text has been revised and expanded to reflect advances in knowledge and the role of manipulative physiotherapy within contemporary clinical practice. This includes: the reference to the International Classification of Func tioning, DisabiLities and Health (rCF, WHO 2001); pain mechanisms; biopsychosocial paradigms; the rehabili tation process and current definitions and descriptions

of physiotherapy practice. Guidelines for assessment, examination and treatment have been updated with relevant evidence from the current literature, including: contemporary developments in physiotherapy practice (Chapter 4); clinical reasoning science; the biopsycho social paradigm, including psychosocial assessment (Chapters 4 and 5) and fue essence of self-management strategies with a focus on compliance enhancement and behavioural change (Appendix 2). Appendix 1 is preceded by a review of topical issues in the definition of R], the definition of grades of mobilization and manipulation, and the reliability of detecting and repre senting the parameters encountered during passive movement testing. A bullet-point method of presenting the text has been used for clarity and to improve the user-friendliness of the book. The line drawings so expertly produced by Anne Maitland have been superseded by photographs. The main reason for tlUs is to complement the CD-ROM which accompanies this fourfu edition and helps to bring to life most of the techniques of examination and treatment described in the book. Kevin Banks expresses his thanks to: Jukka Kangas and Donna Ardron for their constructive comments on the revised text; Robin Blake for sharing his knowl edge and expertise over many years, and Nancy and the kids for their patience and understanding in seeing this project through. Elly Hengeveld wishes to thank everybody who has given constructive suggestions to the texts, in particu lar Renee de Ruyter-Bouwman and Hugo Stam; Gisela Rolf, as a teacher in the 1980s, for her dedication, thoroughness and determination to give everything 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 all to Charles, Lijda and Kees, I remember what is truly important in life. Both authors thank the medical publishing team at Elsevier and their IMTA colleagues for their support and guidance. Last but not least to Geoff and Anne Maitland to whom we owe everything and to whom we feel it is

our duty to be the custodians of their knowledge and to nurture and develop this concept into its early adulthood. Kevin Banks, Rotherham, UK Elly Hengeveld, Oberentfelden, Switzerland 2004

xi

Preface to the first ed ition

Treatment of painful peripheral joints by passive move ment has become almost a forgotten art among physio therapists. In the present era active exercise, combined with heat or cold therapy, is the popular and estab lished approach. Passive movement is not routinely used because in the past its techniques have been used too strongly, causing the patient unnecessary discom fort and sometimes aggravating the condition. Hesitation on the part of doctors and physiother apists to use passive movement arises from a lack of understanding of how and when to apply gentle tech niques, and of their effectiveness. P hysiotherapists, inex perienced in handling painful joints passively, may have inadvertently aggravated the pain and thus wrongly concluded that passive movement should not be used. This condition is unfortunate; when precise physical signs of joint disturbance can be determined, quicker and better results may be achieved using pas sive movement guided by the signs. Often quite gentle techniques can be used. Many books have been written about manipulation of peripheral joints. Among these are important con tributions by Dr Cyriaxl and Drs James2 and John Menne1l3 Dr Cyriax's work is particularly notable for the presentation of accurate methods of examination. The treatment techniques he outlines are those of the stronger type, some of which require the assistance of physiotherapists. Dr John Menne1l3 continues the work Cyriax, J. Textbook of Orthopaedic Medicine. Vol. II, 7th edn. London; Bailliere TindalJ (1965) 2 Mennell, James Science and Art of Joint Manipulation. Vol. II. London; Churchill (1952) 3 Mennell, John McM. Joint Pain. Boston; Little Brown & Co (1965) London; Churchill (1964) I

of his father, Dr James Menne1l2, who stressed the importance of accessory movement (or, in his own ter minology, 'joint play'). Even with these books, and others written by lay manipulators, there are still several facets of the field of passive movement treatment which are not covered. There are occasions when patients are referred for physiotherapy with joint disorders which require tech niques not previously described, or when the reasons for choosing particular amplitudes and positions in the range have not previously been described or related to the examination finding of the joint disorders. The purpose of this book is to present techniques for all peripheral joints, to discuss in detail the relevant parts of examination by passive movement, and to relate the method of applying the techniques to the examination findings. Most people think of passive movement treatment as a stretching process to increase the range of move ment of a stiff joint. However, the application of passive movement to painful peripheral joints is far wider than this. Its use in the treatment ofjoint pain, whether the range of movement is limited or not, has not been appreciated. This subject has not been treated in any other text published and possibly may not have been considered before. For this reason alone the following text is necessary to fill a gap in the physical treatment of joint pain. Although some of the techniques will be similar to those published by others, many will be different, and some of the moving parts for which techniques are described have not been presented before. Also, some of the movements described for certain joints have not 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 joint movement must be undertaken by the physiother apist. The findings will guide the choice of technique and the style of movement to be used (i.e. small ampli tude, large amplitude, avoiding pain or moving into pain), and the range in which it is performed. The find ings also act as guides for the assessment of progress. When any new form of treatment becomes popular, people tend to think only about the new techniques; the idea being that once the techniques are learned, nothing remains but to apply them to patients. If this idea is carried out by numerous people, it follows that standards of treatment fall, results are poor, and con sequently the treatment method lapses. This idea of solely learning techniques and applying them indis criminately is totally inadequate. For this reason con siderable space in the ensuing text is given to minute examination detail and to the ways in which the tech niques should be applied to the findings. The process may seem tedious at first and may even emphasize the points which seem too trivial to mention. However, this depth of detail is designed to prevent misunder standing of the reasons for the application of the tech niques. Also, as a musculoskeletal disorder may present different joint signs at different stages of devel opment of the complaint, it is essential that examin ation of the joint signs be carried out in detail. Different joint signs require different treatment techniques. In the chapter on Examination appreciation of the various factors which constitute the joint signs deter mined by passive movement tests is discussed. In the appendices 'movement diagrams' have been offered as the best method at present available for teaching this appreciation. The 'movement diagram' has also been used in the chapter on Treatment to express more

clearly the relationship between passive movement used in treatment and the clinical signs. The concept of a 'movement diagram' was evolved by Miss J-M. Ganne, MCSP, MAPA, DipTP, and further developed in an article jOintly written by Miss Jennifer Hickling, MCSP and the author, published in the Journal of the Chartered Society of Physiotherapy4 and the Australian Journal of Physiotherapy5 Thanks are due to Miss Hickling and to the Editors of both journals for permit ting part of the article to be reproduced in this book. Dr D. A. Brewerton, MD, FRCP, has provided an invaluable medical approach to the many aspects of passive movement treatment, and I am grateful to him for his contribution. Much needs to be said about atti tudes to and prejudices against this form of treatment which cannot properly be said by a physiotherapist, and I am very pleased to have Dr Brewerton's willing support and I thank him sincerely. Many amendments regarding presentation were made to the text as it evolved and Mrs J. Trott, Miss P atricia Trott, AVA, Grad. Dip. Manip. Ther., MAPA, MCSP, and Miss M. J. Hammond, AVA, MAPA, MCSP, Dip.TP, have been patient, helpful and encouraging. The illustrations drawn by my wife more than achieve their purpose. They clearly and simply illustrate the text and avoid the distractions often present with photographs. I am especially grateful for her helpfulness and suggestions throughout the project. Without the willing help of the many people who carried out typing, modelling, and drawing of graphs, the book could not have been com pleted and I extend to them my grateful thanks.

G. D. Maitland Adelaide 1970

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

4

Physiotherapy,

XVL 13 (1970)

xiii

Compan ion texts to this ed ition

Boissonnault, W. 1995. Examination in Physical Therapy Practice - Screening for Medical Disease. New York: Churchill Livingstone Butler, D. 1. 2000. The Sensitive Nervous System. Adelaide: NOIGroup Corrigan, B. & Maitland, G. D. 1983. Practical Orthopaedic Medicine. London: Butterworth Goodman, C. & Snyder, T. 1995. Differential Physical Therapy, 2nd edn. Philadelphia: W. B. Saunders Higgs, J. & Jones, M. A. 2000. Clinical Reasoning in the Health Professions, 2nd edn. New York: Butterworth-Heinemann

Jones, M. & Rivett, D., eds. 2004. Clinical Reasoning for Manual Therapists. Edinburgh: Butterworth-Heinemann Maitland, G. D. 1992. Neuro/musculoskeletal Examination and Recording Guide, 5th edn. Adelaide: Lauderdale Press Maitland, G. D., Hengeveld, E., Banks, K. & English, K. 2005. Maitland's Vertebral Manipulation, 7th edn. Oxford: Bu tterworth-Heinemann Sahrmann, S. A. 2002. Diagnosis and Treatment of Movement Impairment Syndromes. St Louis: Mosby

Chapter

1

The Maitland Concept - an introduction

THIS CHAPTER INCLUDES: • • •

Key words for this chapter A glossary of terms for this chapter General themes of the book

KEY WORDS

Maitland Concept, movement system,

GLOSSARY OF TERMS

Accessory movement - accessory or joint play movements are those movements of a joint that cannot be performed actively by the individual. Such accessory movements include the roll, spin and slide which accompany a joint's physiological movements. Accessory movements should be examined passively for range and pain (symptom) response in the joint's loose packed position, in painful positions of a free range of movement or at the end of a limited range. Analytical assessment - assessment made during the episode of care or at its conclusion. It takes into account all details of the past and present history of the patient's disorder, the diagnostic details and the response to the different

• • •

Introduction to the Concept The central core The brick wall approach to clinical decision making

• • • •

Examination Treatment techniques Assessment The Concept in context.

personal commitment, symbolic permeable brick wall, examination,

treatment techn iques, assessment, context.

treatments that have been admin istered. This collection of information is analysed so as to allow understanding of the likely future of the patient's disorder. Biomedical engineering - the association between cellular and tissue biology and disease and engineering as in prosthetics, materials used in tissue healing and replacement and, more recently, gene therapy. Clinical reasoning - the th inking underlying clin ical practice through information gathering, interpretation of information, actions upon findings and evaluation of such actions, each strand of information resulting in an ever-evolving understanding of the patient and their disorder. Differentiation testing examination procedures which assess which joint or structure is

the source of symptoms when one or more joints or structures is involved in a particular movement. Disorder - any complaint from w h ich any patient may suffer and be referred to a physiotherapist. This will include those disorders which can be given an accurate titled diagnosis, as well as those that, though perhaps being recognized as a syndrome, cannot be precisely titled. Frame of reference - the context into wh ich the patient places their experiences (of pain) based on their present and past experiences of similar situations. In turn this determines the manner in w h ich they will respond to pain and functional impairment and the endeavours of health professionals to help them. Functional corners - combinations of functional joint movement

2

MAITLAND'S PERIPHERAL MANIPULATION

which are regularly incorporated into everyday activities. Such functional corners need restoring to their ideal pain-free status with passive movements in cases where minimal joint signs are preventing full recovery (e.g. h ip flexion / adduction, elbow extension / abduction). Illness behaviour - during illness, pain experience or functional impairment, the means by which an individual can sample and express their feelings, thoughts and emotions about their state of health or illness. This can be through verbal or non-verbal expressions, including both actions and inactions, which may be either adaptive and beneficial to recovery or maladaptive and unhelpful to recovery. Impairment - problems in body function or structure such as a significant deviation or loss. Injuring movement - re-enactment of a particular injuring direction of stress in the physical examination in order to reproduce symptoms or divulge relevant comparable signs. Mode of thinking - the separation of th inking into a theoretical compartment and a clinical compartment so that thoughts related to the theory of a patient's disorder do not inh ibit the discovering of the finer details of

the disorder's history, symptoms and signs. This mode of thinking also takes into account diagnoses which are incomplete or uncertain. Movement diagram - a two dimensional pictorial or mental image, a dynamic map showing the physiotherapist's perceptions of the extent and relationship between joint signs (usually pain, spasm free resistance, and protective muscle spasm) during the assessment of a particular passive movement direction of a joint. Movement diagrams serve as a self-learn ing process, a teaching medium and a means of commun ication. Movement system - an anatomical and physiological system that functions to provide motion of the body as a whole or of its component parts (Sahrman n

2001). Overpressure - every joint has a passive range of motion which exceeds its active range. To this passive range, further normal movement can be gained by a stretching application of overpressure. This overpressure range has, in nearly all examples, a degree of discomfort or hurt and should be assessed before declaring a joint movement to be normal or ideal.

GENERAL THEMES AROUND WHICH THE 4TH EDITION IS BASED The fundamental components of the Maitland Concept are inextricably linked and interrelated. They give the manipulative physiotherapist a platform for the deliv ery of a flexible and innovative clinical reasoning approach to the management of neuromusculoskeletal and movement-related disorders. The following sum mary reflects the themes which will emerge throughout the text. These themes are presented in order of their

Pain mechanisms - the complex interactions within the neuromatrix by wh ich sensory input is processed, influenced by autonomic, endocrine and motor output and consequentl y experienced b y a n individual patient as pain. Paradigm - a model of beliefs based on a professional body of knowledge, such as the paradigm that physiotherapy is a rehabilitation profession with an expertise in disorders of the movement system. Physiological movement - those movements of a joint which can be performed actively by the individual and wh ich can be examined for range, quality and symptom response, both actively and passively. Prognosis - the forecast of the probable course of a case of disease or injury, or the art of making such a forecast (The Shorter Oxford Dictionary

1980). The body's capacity to inform the patient's perception of their own bodily health, disorder or functional status and how, w ith guidance from their physiotherapist, they can express these perceptions through description and / or demonstration.

importance to the patient and the order in which the physiotherapist should be thinking about them (Fig. 1.1 ): •

•

•

•

The patient-centred approach to dealing with movement disorders The brick wall approach and the primacy of clinical evidence The paradigm of identifying and maximizing movement potential The science and art of assessment.

The Maitland Concept - an introduction

C e nt thi

nking

col' .. ,tie 'orick wall ' ,tie Ilfimacy of clinical ev;ae f/ce J>.llllfollnate wording .

•

•

•

The patient-centred approach to dealing with movement disorders

This key component is based around a personal com mitment to the patient. In the context of the Maitland Concept a personal commitment means: •

developing a level of concentration such that the manipulative phYSiotherapist feels mentally and physically challenged throughout each episode of care: take for example the Test cricketer who makes a Test Match century and is at the crease for several hours. A high level of concentration is needed to enable his shot selection to be accurate throughout his innings. Likewise the physiotherapist who is with a patient must see each piece of information as 'a good length ball' and think how to reply or ask

a relevant follow-up question, carry out another examination procedure, or select an appropriate treat ment technique in order to build a problem solving innings each time the patient is seen (Fig. 1 .2) •

•

•

being prepared to revisit, time and time again, the patient's sensory, cognitive and emotional world until the information that the patient provides makes sense being totally non-judgemental at all times, actively listening to the patient and believing that every thing the physiotherapist is told is true developing a skilled understanding of verbal and non-verbal communication and being prepared to critically appraise one's own communication skills;

3

4

MAITLAND'S PERIPHERAL MANIPULATION

[ the physiotherapist should always shoulder the blame for errors in communication •

using the patient's own terminology (the physio therapist should adapt to the patient rather than continuously expecting the patient to adapt to the clinician)

•

•

•

endeavouring to understand the 'frame of refer ence' from which the patient expresses the effects of the disorder knowing what the clinician should know creating an interpersonal environment in which the patient feels comfortable, confident and trusting in the clinician.

The brick wall approach and the primacy of clinical evidence

Figure 1 .2 Australian Test Cricket Captain Steve Waugh (1999-2003) who scored over 1 0 600 Test runs including 32 Test centuries. Reproduced by kind permission from The Wisden Cricketer(January 2004) and from Steve Waugh. © Patrick Eagar (photographer).

The brick wall approach to clinical decision making applies to all aspects of this manipulative physio therapy model. The manipulative physiotherapist is encouraged to decide which side of the brick wall is being considered during each stage of decision mak ing. The decision-making process of the Maitland Concept is primarily on the clinical evidence side of the brick wall although diagnostic/theoretical consid erations will influence the exact nature and dosage of the intervention. Therefore the primacy of clinical evi dence is a major part of the Maitland Concept. For example, the prime concern of a patient with a diagno sis of tennis elbow will be that the problem resolves and does not recur (history), that the pain being experi enced will go away (symptoms) and that grip strength when lifting things will return to normal (signs). Figure 1 .3 is a dynamic representation of the use of the brick wall for clinical decision making. At the heart of the Maitland Concept is a special mode of thinking in two interdependent compartments separated by a symbolic permeable brick wall, thus allowing for hypotheses and speculations. The separ ation into 'theoretical compartment' and 'clinical com partment' in the clinician's mind prevents thoughts relating to the theory of a disorder overriding the Figure 1.3 The symbolic permeable 'brick wall'. . - Elbow pain and soreness since decorating

Symptoms - Sharp pain on the outside

of the elbow when gripping - Reduced grip strength

o o

�

o

painful and stiff elbow extension/adductions

o

�

The Maitland Concept - an introduction

clinician's decision-making processes and does not inhibit the clinician from discovering the patient's dis order in terms of its history, its symptoms and its signs in fine detail. It also allows for safe and effective man agement of disorders where there is an incomplete or uncertain diagnosis. The paradigm of identifying and maximizing movement potential

The World Congress of Physical Therapy (WCPT 1999) in an updated description 'recognizes that physiother apy is concerned with identifying and maximizing movement potential within the spheres of promotion, prevention, treatment and rehabilitation'. The Maitland Concept, with attention to detail in the analysis of quantity and quality of human movement and with mobilization/manipulation techniques designed to restore movements to their pain-free ideal state, is well placed to contribute to the realization of such a paradigm.

Examination An essential requirement is believing that a patient can have: • • •

more than one kind of pain different pains in overlapping areas different pains with different behaviours and histories.

It is also important to believe that there are fine details of information which the body can tell the patient and that the clinician cannot know about unless the patient is encouraged to talk about these trivia, thereby encour aging a personal and total commitment to the patient. In the physical examination, aspects which are emphasized within the Maitland Concept are: •

•

• •

• •

•

functional movements which the patient can perform to demonstrate the pain or other symptoms for which treatment is being sought re-enacting the injuring movement when the disorder has been caused by some traumas differentiation tests pain response to accessory movements performed in loose-packed positions and at the end of range of physiological movements pain response to 'combined movement' tests pain response to the testing of 'functional corners' pain response to movement, both physiological and accessory, performed while the joint surfaces are held compressed together

•

•

•

test movements requiring overpressure to establish . normality not thinking of range of movement without relating the pain response to it and vice versa movement diagrams for the purpose of learning and teaching.

Mobilization/manipulation techniques Although it is necessary to have a basic set of techniques from which to teach, the clinician must be totally open minded and capable of adapting and modifying tech niques to achieve the purposes for which £hey were cho sen in relation to movement and pain. A technique is the brainchild of ingenuity. For example, a patient may experience pain at the front of the knee when going up stairs. A possible treatment technique may be tibiofemoral joint passive accessory movement in the weight-bearing position, thus reproducing the pain, the desired effect being to enable the patient, subsequently, to go up stairs without any symptoms (Fig. 1.4). Grades of passive movement and rhythms are used for teaching, communication between clinicians, recording purposes and to allow the clinician to think in finer detail about the technique. Two styles of tech nique are specific to the Concept: •

•

Performing a movement in an oscillatory manner within a range of movement where there is no stiffness, muscle spasm or pain. Using compression as a component of a treatment technique.

Figure 1.4 bearing.

Tibiofemoral accessory movement in weight

5

MAITLAND'S PERIPHERAL MANIPULATION

Recording of treatment must be complete and in depth, yet brief.

approach to dealing with patients who suffer from dis orders of their movement system (Sahrmann 2001).

The science and art of assessment

The central core

Repeated assessment and ongoing analytical assess ment are the means of evaluating and reflecting on everything done during the clinical decision-making process. Assessment is the epitome of the Concept. Clinical proof of whether treatment is working or not is achieved by continually comparing the effects of the selected treatment forms on the patient's symptoms and signs. At the same time hypotheses about the cause of the problem, the structures at fault, the pathobiological mechanisms involved, expectations for recovery and appropriate management strategies can be confirmed, discarded or re-ranked. Therefore this process of evaluation involves the clinical science of measurable change and the art of decision making about treatment, often based on clinical experience and intuition. Assessment is used at the initial consultation in a manner which determines the effects of the disorder on the patient as a person and to identify relevant movement impairments and consequent activity limi tations. The second application of assessment is in clin ically proving the value of treatment techniques by repeated, detailed assessment and re-assessment of the patient's symptoms and signs. Analytical assessment is used throughout the episode of care. Such assessment must be made in light of the fact that the body has an enormous capacity to compensate for injury, disease or congenital abnormalities. The body also has the capacity to inform the patient of seemingly trivial details which the clinician must encourage the patient to report so that assessment can be more informed and accurate.

The central core or theme of the Concept is a positive personal commitment to understand what the person (patient) is enduring. Therefore the Maitland Concept is a patient-driven model. It is inclusive and places the patient and their main probLems at the centre of every thing the manipulative physiotherapist will do or say. The body's capacity to give information about how the patient is affected by these problems (symptoms, activ ity limitations, etc.) is the key to the planning, selection and progression of manipulative physiotherapy inter vention. For example, if a patient is unable to put his socks on in the mornings because of pain and stiffness in his groin, the prime aim should be to use this func tional loss in examination and assessment to discover the source and cause of the symptoms and treat them in a way that allows the patient to put his socks on in the morning without pain and stiffness in his groin. To achieve a high level of commitment it is also essential to achieve a high level of verbal and non verbal communication (Chapter 3) and a self-critical approach to the task of translating the patient's story into a clinical picture that can be helped by manipula tive physiotherapy. This includes listening carefully and believing the information that the patient is giv ing, interpreting the non-verbal messages which are a reflection of illness experience and carefully consider ing the wording, relevance and impact of the next line of questioning. It is sad to hear patients say that their doctor or physiotherapist does not listen to them, or listen care fully enough, or listen sensitively enough, or listen in sufficient depth, when they want to discuss their disorder. The following quotation from The Age, an Australian daily newspaper, sets out the demands of 'listening' very clearly:

It is open-mindedness, mental agility and mental discipline linked with a logical and methodical process of assessing cause and effect which are the demands of the Concept.

THE MAITLAND CONCEPT - A MANIPULATIVE PHYSIOTHERAPY MODEL Introduction

The International Maitland Teachers' Association (IMTA) defines the Maitland Concept as a process of examination, assessment and treatment of neuromus culoskeletal disorders by manipulative phYSiotherapy (Hengeveld 2002). The Concept demands an open minded, non-judgemental, unassuming and flexible

Listening is itself, of course, an art: that is zuhere it differs from merely hearing. Hearing is passive; Listening is active. Hearing is voLuntanj; Listening demands attention. Hearing is naturaL; Listening is an acquired discipline. The Age (1982) Believing the patient is essential if trust between patient and clinician is to be established. We must believe the patient's subtle comments about the dis order even if they may sound peculiar. Expressed in another way, the patient and the symptoms are inno cent (i.e. the patient is giving a truthful report about the disorder) until proven guilty (i.e. the patient's report is unreliable, biased or downright false). In this

The Maitland Concept - an introduction

context the patient needs to be guided to understand that the body can reveal things about the disorder and its behaviour and that we (the clinicians) cannot know these things unless the patient expresses them. This central core of the concept of total commitment (putting the patient at the centre and making as much use as possible of the body's capacity to inform) must begin at the outset of the first consultation and be car ried throughout the total episode of care, right to the end, and should include: •

your wrist like this (performs a posteroanterior movement of the carpus on the radius and ulna), tell me the exact point at which the sharp pain deep in your wrist comes on.' •

Question 1 (Chapter 6) - 'In your own words, as far as you are concerned, what do you consider to be

your main problem(s)':

(a) Pain, discomiort, stiffness, weakness, swelling, fear of movement and many other symptoms (b) Functional loss of activities of daily living, job, hobbies, sleep disturbance, etc. (c) An injury resulting in pain and disability. •

Communication strategies (Chapter 3) - calibrated to the patient's frame of reference including: (a) use the patient's terminology (b) seek spontaneous information: - Where does it hurt? - What makes it worse, what makes it easier? - How did it start, when did it start? - How is your general health? - How have you been since 1 saw you last time? (c) listen for key words (which require an immediate response or confirmation of their importance): - 'I always seem to get the pain in my knee at work.'

- The soreness in my elbow started in the summer.' - 'After treatment my hip was sore up until

Tuesday.'

(d) inspire confidence and trust: - remove non-verbal barriers such as desks from between you and the patient - arrange the seating and plinth so that you are never looking down on the patient. •

Functional demonstration (Chapter 6) - asking the patient to 'show me' the function, movement, activity or position which the patient knows will reproduce the symptoms or which the patient knows will be difficult to perform.

•

•

Differentiation tests (Chapter 6) - 'Now you are squatting down you have a pain which you say you feel under your knee cap. Does it change if 1 squeeze your knee cap like this?' (adds patellofemoral com pression only). Palpation, passive testing and construction of movement diagrams (Chapter 6, Appendix 1) - 'When I move

•

•

Selection of mobilization technique (Chapter 8) - 'It seems that you get the pain and stiffness in your ankle when you have your weight on it as in walking. The best way I have found that reproduces your symptoms is for you to stand with your weight on your foot and for me to push on your fibula (pos teroanterior movement of the fibula). This will be the mobilization technique 1 will use and then we will see if the pain and stiffness with walking has changed.' Progression of treatment (Chapter 8) - 'You have the feeling that 1 now need to stretch your shoulder a bit firmer (into the quadrant position, Chapter 1 1 ) and that this will get rid o f the stiffness quicker, is that correct?' Decision to stop treatment (Chapter 5) - 'After all the treatment you have had on your knee you have the feeling that the mobilization has done its job. You are now about 80% better and you feel it just needs time and the exercises and rehabilitation you are doing now to get full recovery.'

Concept thinking, the symbolic permeable brick wall and the primacy of clinical evidence

At the heart of the Concept is what has been called the symbolic permeable brick wall. This flexible, open minded and non-judgemental approach to thinking about clinical presentations and how to treat them pro vides the clinician with the facility to explore all pos sible hypotheses relevant to neuromusculoskeletal disorders. The permeable brick wall separates the the oretical compartment from the clinical compartment in the clinician's mind. However, a free flow of informa tion can take place across the permeable brick wall for the purpose of hypothesis formulation and testing. This mode of thinking is not used in any other phil osophy of manipulative therapy; it is the strength of the Concept and the security of the therapist whose primary concern should be the importance of the clin ical compartment in the decision-making process. There are five requirements that enable the ther apist to make the most of the brick wall approach to clinical decision making, as follows.

The first requirement The first requirement is to learn to think in two dis tinctly separate compartments which, although separate

7

8

MAITLAND'S PERIPHERAL MANIPULATION

[ Figure 1 .5

The two-compartment mode of thinking.

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� Figure 1.6 The symbolic permeable ·brick wall": theoretical and clinical compartments.

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and quite different, are interdependent. One compart ment should contain all the theoretical information (known and speculative) and the other compartment should contain all the clinical information about the patient's disorder (Fig. 1 .5). Because much of the medical theoretical knowledge (e.g. diagnosis, pathology, biomedical engineering, etc.) is still incomplete, it should not be given any opportunity to obstruct the searching for all the appro priate clinical facts associated with a patient's disorder (Le. its history, its subjective presentation and its effects on the patient's movements) (Fig. 1 .6). In the day-to-day encounters with patients, such obstruction is a frequent occurrence and the theory does spoil the clinical search, thereby affecting the treatment poten tial. The two-compartment modus operandi is there fore a demand requirement. It is helpful to imagine that the two interdependent compartments are separated by a symbolic, permeable, 'brick wall'.

This mode of thinking also allows for discussion about hypotheses and speculations about patients' clinical presentations without there being any restric tions placed upon the progress of knowledge and skill. It also encourages the formulation of sensible research questions and projects which take the physiotherapy profession forward in its understanding of the causes of disabilities, particularly painful disabilities. A bonus from the 'brick wall' is that the theoretical compart ment allows for the widest of thinking (in fact, it encourages it) while knowing that, if the thinking is correct, it must match the clinical compartment which must always be correct (Fig. 1 . 7).

The second requirement The clinician must know the history, the symptoms and the signs very clearly, and while keeping these at the forefront of thinking, full use can be made of the

The Maitland Concept - an introduction

F igure 1 .7

Freedom for speculation,

hypotheses and research.

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theoretical compartment in terms of formulating as accurate a diagnosis or classification as possible. In such a manner, as clear an understanding as is possible about the patient and the disorder can be achieved. Coping with diagnosis and diagnostic titles is diffi cult. Even within medicine, many diagnostic titles are somewhat inadequate or even incorrect; they may be merely linked to patterns of symptoms or even based on suppositions. Titles are often used loosely and even inappropriately. It is often impossible to arrive at a specific, complete diagnosis, yet the treatment required is clearly known. Many people consider that treatment should not be administered unless an accurate diagno sis is available. This is true to some extent; it is neces sary to know whether a patient's symptoms are believed to be arising from a musculoskeletal disorder rather than an active disease, but it is not always neces sary to have a precise diagnostic title. Provided that the word 'diagnosis' is used in the terms defined in Butterworth's Medical Dictionary (Critchley 1978) quoted below, there is no difficulty:

Diagnosis. The art of applying scientific methods to the elucidation of the problems presented by a sick patient. This implies the collection and critical evaluation of all the evidence obtainablefrom every possible source by the use of any method necessary. From the facts so obtained, combined with the knowledge of basic principles, a concept is formed of the aetiology, pathology, lesions and disordered functions which constitute the patient's disease. This may enable the disease to be placed in a certain recognized category but, of far greater importance, it also provides a sure basis for the treatment and prognosis of the individual patient.

Therefore the 'brick wall' mode of thinking caters for the recognizable syndromes and recognizable patholo gies, it caters for the partially diagnosed disorder and it also caters for the clinical disorders of the movement system which are yet to fall into any recognizable clas sification. In all cases the clinical compartment has pri ority over the theoretical compartment in the final treatment/management decisions. Take for example the diagnosis 'chronic tennis elbow'. Such diagnostic specificity may encourage narrow thinking in terms of the nature and a locality of the disorder. This may limit the examination and assessment of the problem and so confine treatment, which thus may be ineffective. By broader-based thinking, a detailed examination of the associated joint structures and muscles, the sensitivity of the neural tissue in the arm, neck and thoracic spine and their reaction to movement testing, as well as asso ciated cervical and thoracic joint examination, may reveal relevant comparable signs to consider in treat ment. By coupling this to all the other clinical features of the problem, a working hypothesis can be made in which all the components of the condition and its clin ical presentation fit together.

The third requirement The clinician is required to use words in particular ways. To speak or write in incorrect terms means that the thought processes required to choose the words must also be incorrect. The phrases used show very clearly the way the thought processes are working. A simple example may help to make this point clear. If a patient describes a symptom area and the clinician describes the patient's pain as being 'hip joint pain', this is a poor choice of words. To be true to the Concept,

9

10

MAITLAND'S PERIPHERAL MANIPULATION

L i.e. true to the separated theoretical and clinical com partments of thinking, the words that should be used in place of 'hip joint pain' are 'pain in the hip area'. It would be better still if the clinician demonstrated the area of pain and said 'pain in this area'. To have used the words 'hip joint pain' indicates that the thought processes could include the thought that the hip joint is the cause of the pain. Obviously it does not mean that the thought processes must include this thinking, but it does mean that it could. On the other hand, by using the words 'hip area', or demonstrating the area of pain, indi cates that although the thought processes may include the thought that the hip joint could well be the source of the pain, it is virtually impossible for the subconscious thought process to include the thought that the hip joint is the source of the pain. This is an important and essen tial element of the Concept. Some readers may believe that attention to this kind of detail is unnecessary. Quite the opposite is true: if the correct choice of words is made with care, and with the right mode in mind, then the thinking processes must be right. And when this is so, the whole process of examination, treatment and inter pretation must be the best that is possible. A clinician's written record of a patient's examination and treatment findings shows clearly whether the thinking processes are right or wrong for this concept (Chapter 9).

The fourth requirement The clinician is required to choose a treatment tech nique in relation to the patient's signs and symptoms rather than the diagnostic title. However, the theoret ical compartment may influence the vigour and choice of the technique. For example, a patient may have been diagnosed as suffering from an 'acute subacromial bursitis' with severe pain in the area of the shoulder when trying to lift the arm out to the side. The tech nique of choice is likely to be an accessory passive movement of the shoulder or shoulder girdle per formed in such a manner that it achieves the desired effect of enabling the patient to lift the arm out to the side without experiencing as much severe pain. The acute stage of the disorder would require the tech nique to be gentle, soothing and pain modulating. Planning the treatment, therefore, demands logical thinking. The treatment carried out at any one session is chosen with care and it must make sense both logic ally and methodically. Each step in the planning of the whole treatment programme is made on the basis of the same logical methodical sense. Prognosis is another aspect of treatment that is deter mined logically. This is achieved by assessing changes in the patient's symptoms and signs effected by treat ment, at the same time relating to the hypothesis about

the diagnosis. Full use is made, therefore, of the two interdependent compartments of thinking to achieve the best end result. In such a way, when a seriolls dis order is present, the importance of accurate diagnosis takes priority. However, when the presentation clearly shows a movement system disorder is present, the clin ical compartment takes precedence.

The fifth requirement The clinician should be encouraged to apply and adapt the two-compartment mode of thinking to contempo rary models of clinical decision making. The brick wall approach to clinical reasoning is well suited to estab lished hypothesis categories and the decision-making models (Box 1.1) which are relevant to the manipulative physiotherapy management of neuromusculoskeletal disorders (Higgs & Jones 2000). Examination

Examination is analytical assessment at the initial con sultation. Clinical information is gathered, hypotheses made, treatment options planned and prognosis specu lated upon. Information is gathered and interpreted during the subjective examination (Chapter 6). The oretical and clinical hypotheses are formulated during the planning of the physical examination. The hypotheses are then put to the test during the physical examination and subsequently through the application of carefully

Hypothesis categories • Pathobiological mechanisms: diagnosis, mechanisms of symptom production (Fig. 1.8) • Dysfunction: impairment and disability - both physical and psychological (Fig. 1.9) • The source and cause of the source of the symptoms (Fig. 1.10) • Contributing factors (Fig. 1.11) Precautions and contraindications (Fig. 1.12) • Prognosis (Fig. 1.13) • • Treatmentl management (Fig. 1.14) Decision-making models • Hypothetico-deductive reasoning (Fig. 1.15) • Pattern recognition (Fig. 1.16) • Lateral thinking (Fig. 1.17)

The Maitland Concept - an introduction

Figure

1.8

Pathobiological

mechanisms. - Felt something 'go' when throwing javelin 2 days ago - Sore, sickly pain outer elbow - Local, red, swollen, hot, tender

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1 .9

Dysfu nction: im pairment !

di sab i l ity.

Torn fibres of the

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Source

1 .10

Source

and cause of the source

- Common extensor origin - Radiohumeral, radioulnar joints - Radial nerve

of symptoms. - Painful isometric testing of finger extensors - Elbow supination stiff and painful - 'Tingling' back of hand with ULNT 2B (Butler 2000) testing - Wrist extension stiff

- Shoulder quadrant stiff

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11

12

MAITLAND'S PERIPHERAL MANIPULATION

c::: Figure

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1.12

Precautions and contra indications.

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1.13

Prognosis.

Contributing factors.

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1.11

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The Maitland Concept - an introduction

Figure 1.14

o

Treatmentl management.

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� Figure 1.15

Hypothetico-deductive

reasoning.

Possible components: - Patellofemoral - Tibiofemoral - Hip - Lumbar spine - Alignment faults - Femoral nerve

Anterior knee pain

- Footwear/Biomechanics

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ligaments

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Pattern recog nition.

13

14

MAITLAND'S PERIPHERAL MANIPULATION

Figure 1.17

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chosen and performed treatment techniques. All relevant treatment/management strategies should be con sidered for all relevant components of the disorder. Recognized clinical methods of history taking and routine examination by physical means are used and are not necessarily special to the Maitland Concept. The universal aim of any concept of manipulative physiotherapy should be to identify movement dis orders and maximize movement potential. However, knowing in detail the intensity, behaviour and rela tionship of pain, stiffness and muscle spasm during the test movements is special. Such care reveals to the clinician the evidence of 'through-range pain', 'end-of range pain', 'irritability' and the var ieties of 'latent pain', all of which are special and fundamental to the use of passive movement espoused by this Concept. There are particular details to examination procedures which are special and do relate to the Concept. Examination, therefore, should be logical, method ical, comprehensive and relevant (Wells 1988).

Subjective examination (C/O) The clinician should be able to 'live' the patient's symp toms throughout a complete cycle and 'feel' emotion ally what the patient is experiencing. The aims of the subjective examination should be to:

•

•

•

•

• • •

•

•

•

•

place the patient at the centre of everything that the clinician wishes to do identify, with asterisks (Chapter 6), the kind of disorder, the site, nature, bel;laviour and histor y of the patient's symptoms identify how the patient is affected and has been affected by the disorder (impairment/ disability)

establish the extent of the physical examination required and the desired effect of treatment based on the sever ity, irritability and nature of the symptoms and the stage of the disorder identify precautions and contraindications for treatment identify the structures at fault (the source/the cause of the source of the symptoms) hypothesize about the mechanisms of symptom production (nociception, per ipheral neurogenic, central, autonomic, affective) identify the factors contributing to the disorder hypothesize about the pathology involved identify clues to possible treatment techniques (e.g. the injuring movement, functional demonstr ation, or strategies which the patient has developed) establish factors which help to make a forecast for a favourable or unfavourable prognosis record findings in a logical methodical way.

Table 1.1 provides a summary of the subjective exami nation; Box 1.2 outlines the planning of the physical examination (planning sheet).

Physical examination (PIE) (Chapter 6) The aims of the physical examination should be to: •

•

Lateral thinking.

•

•

•

establish, with asterisks, the signs relevant to the patient's disorder test the clinical and theoretical hypotheses identified in the C/O analyse movements in ter ms of their range/ symptom response / quality apply an appropriate amount of examination (shor t of symptoms, up to the onset of symptoms,

The Maitland Concept - an introduction

Ta ble

1 .1

Su m m a ry of the subjective exa m i n a t i o n Question

Areas of symptoms

Where are the symptoms?

Fi l l in a body chart

1:

Esta b l i sh the k i n d of d isorder

Behaviour of symptoms

History of symptoms

Speci a l questions

Can I do harm?

What makes the symptoms

How did it start?

worse, what makes them better?

When did it start?

The effects of rest, activity and

The history of the present

position on the pain / symptoms

episode of symptoms from

precautions and

onset to present

contra ind ications to

Be aware that different

Determine all possi ble

kinds of pa i n (symptoms)

Be aware that the pain (symptoms)

can interact together in

can behave i n many different ways.

The history of 011 past episodes

physiotherapy and any

associated areas

It is necessary to know the behaviour

of the symptoms from onset

factors contributing to or

manipu lative

of the patient's symptoms if a

incl uding progression of

infl u encing the resol ution

Be aware that there co uld

reasonable understanding of the

symptoms

of the disorder

be overlapping areas of

status of the disorder is to

pa i n (symptoms) from

be determined

different components of

Determ i n e the stage in the natural history of the disorder

one disorder

• • •

• •

•

• •

to the limit of range, to the limit of range with overpressure added) reproduce symptoms find comparable signs establish the source, cause of the source and contributing factors to the disorder exclude structures not at fault confirm or rule out the need for caution with special testing (e.g. neurological examination, vertebral artery testing) follow a logical, methodical, comprehensive, relevant and integrated format record in a logical methodical way follow-up examination not completed at the initial consultation during subsequent visits (D + 1).

Physical examination should include the following (asterisk as you go along). Calibration of the symptoms (pain) pres ent before the physical examination commences.

Present pain

Alignment faults, protective/adaptive deformities, structural deformity, wasting, swelling and other signs of injury or disease. The effects on the symptoms/pain of correction or overcorrection of the deformity.

Observation (correct! overcorrect deformities)

Functional demonstration (functionally reproducing move ment, to P, or limit) When pain, rather than stiffness

is the problem, the patient can quite often demonstrate a particular movement, activity or function that will reproduce the symptoms (and it is the use of this that is

the aspect related to the Concept). Encouraging the patient to so demonstrate the movement, together with the clinician's analysis of it, is another aspect that is special to the Concept. Frequently the demonstrated movement may be used, or give an idea for the treat ment movement. When a comparable examination movement/pain response cannot be found, or when a sprain or injury has been the cause of the symptoms, re-enacting the injuring direction of the stress as an examination procedure may divulge the comparable sign. Again, such use in physical examination, which is routine in the Maitland Concept, is not found in other examination routines.

Injuring movement

Differentia tion tests are special tests that can be used when a test

Differentiation (including compression tests)

movement (active or passive), causing simultaneous movement of at least two joints or two movement sys tem structures, reproduces the patient's symptoms. The method is as follows: when the test movement is at the point in the range of reproducing the patient's pain, further movement is produced in one of the two j oints or structures, which, at the same time, either reduces the movement in the joint or retains it at an unchanged degree of mechanical stress. This test, which increases the stress at one joint or structure and reduces it at another will either increase or decrease the reproduced pain. The test is then performed in the reverse manner. The pain response (i.e. increase or

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MAITLAND'S PERIPHERAL MANIPULATION

[

A) REFLECTION OF THE SUBJ ECTIVE EXAMI NATION (Verification that the subjective exa m i nation is complete i n order to be able to start the physical exa m i nation a n d to perform a reassessment of subjective parameters - 'asterisks' - in subsequent sessions.) 1.

S u m m a ry of the main information of the subjective exa mination :

2. Agreed treatment objectives based on the findings of the subjective exa minatio n :

3. W h i c h subjective para meters ('asterisks') w i l l be used in subsequent sessions as part o f the reassessment procedures? (Describe the parameters i n sufficient deta i l ) :

4. Has t h e subjective examination been sufficiently comprehensive t o b e a b l e t o m a k e confident statements a nd t o develop hypotheses with regard to precautions and contra i n dications to physical exa mination procedures? (Check information of 'Q1 ', body chart, behaviour of symptoms, Hx, SQ):

B) HYPOTH ESES •

Dominant neurophysiological symptom mechanisms List the subjective information which supports the hypotheses of the various neurophysiological symptom mechanisms:

•

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I n put mechanisms - nociceptive symptoms: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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I n put mechanisms - peripheral neurogenic mechanisms:

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-

Processing - central nervous system mechanisms a n d / o r cog n itive/affective /sociocultural influences: . . . . .

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Output mechanisms - motor and autonomic responses:

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Sou rces of sympto ms / i m pa irments List all the possible sources of a ny part of the patient's symptoms that must be exa m i ned :

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Joi nts underlying the symptomatic area(s):

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Joints referring into the symptomatic area(s):

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Neu rodynamic elements related to symptoms and dysfu nction:

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Muscles underlying the symptomatic area(s):

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Soft tissue structures underlying the symptomatic area(s) :

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Others:

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Neuromusculoskeleta l : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Contributing factors Which associated factors may be contributi n g / causing / ma i nta ining the problem and disabi l ity?: -

(a) as reasons why the joint/ muscle or other structure has become symptomatic/ as reasons why the disorder may recur (e.g. posture, muscle imbalance, muscle coord ination, obesity, stiffness, hypermobility, instability, deformity in neighbouring joints, etc.):

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(b) the effect of the disorder on joint stability: -

Medical factors:

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Cognitive factors:

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Affective factors:

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Behavioural factors:

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Specify: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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When do you expect to incorporate these factors i n physical exa mination procedures (im mediately / i n later sessions?). •

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Precautions a n d contra i n d ications to examination procedures and treatment interventions -

Yes / No

Are the symptoms severe / irrita ble?

(a) Specify your answer with examples from the subjective exam ination: (b) Is it possible that ongoing sensitivity takes place due to central nervous system sensitization or avoidance behaviour? Specify your answer: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -

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Does the nature of the problem indicate caution? Yes / no (a) Tissue pathology: .

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(b) Other pathological processes (e.g. osteoporosis):

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The Maitland Concept - an introduction

17 ]

(c) Stages of tissue hea ling:

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(d) Stage of the disorder (Hx) (progressive/ regressive / static): . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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(e) Easy to provoke exacerbation or acute episode (sta bil ity of disorder): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(f)

Confidence to move/ extreme guarding of the patient:

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What are the impl ications of this answer with regard to the extent of the physical examination?: •

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Management - objectives / i f treating

local movement impairment - P or R 1 . Which short-term or long-term goals of treatment are pursued?: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. If passive mobilization is a treatment option, do you expect to be treating pain, resistance but respecting pain, resista nce or resistance to provoke 'bite'?: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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3. Are there any precautions or contra indications which need to be respected ('nothing at the price of . . . )?: . . . . . . . . . . . . . . . . . .

4.

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What advice should be included a nd / or measures would you use to prevent / l essen recurrences and provide the patient with a sense of control over the symptoms?: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

.

C) PROCEDURES OF EXAM I N ATION •

Anticipation of the results of exam i nation procedu res -

Do you think you will need to be gentle or moderately firm with your exa mination proced ures?: . . . . . . . . . . . . . . . . . . . . . . . . .

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Do you expect a 'comparable sign' to be easy/hard to find? (if hard to find, 'functional demonstration tests' a n d 'if necessa ry

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tests' may be plan ned in advance, hence saving time). Explain why: -

What movements do you anticipate to be 'comparable'?: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Might there be any positions or movements that need specific consideration during physical exa m i n ation? (e.g. lying i n

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prone positions): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . •

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Extent of examination procedures -

Any positions you may need to avoid in the exa m i nation? (e.g. prone lying):

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Which symptoms would you l i ke to reproduce?:

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Are there any symptoms which you would not want to produce? (e.g. dizzi ness, paraesthesia): . . . . .

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To what extent may you provoke symptoms? (list this for each relevant symptom area): Until the onset of P , / ca refu l ly

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beyond P, - maybe exploring 'Trust, ' / move to the limit of the test movements: -

Number of tests you will be performi n g : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Few tests (active short of l i m it) /Sta ndard tests without overpressure (active limit of movement) /Standard tests with overpressure (active limit plus overpressure ) / ' I f necessary' (or 'when appl icable') tests •

Which components do you exa m i ne and which tests (includ i ng reassessment procedu res) w i l l you perform i n the first session? . .

•

W h ich components do you expect to examine in the second session? (And with which tests?) : . . . . . . . . . . . . . . . . . . . . . . . . . .

•

W h ich components or contributing factors do you expect to exa m i n e in later sessions? (And with which tests?) :

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Sequence of exam i nation procedures of the first session:

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Observation :

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Functional demonstration test and differentiatio n :

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Active movement tests (specify w h ich):

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Isometric tests (with which purpose?):

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Specify which tests: -

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Are any special tests indicated?:

(a) neurological exa m i nation (conductivity): (b) others (e.g. insta b i l ity testing):

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Neurodynamic testing :

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Palpation a nd passive movement testing:

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(a) accessory movements (specify joint position; which acc. mvts) : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (b) physiological movements:

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(c) others: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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When do you plan to perform reassessments d u r i n g the P I E procedures?

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(Indicate this with a double line behind the above-mentioned test procedures.)

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18

MAITLAND'S PERIPHERAL MANIPULATION

decrease) confirms which structure was found to be at fault with the first test (Chapter 6). Compression testing can be used when, during the physical examination, it becomes evident that the two joint surfaces should be held firmly compressed together when performing a test movement (Maitland 1 985). Only by adding such compression may the evi dence of origin of the patient's symptoms become clear (Chapter 10).

movement may be recorded with two ticks, as shown below, indicating its normality: F ,/ ,/

The F represents the movement being tested, in this case flexion. The first tick means that overpressure has been applied and that the range is normal; the second tick means that the stretch response to the overpressure has been normal.

Brief appraisal tests - peripheral and vertebral These are quick active tests of peripheral joints or regions of the spine to determine the degree to which they are involved or not involved in the generation of the patient's symptoms.

Isometric tests

Active movements - range/pain (symptom) response/ quality of movement (to P, or limit) - peripheral and spinal

Neurological examination and neurodynamic testing are described in detail in Butler (2000) and Maitland et al (2001) and therefore the descriptions of such techniques are not included in this text.

It is a mandatory rule in this Concept that when testing a movement in any direction, the recording of the findings must include both the range and the pain response and, when appropriate, the quality of the movement (this should include both active and passive movement). A detailed examination of movement seeks to reveal the smallest change in the behaviour of the pain and the limitation of the range with each direction of movement. For example, the patient may perceive pain or discomfort throughout the range or only to the end of the range (Chapter 8). The behaviour of the pain with the movement may match the behaviour of the resistance with that same movement within its avail able range. Appreciating the fine differences in behav iour of the abnormal elements of the movement is imperative to the best application of treatment: never

think of range without thinking of pain; never think of pain without thinking of range.

Combined movements Although the physical exami nation of routine physiological movements is not special to the Concept, the coupling together of these movements into any possible combination is. Com bining accessory test movements with physiological movements is equally important. The method of com bining movements should be determined more by the desire to provoke or relieve the patient's symptoms than by biomechanical considerations. The formaliz ing of these tests has been the original contribution of Brian Edwards (Edwards 1992). Overpressure When examining a movement of a par ticular structure, it can only be classed as being normal or ideal (Maitland et al 200l) if a firm overpressure can be applied without provoking anything more than the expected normal stretch response. Under these cir cumstances when the stretch response is normal and the overpressure has been of adequate firmness, the

Isometric tests are of value in testing for muscle function, strength and pain response only if it is considered that other structures may also be compro mised and therefore pain sensitive. In such cases further differentiation would be necessary (Kendall et al 1993).

Palpation of structures in the peripheral regions should be accompanied by an in-depth know ledge of surface anatomy (Hoppenfeld 1976).

Palpation

Passive movement (peripheral, vertebral)

Examining

accessory movements in both the loose-packed position and at the end of limited ranges, or in painful positions of a free range of movement, are, in one way, special to the Concept. Although assessing the range of acces sory movements appears in other concepts, assessing the pain responses in relation to the suffered pain does not, nor does the assessment of the pain response of accessory movements in a painful, yet not limited phys iological position. To know which accessory movement most closely relates to the patient's symptoms gives information about tl1e disorder which cannot be gained in any other way. This aspect is special to the Concept. The testing of functional corners - such as hip flexion/ adduction, shoulder quadrant, knee extension/ abduction - are special to the Concept in that a joint cannot be classed as normal unless these functional corners have been examined in detail and deemed so. Often, in patients with minor symptoms, physioLogical movements will be pain-free. However, when the func tional corners are examined it is possible to reproduce the patient's symptoms. Treatment is likely to be effect ive, therefore, if directed into these corners.

Movement diagrams Movement diagrams (Appendix 1) are included as part of the Concept for two reasons: 1.

They formulate a basis from which the clinician can learn more from each clinical experience. To draw a diagram representing the findings on examining

The Maitland Concept - an introduction

Rather than thinki ng about all the physical examination tests which it is possible to use for each structure of the movement system, both the novice and the experienced clinician should think about which tests for each compo nent can be carried out in each of the following starti ng positions (for the patient): • • • • •

Standing Sitting Side lying (R) (L) Supine Prone

•

•

For example, the following test seq uences may be used to examine a patient with anterior knee pain: •

•

Standing: observation (local and global) gait analysis functional demonstration, injuring movement, differentiation - brief appraisal of movements - active movements: knee, hip, foot, spine Sitting: - alignment faults with active knee extension - isometric quadriceps in varying degrees of knee flexion

a particular movement forces the clinician to analyse the relationship of the pain/stiffness/muscle spasm (joint signs) which may be present.

2. As a means of communication in the teaching situa tion, the diagrams provide a tool for learning which can be used in a way that is foolproof.

Selection and reassessment of treatment technique (Cha pters 5 a n d 8)

Physical examination techniques are frequently used as treatment techniques as well as to reassess the effects of treatment. A 'clinical tip' outlining an integrated approach to physical examination is shown in Box 1.3. Techniques of mobilization/ manipulation

Passive mobilization of all peripheral joints, whether they be synovial or non-synovial, is the basis for the techniques described in this book. However, passive

•

slump test passive patellofemoral movements in varying degrees of knee flexion Side lying: side lying slump (femoral, saphenous nerve) lumbar passive physiological intervertebral movements (PPIVMs) h i p accessory movements gluteus medius function, iliotibial ba nd length Supine: SLR - sacroiliac stress tests - hip: physiological, accessory movements, flexion / adduction palpation around the knee patellofemoral passive movements + compression tibiofemoral passive movements and functional corners q uadriceps lag test muscle length tests: rectus, il iotibial band, iliopsoas Prone: intervertebral palpation and accessory passive movements passive tibiofemoral movements in knee flexion passive movements in hip extension hamstrings / gluteus maximus function

movement can be applied to any structure of the movement system which has had its mobility comprom ised by injury, overuse or disease. The principles of the technique can be and should be applied to any move ment impairment (Banks 1997). Techniques as they apply to this concept are never ending and they never should have an ending. So long as patients present with different symptoms and signs, the clinician will have to think constantly how, when and why techniques can and should be modified and changed to free the patients of their symptoms. Although there are basic handling techniques which must be taught, the Concept demands that the clinician's mind must be so open as to allow for modifications of the techniques until they achieve what they have set out to achieve. The basic treatment techniques must include every movement of which the body is capable, both the physiological movements and the accessory move ments and all possible combinations of them. In each relevant chapter of this book techniques will be described in a way that relates to the fundamental

19

20

MAITLAND'S PERIPHERAL MANIPULATION

skills required for the safe and effective delivery of passive mobilization/ manipulation to the patient. For each technique consideration should be given to the following. •

•

•

•

•

to the use of accessory movements while the joint surfaces are compressed. •

The passive movement direction the passive move ment (physiological, accessory, combinations) direc tion or position which provokes or relieves the patient's symptoms. -

The symbol

the recognized abbreviation to denote the movement direction being used. The symbol always corresponds to the patient's anatomical planes of movement (Maitland 1 992). -

Figures/CD-ROM each technique described in the text will be accompanied by photographs and CD ROM clips to assist the reader in visualizing the dynamics of the skill required. -

Starting position of the patient basic starting posi tions and a variety of modifications are required to achieve the desired effect of the technique which is to relieve or provoke the patient's symptoms. -

Starting position of the therapist adapted to achieve the desired effect and to maximize the delivery of the passive mobilization technique. -

•

Localization of forces

•

Application of forces (method)

positioning of the hands, fin gers, thumbs and arms to produce the passive movement locally in the most effective manner. -

the method and style of the treatment technique should include the best use of the therapist's arm and body movements to achieve the desired amplitude, position in range, strength, grade, speed and rhythm of mobilization. When actually performing a technique, the clini cian must become as involved with the procedure as is the soloist musician when performing with a symphony orchestra (clinical tip: try to practise tech niques to different pieces of music which have dif ferent rhythms and tempos). There are two styles of technique with which the Maitland Concept is associated and which are essential to the clinician's manual skills if the best results in the treatment of neuromusculoskeletal disorders are to be achieved. 1. Techniques that include movement in an oscilla tory fashion (two or three per second). These techniques are performed within a range of movement that is neither painful nor affected by any stiffness or musc�e spasm. 2. There are times when adjacent joint surfaces need to be held firmly compressed together while per forming a movement technique. This also applies

•

Variations/adaptations treatment techniques can be varied and adapted in many ways to suit the patient, the therapist or the situation at hand. Alternative starting positions, localization of forces and style of mobilization may be needed to achieve the desired effects of treatment more readily. -

Uses/evidence-based practice some techniques have been found to benefit or suit some clinical syndromes or painful movement directions more readily than others. Additionally, some techniques may have been the subject of randomized controlled trials or clinical scientific study. -

There are, therefore, no set techniques or invariable techniques; there are no times when a teacher of manipulative physiotherapy should say 'you must always do it this way'. The only 'must' in this concept is that the treatment technique must achieve its intention both while it is being performed and after it has been performed. The clinician's mind must always be open; the teacher must never be dogmatic: a technique is the brainchild of ingenuity; a technique must be as indi vidual as the patient.

In essence it is essential to have an open-minded attitude towards treatment techniques, being able to innovate and improve freely unhindered by theory and to relate the techniques to the functional disturb ance, i.e. adapt, adopt, improve.

-

Assessment

Repeated assessment and analytical assessment are the means of evaluating and reflecting on everything done during the clinical decision-making process. 'Proof' of whether treatment is working or not is achieved by continually comparing the effects of the selected and progressed treatment techniques on the patient's symptoms and signs. At the same time hypotheses about the cause of the problem, the struc tures at fault, the pathobiological mechanisms, the fac tors contributing to recovery and optimum treatment strategies can be confirmed, discarded or changed. Analytical assessment is the most important skill of the evaluation/reflection process. Every aspect of the patient's disorder is considered in an effort to establish every detail about the problem in order to 'make fea tures fit'. Assessment and reassessment follow closely behind whereby continuous and repeated evaluation of the effects of treatment is carried out. Assessment and analytical assessment are considered to be skills of greater priorities than examination and techniques in the clinical decision-making process (Fig. 1 .18).

The Maitland Concept - an introduction

-f-- Analytical assessment •

•

•

Examination •

•

•

•

(Higgs S.J. Jones M 2000)

Hypothesis Pattern recognition Establish c/O P/E ..

-r-r-- Assessment/reassessment •

•

•

•

Desired effeCts

•

A means to an end

•

Selection and progression

•

based on detailed

•

assessmentlreassessment

•

•

•

Figure

1.18

Analytical assessment at the first consultation

During the initial examination of the patient, informa tion is gathered through the subjective and physical examination and should establish and test a working hypothesis about the kind of disorder that the patient has and by how much it is affecting everyday life. Consideration should also be given to the stage and pathological stability of the disorder. For example, a young man with acute, severe, irritable pain in the shoulder area after a recent injury may be having pro gressive difficulty putting a shirt on in the morning. He may have grossly restricted shoulder movement in all directions because of pain. The desired effect of treatment is to deliver pain-relieving mobilization techniques to his shoulder in order that he can carry out his daily activities with less painful restriction. Other modalities may also be necessary to facilitate the desired effects, such as explanation of the expectations for recovery, anti-inflammatory medication and home management strategies. 2.

'Proving' the clinical value of the technique Comparison of the effect of treatment Before each session During each session Immediately after treatment Periodically after every 3/4 sessions Retrospectively Final analytical assessment Prognosis/outcome

Representation o f the i m p o rtance of assessment and analytical assessment i n t h e c l i n ical decision-making process.

Obviously, the best treatment cannot be given without highly skilled examination and treatment techniques. However, flawless analytical assessment is the vital link in this concept of manipulative physiotherapy. It is the keystone, without which the whole concept would collapse. There are six categories of assessment relevant to each episode of care. 1.

The thinking underlying clinical practice

Initial analytical assessment

Techniques

•

'Making features fit'

Thinking one step ahead

Pretreatment assessment

Before every treatment session begins the effects of the previous treatment session should be evaluated. The

therapist, therefore, should start each session with the question: 'How have you been since I saw you last time?' Comparisons should be made of the effects of treatment on the patient's signs and symptoms since his last visit. Established daily activity limitations and movement impairments (CIO *** and PIE ***), such as the area or quality of pain, and the effects that activ ities, positions or particular times of day have on the pain, should be used for comparison. Likewise, any changes in protective deformities, functional move ments, passive movement, etc. should be assessed. 3.

Assessment and reassessment during and immediately after each treatment session

This is 'proving or assessing the value of a technique' in treatment. This entails knowing what the intention of the technique should be while it is being performed and having expectations of what changes the technique will effect follOWing its use. Two applications of a tech nique are necessary before it is discarded as being use less for the present stage of the disorder. The effects of treatment from one session to another should also be evaluated in detail. For example, the treatment selected for the above patient may be a grade I shaft rotation of the humerus which produces the desired effect of the feeling of movement without pain or discomfort. After 2 minutes of the slow oscilla tory passive technique the patient begins to experience an ache. This is not desired so the treatment is stopped based on the assessment of effects during the adminis tration of the technique. Immediately afterwards the patient feels the same level of discomfort as before the treatment but feels that he can move his arm a few

21

22

MA I TLAND'S PERIPHERAL MAN I PULATION

L

degrees further before he perceives an increase in pain, compared with before the treatment. Thus, by assess ing the immediate effects of treatment, a favourable though slight improvement is detected. Two days later a pretreatment assessment may reveal that the level of discomfort had diminished Significantly from the pre vious two days and that the patient had felt that his ability to put his shirt on was no longer getting worse by the day. Reassessment therefore helps in deciding the next course of action or progression of treatment. In this case it would be desirable to recreate the same effects as the previous treatment session.

The body's capacity to adapt, compensate and inform

The body has two capacities that influence assessment and must be borne in mind when making analytical assessments. Each of these capacities can have an effect on the development, rate of recovery and resolution of signs and symptoms. 1.

The body's capacih} to adapt

the body has an aston ishing capacity to adapt to changes that are forced upon it by congenital abnormalities, trauma, life long heavy work and disease -

2. The body's capacity to compensate the body also has an enormous capacity to compensate for damage and disease. -

4.

Progressive assessment

After every three or four treatment sessions it is wise to compare the patient's signs and symptoms over a longer period of time in order to gain an overview of the rate of improvement of the clinical features of the patient's disorder. For example, after four sessions the patient with shoulder area pain may have improved slightly between treatment sessions but the reduction in the area of the pain felt may have diminished quite significantly over the compared longer period.

5.

Retrospective assessment

Retrospective assessment is often valuable after a planned break from treatment to assess whether the disorder is spontaneously recovering, recovered faster during the treatment period, a combination of both of these or not recovering at all. For example, after hav ing treatment for 2 weeks at regular intervals the above patient is much better both in terms of pain and functional activity. He has a 2 week break from treat ment and returns almost problem free, thus indicating that spontaneous recovery is now taking place and any further treatment is probably unnecessary.

The body has one other capacity which can and should be utilized in assessment and this is the body's capacity to inform. The patient's body can tell him things relating to his disorder that can never be detected by the clinician, even by the most thorough physical examination. These are frequently subtle messages which the patient may comment upon, yet feel that they are almost too trivial to state. Nevertheless they may be priceless. The only way the clinician can elicit these subtleties is to listen to the patient, believe him and encourage him to mention anything that might be relevant, irrespective of how trivial or unimportant it may seem to him. The patient who is 'tuned in to his body' will be aware of these subtleties, and the clinician can educate the patient to notice these trivia and to report them. This is an essential way in which the patient can assist in the moment-by-moment subjective assessment of his dis order and its behaviour. The achievements possible through assessment are limited only by the extent of one's lateral and logical thinking. Therefore the clinician should think, pLan,

execute to prove. Recording

6.

Final analytical assessment

At the completion of the episode of care a final analyt ical assessment will be useful to determine, amongst other things, the future prognosis of any mode of treat ment and the likely recurrence of the patient's disor der. For example, the above patient can be expected to make a full recovery and return to his normal level of activity given the nature of the injury, the response to treatment and the natural recovery. Recurrences are possible if the patient is in a position during his everyday activities such that the same injury could occur again.

Recording of examination, treatment and assessment is a visualization of reasoning and reflects the discip line of the logical, methodical approach to decision making. The Concept encourages the clinician to com mit facts, thoughts, impressions and reflections to paper in a detailed but abbreviated form. The Concept demands that recording of patient information should be detailed enough to hold up to cross-examination in a court of law. Recording each treatment session (Chapter 9) should include: •

a quotation of the patient's opinion of the effects of the previous treatment as a comparison rather than

The Maitland Concept - an introduction

a statement of fact. For example - Comparison: 'I can lift my arm higher than I could last time'; Statement of fact: 'My shoulder still hurts when I lift my arm' (the immediate response to this answer is for the cli nician to say 'how does it feel compared with when I saw you last week?') •

•

•

•

•

pretreatment planning and reasoning behind the selection of treatment the treatment technique, its grade, its rhythm and its symptomatic response while being performed immediately after treatment, the patient's compari son of any changes in symptoms resulting from the technique re-examined movements, their range, symptom res ponse and quality compared with before treatment thoughts about how treatment may need to be modi fied at the next session. This will stimulate memories of the last treatment session and makes assessment complete in terms of knowing the path the treatment is moving along.

Context

The Maitland Concept is a holistic approach which not only seeks to clarify the physical components of an individual's movement disorder but also takes full measure of the many aspects of the individual's per sonal illness experience, lifestyle and emotional state and how these impact on the problems. While manual techniques of passive movement are the mainstay of the treatment methods in this Concept, other modalities

such as home programmes of active, functional exer cise and self-treatment procedures, the assessment and correction of muscle imbalance as well as atten tion to ergonomics in the workplace and recreational activities are incorporated as necessary, based on sound clinical reasoning and evaluation. Hence this system has developed as one which incorporates rather than excludes new methods and techniques of assessment and clinically valid treatment. Wells (1996) has developed a contemporary model of how the Maitland Concept is able to incorporate such issues as psychosocial factors and pain mecha nisms into the management of neuromusculoskeletal disorders (Fig. 1.19). Maitland (1987) says of the Concept, 'It did not "come" [to me] fully developed, but as a living thing, developing and extending'. Butler (2000) considers that 'the self-management concept of McKenzie, the inherent reasoning strategies of Maitland, the skill in joint management of Kaltenbom/ Evienth and Paris are superb aspects of management that we must never lose, but adapt'. Wright and Sluka (2001) conclude that 'emerging evidence therefore supports the concept that manual therapy techniques [mobilization of the cervical spine, specifically] exert important neurophysiologi cal effects that may contribute to the ability of these treatments to reduce pain'. However, they conclude that 'there is also a noticeable lack of studies address ing the use of manipulation or mobilization tech niques to treat peripheral joints'. COincidentally, various studies including that of Salter ( 1989) have concluded that passive movement

Figure Psychosocial (e.g. attitude, mood, stress)

.-I I I I I I I I I

Muscles and connective tissues

Postures Work practice General fitness

Joints

and associated tissues

Mechanisms (e.g. chronic pain)

1 .1 9

Components, mecha nisms and dimensions

relevant to manipulative th erapy. Reprodu ced by k i n d perm ission from We lls

( 1 996).

23

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MA ITLAND'S PE RIPHE RAL MANIPULATION

seems to be the best means of promoting the healing of defects in synovial joint articular cartilage (Chapter 8). Maitland (1986) recognizes that pain 'is influenced by an enormous variety of factors and it presents in many different ways'. The nature of the person may require that treatment techniques are 'modified to suit the patient first and then suit the disorder ' (Maitland 1991). Likewise Gifford (1997) suggests that if pain and the patient's experience of pain are to be understood, the cognitive and affective dimensions of pain should be considered as well as the sensory dimensions, and that pain should be viewed in terms of these three interrelated mechanisms.

Hengeveld (1999), in her review of the WCPT description of physical therapy, notes that the adapta tion to the principles of the Maitland Concept can be recognized. Key words, such as assessment, examina tion of functional limitations, evaluation, clinical rea soning and re-examination, have their roots within the Maitland Concept. However, as we see and hear the term 'Maitland Concept' used less and less we recog nize its core features in the ever-developing science and practice of manipulative physiotherapy and other specialities of physiotherapy. If this process continues, Geoff Maitland will have had his wish.

References Banks, K. 1997. Passive techniques: a review of their use in clinical practice. In Rehabilitation of Movement: Theoretical Basis of Clinical Practice, ed. J. Pitt-Brooke, pp. 319-360. London: W B Saunders Butler, D. S. 2000. The Sensitive Nervous System. Adelaide: NOI Group Critchley, M., ed. 1978. Butterworth's Medical Dictionary, 2nd edn. London: Butterworth Edwards, B. C. 1992. Manual of Combined Movements, 1st edn. Edinburgh: Churchill Livingstone Gifford, 1. S. 1 997. Pain. In Rehabilitation of Movement: Theoretical Basis of Clinical Practice, ed. J. Pitt-Brooke, pp. 196-232. London: W B Saunders Hengeveld, E. 1999. Review of WCPT description of physical therapy. IMTA Newsletter, 6 Hengeveld, E., ed. 2002. International Maitland Teachers' Association Draft Rules and Regulations. Switzerland: Zurzach Higgs, J. & Jones, M. 2000. Clinical Reasoning in the Health Professions, 2nd edn. Oxford: Butterworth-Heinemann Hoppenfeld, S. 1 976. Physical Examination of the Spine and Extremities. New York: Appleton Century Crofts Kendall, F. P., McCreary, E. K. & Provance, P. G. 1993. Muscles: Testing and Function, 4th edn. Baltimore: Williams and Wilkins Maitland, G. D. 1985. The importance of adding compression when examining and treating synovial joints. In Aspects of Manipulative Therapy, 2nd edn, pp. 109-115. Melbourne: Churchill Livingstone Maitland, G. D. 1986. Vertebral Manipulation, 5th edn. Oxford: Butterworth-Heinemann Maitland, G. D. 1 987. The Maitland Concept: assessment, examination and treatment by passive movement.

In Physical Therapy of the Low Back, Vol 13, ed. 1. T. Twomey & J. R. Taylor, pp. 135-155. Edinburgh: Churchill Livingstone Maitland, G. D. 1 99 1 . Peripheral Manipulation, 3rd edn. London: Butterworth-Heinemann Maitland, G. D. 1992. Neurolmusculoskeletal Examination and Recording Guide, 5th edn. Adelaide: Lauderdale Press Maitland, G. D., Hengeveld, E., Banks, K. & English, K. 2001. Maitland's Vertebral Manipulation, 6th edn. Oxford: Butterworth-Heinemann Sahrmann, S. A. 2001. Diagnosis and Treatment of Movement Impairment Syndromes. St Louis: Mosby Salter, R. 1989. The biological concept of continuous passive motion in synovial joints, the first 18 years of basic research and its clinical application. Clinical Orthopaedics and Related Research, 242, 1 2-25 The Age. 1982. 21 August The Shorter Oxford Dictionary. 1980. The Shorter Oxford Dictionary on Historical Principles, 3rd edn. Oxford: Oxford University Press Wells, P. 1988. The Maitland Concept, Course notes assessment, examination and treatment by passive movement: The Maitland Concept, level 2. Switzerland: Bad Ragaz Wells, P. 1996. The Maitland Concept, Course notes: The Maitland Concept of Manipulative Physiotherapy, level 2a. UK: Rotherham WPCT. 1999. Description of Physiotherapy. 14th General Meeting, May 1999, Item 1 . 1 . Wright, A. & Sluka, K. 2001. Non-pharmacological treatments for musculoskeletal pain. Clinical Journal of Pain, 17, 33--46

25

Chapter 2

Mobilization and manipulation definitions. desired effects. role in rehabilitation and evidence base

THIS CHAPTER INCLUDES:

•

Definitions of mobilization and

•

•

Key words for this chapter

•

A glossary of terms for this chapter

•

The use of passive movement in clinical practice

•

The role of mobilization and manipulation in rehabilitation

manipulation •

Evidence-based practice and mobilization I manipulation.

The clinical 'desired effects' of mobilization I manipulation

KEY WORDS

passive movement. desired effects,

Mobilization, manipulation,

evidence-based practice.

GLOSSARY OF TERMS Activity intolerance - an individual's intolerance of movements or activities which they know to be painfully unacceptable or which they fear will harm them further. Chronic pain - pain which persists beyond the expected natural history of a condition or disorder. Alternatively, pain which accompanies conditions which are ongoing or recurrent such as rheumatoid arthritis or osteoarthritis. Deconditioned tissue - structures of the movement system such as articular cartilage, capsule and ligaments, tendon, contractile elements of muscle and neural connective tissue which have been underused functionally and lost their tolerance to activity

due to immobilization, chronic disuse or acquired loss of trust in movement. Desired effects - the effects which

Homeostatic facilitation - the context of rehabilitation of movement where the desired effects of treatment are to

are desired of a mobilization I

maintain ideal movement, tissue

manipulation technique, based

nutrition, tissue metabolism and

on what the patient wishes

structure or to restore them to an

treatment to achieve and the

ideal status.

role which mobilization and manipulation might play in this. Fear avoidance - due to current and

Hyperalgesia - an increased pain response to a painful stimulus. This may be primary (at the site of actual or potential tissue damage)

past pain experience, and

or secondary (at a site removed

misunderstandings about pain and

from the actual or potential tissue

tissue healing, a patient may be frightened of moving normally for fear of causing harm or being in

damage). Hypoalgesia - a reduced pain response to a painful stimulus.

pain. Consequently, patients will

Hypoalgesia is one of the proposed

avoid movements or situations of

pain-modulating effects of

which they are fearful. The result is often maladaptive movements

mobilization techniques. Joint signs - the abnormal physical

which compound and delay

findings or movement impairments

recovery.

which can be detected by a

26

M AITLAND'S PERIPHERAL M ANIPULATION

physiotherapist during passive

physiotherapist, anaesthetist,

movement of a joint. Such joint

employment agencies, clinical

signs include movement-related

psychologist, and family and

carried out in such a way that

pain (P), spasm-free resistance or

friends acting in a coordinated

periods of treatment and the

effort to achieve maximum

effects of treatment can be

potential recovery.

compared with periods of no

stiffness (R) and protective involuntary muscle spasm

(5). The

relationship of joint signs with

Single instance case study - the use of single patient case studies

Nociception - the experience of pain

joint passive movement can be depicted on a movement diagram.

treatment. The response of the

which is being generated at or near

patient in the comparable periods

the site at which it is felt and is

can go some way in determining

due to mechanical, chemical or

the effectiveness of a particular

the scope of practice of

ischaemic stimulation of

treatment in a qualitative

physiotherapy in ensuring that,

nociceptors in the injured or

framework. A number of single

through therapeutic intervention,

stressed tissue.

instance case studies can be

Maximizing movement potential -

each individual patient has the

Randomized controlled trials (RCT) -

analysed statistically in order to

opportunity to attain as much

scientific experimentation with the

enhance or reject the validity of a

functional movement as possible,

aim of answering a particular

treatment approach.

given their condition and health

scientific question through null

status.

hypothesis, randomized or double

Multidimensional

- (1)

Conditions

Sympathetic maintained pain - pain which persists because of

blinded allocation of representative

abnormally high or prolonged

which are multifaceted in terms of

populations, ethical and

output of sympathetic activity.

their presentation. For example, a

reproducible methods free of

patient with chronic frozen

contaminating variables, results

of research, the statistical analysis

shoulder may have developed

which can be statistically analysed

of all available quality studies or

Systematic reviews - in the context

stiffness in many of the joints of

and conclusions which may or may

trials on a particular subject,

the shoulder complex, the pain may

not answer the question asked.

modality or intervention. Such

have had both acute and chronic

Shaft rotation - mobilization

qualities to it and the pain may be

studies can then be rated and the

techniques whereby the movement

overall scientific acceptability of

compounded by fears that there

of rotation is performed about an

the subject, modality or

may never be full recovery. Thus a

axis which is along the shaft of a

intervention can be reported.

recognition should be made that all

bone. Generally this relates to long

the dimensions of the patient's

bones such as the humerus and

disorder must be addressed to

femur but can also be applied to

approach on a patient. If it does

bones such as the navicular. The

not work the approach can be

dimensional or multiagency

shaft rotation will produce roll,

refined either until it is abandoned

approaches to dealing with

spin and slide at the joint surfaces.

as ineffective or until it achieves its

conditions such as chronic low

In treatment, therefore, shaft

purpose.

maximize recovery.

(2)

Multi

back pain. In such cases the patient

rotation is often used in the same

may need the services of their GP,

way as accessory movements.

Trial and error - the process of using wise actions to try out a particular

DEFINITIONS OF MOBILIZATION AND MANIPULATION

manual traction, joint manipulation (short or long

The word 'manipulation' derives from the Latin word

lation which best suit the Maitland Concept are:

lever dynamic thrust) and joint mobilization'. The specific definitions of mobilization and manipu

manipulare meaning to handle, the use of the hands in a skilled manner, or skilled treatment by the hand.

•

The term 'manipulation' can be used loosely in clin

techniques include soft tissue manipulation, massage,

passive movements performed in

within the control of the patient so that movement can be prevented if the patient so chooses.

(1992) states that 'Many techniques

are considered manual therapy procedures and these

-

such a manner and speed that at all times they are

ical practice to mean passive movement procedures of any kind. DiFabio

Mobilization

•

Manipulation

-

(1) A passive movement consisting

of a high velocity, small amplitude thrust within

Mobilization and manipulation

27

J the joint's anatomical limit performed at such a speed that renders the patient powerless to prevent it. (2) Manipulation under anaesthetic (MUA) is a medical procedure performed with the patient under anaesthetic and used to stretch a joint to restore a full range of movement by breaking adhesions. The pro cedure is not a sudden forceful thrust as mentioned in the preceding definition, but is done as a steady and controlled stretch. This procedure can also be performed on the conscious patient. If adhesions are torn during mobilization techniques then the tech nique may be classed as a manipulation even though a sudden thrust has not been used.

Mobilization

Types of mobilization include passive oscillatory movements (two or three per second) of small or large amplitude, applied anywhere in a range of movement, typically for anything between 30 seconds and several minutes depending on the response and desired effects, or sustained stretching with or without tiny amplitude oscillations at the limit of the range. The style of mobilization can be refined further to include different rhythms of mobilization such as slow/ smooth or quick/staccato. These oscillations or sustained stretches may consist of accessory movement, shaft rotation, physiological movement and combinations of any of these.

Accessory movement Accessory movements are movements that a person cannot perform independently but can be performed on them by someone else (such movements primarily constitute the roll, spin and slide movements of joints described in Gray's Anatomy (Williams & Warwick 1980). However, it is worthy of note that accessory move ments can be performed on muscle tissue (Hunter 1994) and peripheral nerves (Butler 2000). The importance of restoring accessory movements to their pain-free, stiffness-free and spasm-free state cannot be underesti mated as the quality of physiological movement and therefore ideal functioning of the limbs is often depend ent on the quality of the accessory movements.

Physiological movement Physiological movements are those movements that a person can also carry out actively.

Movement combinations These include: • accessory movements/shaft rotation in the neutral range and symptom-free position or in any physiological position including the end of the available physiological range • physiological movements singly or in combination with other physiological movements or at the end of other physiological movements (e.g. glenohumeral medial rotation in extension and adduction) or into functional corners such as the shoulder quadrant or knee extension abduction/adduction • techniques which involve combining accessory and physiological movements at the same time (e.g. extension of the first carpometacarpal joint with a posteroanterior accessory movement) • any of the above performed while the joint surfaces are distracted/kept apart or compressed/squeezed together (note that distraction and compression can be used for examination or differentiation purposes as well as for treatment) • passive movements (often sustained) performed in functional weight-bearing positions or in conjunction with active functional movement (such as sustained transverse movement of the patella during active knee flexion and extension) (Fig. 2.1). • accessory or physiological movement performed in conjunction with relevant variations of neurodynarnic test positions, such as mobilization of the head of radius in the ULNPT position biased towards the radial nerve (Fig. 2.2). • the extent of one's logical and lateral thinking capacity is the only barrier to the potential possibilities for mobilization. Other definitions which may be relevant are joint move ment, neurodynarnics and neural movement.

Joint movement Shaft rotation Passive rotation of bones about their long axis gives rise to shaft rotation and accompanying accessory movement within a joint. Although in many cases a physiological movement, shaft rotation is often used to fulfil the same purpose as accessory movement.

Joint movement includes all of the intra-articular struc tures, the capsule and all of the non-contractile tissues which move during every passive and active movement of a joint. The 36th edition of Gray's Anatomy and particu larly the section on arthrology (pp. 420-503; Williams & Warwick 1980) is among the best references related to

28

MAITLAND'S PERIPHERAL MANIPULATION

current knowledge of joint structure and function. It is important to glean information fundamental to exami nation of joint disorders and treatment by mobilization/ manipulation from such texts. It is also important that physiotherapists treating joint disorders are well versed

in musculoskeletal anatomy as well as the principles of movement of each joint, the neurophysiology related to pain with joint movement and the part played by muscle spasm.

Neurodynamics Neurodynamics is the interaction between mechanical and phYSiological functions of the nervous system. Pathoneurodynamics may be used to describe the com binations of pathomechanical and pathophysiological events in neuromusculoskeletal disorders. 'Neuro dynamic testing' (straight leg raise, passive neck flexion, prone knee bend, slump, upper limb neural provocation tests), therefore, is the preferred way of describing how examination may evoke both mechanical and physio logical reactions in the nervous system (Shacklock

1995). Neural movement Neural movement relates to nerves and their infrastruc ture as well as the connective tissue which supports them and the connective tissue of the vertebral canal, foraminal canal and peripheral tissues through which they pass. The physiotherapist dealing with neuro musculoskeletal disorders should be well versed in: •

• •

Figure 2.1 Transverse movement of the patella (during active knee flexion and extension).

•

the courses of peripheral nerves in the head and limbs where they are superficial and therefore palpable the sites throughout their course where they are vulnerable to mechanical forces their relationship to and influence on the functioning of joints and muscles during daily life and during examination and treatment by manipulative physiotherapy.

THE USE OF PASSIVE MOVE MENT IN CLINICAL PRACTICE

Figure 2.2 Posteroanterior mobilization of the head of radius in the ULNPT 2B position (radial nerve biased).

Passive movement is defined as any movement of any part of one person which is performed on that person by another person or a piece of equipment; continuous passive motion (CPM) and machine traction, therefore, are procedures which also fall within the scope of the passive movement definition. Maitland (1987) points out that passive movement does something different from any other type of move ment in its clinical and therapeutic effects. Frank et al (1984) note that 'a spectrum of passive motion has evolved for various clinical purposes, includ ing diagnosis, correction of deformities, mobilization of stiff joints, stimulation of joint healing, neuromuscular

Mobilization and manipulation

re-education and prevention of immobilization compli cations'. They also note that 'clinical and experimental

THE CLINICAL 'DESIRED EFFECTS' OF MOBILIZATION AND MANIPULATION

evidence supports the probable effectiveness of passive joint motion on joint and tissue levels, but without a

Mobilization and manipulation show their best effects

better qualitative understanding of the mechanisms of

when directed at movement-related disorders, i.e. move

action, dose responsiveness, specific tissue effects and,

ments or positions that repeatedly cause the patient to

most important, their controls, passive motion will con

have symptoms and functional activity limitations.

tinue to be used suboptimally with inconsistent results. When these clinical and research deficiencies are cor rected, passive motion will attain its proper place as a powerful and reliable orthopaedic too!.' Salter

(1989) hypothesized, after 18 years of clinical

observation and experimentation, that CPM should

Restoring structures within a joint to their normal position or pain-free status so as to recover a full-range painless movement

A tear in a meniscus of the knee or damage to the menis

enhance the nutrition and metabolic activity of articu

cus in the temporomandibular joint will result in the

lar cartilage, stimulate regeneration of cartilage and

patient having a restricted range of movement which

accelerate the healing of both articular cartilage and

will be painful and limited in range in some directions. Passive movement treatment aims to alter the position

periarticular tissue.

(1995) advocates the use of passive

of the menisci so that the range of movement of the joint

mobilization to 'increase the flexibility of morphologi

becomes full and pain free. When pain-free movement

Van Wingerden

cally and functionally adapted connective tissues like

has been restored, the next step is to prevent recurrences

capsule, fascia, ligaments and retinacula'.

by exercise designed to maintain ideal alignment and

(1994) reminds us that if soft tis

functional stability of the joint. This aims to increase the

sues are not subjected to compression, shear and ten

strength, endurance and speed with which the muscles

Likewise, Hunter

sion forces, as in everyday life, the tensile strength of

can contract to control the movement. In the case of the

the tissue will decrease. Therefore, 'the key aims in the

temporomandibular joint, the joint may need to be pas

treatment of soft tissue lesions is to encourage the

sively mobilized in a variety of physiological directions

damaged tissue to regain its tensile strength as rapidly

while being distracted. This should be continued until

2.3). Subsequently,

as possible, and specific graded manual therapy tech

the desired effect is achieved (Fig.

niques can achieve this aim' during the various stages

exercises which facilitate the active control of jaw move

of the healing process. Butler

ments can be introduced (Rocabado 1985) (Fig.

2.4).

(2000) places passive mobilization in context

when referring to its role in the management of pathoneurodynarnic problems by suggesting that 'If passive mobilization is combined with or replaced by active educational-based approaches then this may be a better approach especially for chronic pain sufferers . .. .

Stretching a stiff joint to restore range Passive movement techniques can be used to stretch a stiff pain-free joint to improve the range of movement until it reaches the stage of being functional once more.

Passive movement in its various forms may assist restoration of tissue health and the movements may provide for more acute patient memory of the prescrip tion for an active treatment.' Frank et al

(1984) further note that there are poten

tial abuses of passive motion. These include causing additional damage, reinforcing nociceptive or sympa thetic activity, vascular embarrassment, nerve dam age, mobilizing unprotected joints and stretching the wrong tissue. Therefore careful consideration must be made about the force, direction, speed and duration of the passive movement procedure. Shekelle

(1994) emphasizes that 'the clinical res

ponse to [spinal] manipulation can be measured and quantified and the presence or absence of clinical bene fit should be the ultimate test of manipulation, rather than an understanding of the exact pathophysiological mechanisms'.

Figure 2.3 Temporomandibular joint distraction (longitudinal caudad movement).

29

30

MAITLAND'S PERIPHERAL MANIPULATION

Figure 2.5

Talocrural transverse movement in dorsiflexion.

Figure 2.4 Exercise to facilitate the active control of jaw movements.

The movements used should be those described in Gray's Anatomy (36th edn, Williams & Warwick 1980), Le. treatment movements which include the roll, spin and slide which are normal for that particular joint. There are other movements described in the text which are used to increase range. They should be performed as small strong oscillatory movements at the rate of two or three per second for up to 2 minutes (Van Wingerden 1995). The stretching can be repeated sev eral times or until the desired effect has been achieved. Passive movements performed in this way will pro vide the manipulator with more accurate 'feel' of the resistance than would be possible with a sustained stretching technique. When the patient experiences considerable pain during the stretching, the suggested oscillatory move ment must be performed much more slowly; there may even be no oscillation, but rather a slow and grad ually increasing movement stretching tight structures. When pain reaches a peak the movement is retained at that position, allowing time for the pain to decrease before attempting to take the movement further. It may even be necessary, if the intensity of pain sharpLy increases, to quickly slacken the pressure slightly so as to be able to sustain a holding position with an accept able degree of pain and to wait for the pain to decrease before attempting to take the movement further. The following statement is important to make at this stage, because it differs from the opinions and philosophies of other manipulators, yet is primary to the concept of this text:

When endeavouring to restore the patient's ability to achieve a certain movement or position (which may require restoration of more than one direction of

Figure 2.6 Inferior tibiofibular anteroposterior movement in eversion (can also be done in inversion).

physioLogicaL movement) two groups of movement (not just one) must be stretched. The first group consists of those physioLogicaL movements which are restricted (e.g. talocruraL dorsiflexion and inversion); the second group consists of the accessory movements that exist at the Limit of the restricted physiological ranges of movement. These accessory movements will also be restricted in their range in this position of the physiological range - for example, talocrural posteroanterior and transverse movement at the limit of dorsiflexion (Fig. 2.5), anteroposterior movement of the inferior tibiofibular joint at the limit of talocruraL eversion (Fig. 2.6). It is the first group of this section to which other manipu lators have taken exception, yet it is a primary element

Mobilization and manipulation

which this book embraces. In the case of the example given, to enable the patient to walk up hills and on uneven ground without experiencing pain and stiffness in the ankle, although stretching accessory movements may gain an initial improvement, this should be fol lowed up by stretching the physiological movements to achieve full restoration of range. Stretching

Mobilizing techniques to stretch have three other desired effects: • •

•

slow passive movement to retain range stretching to increase an otherwise normal range to make it more mobile (perhaps some would call it making the range hypermobile) stretching to lengthen contracted, fibrosed or shortened muscle tissue.

Stretching to retain range The thought behind this statement is really using the word 'stretch' incorrectly. When a patient is in an active phase of any of the arthritides, there is value in endeav ouring to prevent losing range of joint movement.

However, this should not be done at the expense of exacerbat ing the pain or prolonging the inflammatory response. The movement, therefore, should be neither oscillatory nor repetitive. The movement should be a single movement in the functional directions that are important for the patient's daily needs. Obviously the treatment move ment should not be forceful. Similarly the movement should be performed very slowly and well within the patient's comfort to achieve its desired effect of retain ing the range.

Stretching to increase the normal range There are many fields of endeavour (e.g. sport and dance) where it is necessary, for participants who have special potential, to have a greater range of movement than is normal for the average person. For a ballet dancer to achieve recognition as a good dancer, good 'turn-out' is essential. Some young dancers have this either naturally or gain it by their exercise and training programmes. Others may have good range for other aspects of dance such as 'point' yet be lacking in 'turn out' despite persistent training. When such a person has very good potential in the other requirements of a professional dancer, passive mobilization by a physiotherapist can be utilized to gain range in 'turn out'. When this is applied, the dancer's active training, functional stability of the newly acquired range and warm-up/warm-down must be coupled with the

Figure 2.7 Transverse mobilization of gastrocnemius in a stretch position.

stretching treatment. Additionally, the dancer should not experience any latent pain reaction from treatment (Chapter 14).

Stretching contracted, fibrosed or shortened muscle tissue In these stated circumstances, the movement used should be one that stretches or lengthens the muscle. This will primarily be a physiological movement but be aware that the muscle tissue may need to be stretched in other planes to achieve full restoration of range (Hunter 1994). For example, having tom a gastrocnemius muscle a dancer may need to be treated with specific soft tissue mobilization or passive stretching of the muscle in directions other than the lengthening direction. One treatment technique may be to stretch the muscle func tionally and then apply a specific passive transverse stretch at the site and in the direction of the injury in order to regain full range and function in the muscle. Consequently the risks for recurrent injury will be reduced (Fig. 2.7). Other forms of manual physiotherapy treatment should also be used to both assist in the lengthening of

31

32

MAITLAND'S PERIPHERAL MANIPULATION

[ the contracted tissue (e.g. proprioceptive neuromuscu

or emotional/psychological perceptions of pain. Other

1997) and to restore

therapeutic strategies or treatments need to be employed

lar facilitation, PNF) (Pitt-Brooke

the muscle to its preferred role as a mobilizer or a sta

to deal with these factors.

(2001) describes in detail the meth

If a patient has an active osteoarthritis in a joint, mobi

ods of achieving this and therefore such techniques are

lization will not improve the pain but anti-inflammatory

bilizer. Sahrmann

medication or intra-articular injections may. However, if

not included in this text.

the diagnosis is osteoarthritis, passive movement should always be a foremost consideration because symptoms

Relieving pain by using special techniques

may well be mechanical or movement related, being

A patient may have considerable joint pain which limits

superimposed onto previous joint changes. It is in this

active movement, although there is no loss of passive

area of determining what is the best thing to do to help a

range. In other words, if the examiner were prepared to

patient with distreSSing, yet not disabling, symptoms

ignore the patient's pain and press on regardless, the

that the physiotherapist has an important role to play in

range of movement would be full in all directions

conjunction with the referring medical practitioner. The

though obviously this would be extremely painful.

patient with post-traumatic arthritis and an exacerbation

Mobilization has a definite part to play in the treatment

of symptoms without obvious signs of inflammation is a

of these painful joints if it is identified that the joint or

good example of this.

tissue being moved

Most patients referred by doctors to physiotherapists

is the source of the patient's pain.

Within these joint disorders there is usually a degree

for treatment of musculoskeletal disorders do so

inflammation,

the cause of which is not always evi

because of pain rather than stiffness. Joints should be

primary

tested for range and pain, muscles should be tested for

hyperalgesia and symptoms produced predominantly by nociceptive mechanisms (Wright & Sluka 2001). The

tested for range and pain. If examination is carried out

of

dent. This will be accompanied by a degree of

length, strength and pain and neurodynamics should be

inflammation may be caused by systemic processes

correctly it will be found that most neuromusculoskele

such as rheumatoid arthritis or its variants, or it may be

tal disorders have more than one relevant movement

as a result of a mechanical or movement-related irritat

component and each of these components will have,

ing origin such as strain or sprain of the joint tissues.

within them, a pain component and a stiffness compo

The latter can be successfully treated by special passive

nent. Spasm may also be present and this may cloud the

movements; if the passive movement treatment elimi

assessment, particularly if it prevents movement early

nates the movement-related irritating cause, the patient

in the range. These components can be classed as 'joint

will lose the pain.

signs' which are abnormal physical findings of pain and

The patient may have more than one cause of inflam

stiffness, or protective involuntary muscle spasm pro

mation, primary hyperalgesia and nociception occur

duced during passive testing of a joint or for that matter

ring in the joint. For example, it is common for a patient

other neuromusculoskeletal structures. The interrelation

to have osteoarthritis producing an inflammatory reac

ship of 'joint signs' should be reCOgnized, as should their

tion superimposed upon a mechanical or movement

independence. All physiotherapists have treated a stiff

related factor provoking further inflammation. When

painless joint; they will also have treated patients with

this is so, passive movement treatment can effect a

pain associated with stiffness. However, it is surpris

degree of improvement commensurate with the extent

ing how few physiotherapists recognize the group of

of the movement-related cause.

patients who have painful joints that are not limited by

At the first consultation the clinician is aware that it is impossible to determine whether a combination of

stiffness. It is important to be aware that (a) such patients

do exist and (b) that they can be treated by special passive

factors is causing the painful reaction. However, if a

movement techniques directed at the joint pain. When

short trial of controlled passive movement is adminis

this concept of treating the pain component is under

tered, the extent of the mechanical or movement-related cause can be determined, in retrospect,

by assessment.

If

stood, accepted and used, then treatment by manipula tive physiotherapy can be utilized to its fullest extent.

the treatment lessens the patient's pain and improves range then at least part of the patient's pain must have been mechanical or movement related in origin. How ever, if there is no improvement, there is no mechanical factor to the pain and it may be being generated by systemic/autoimmune inflammatory factors or by other

Restoring neurodynamics to their ideal state to provide an ideal environment of mobility within which the nervous system can function optimally Consideration should be given to passive mobilization

mechanisms of symptom production such as referred

techniques performed with an emphasis on recog

pain, neurogenic inflammation, central/higher centre

nized neurodynamic test positions. In this way ranges

processing mechanisms, sympathetic maintained pain

of movement may be increased to achieve the desired

Mobilization and manipulation

effect of providing enough mobility in the limbs and trunk so that the nervous system can function opti mally both mechanically and physiologically. Neuro genic massage and mobilization of tissue surrounding nerves may also go some way to helping achieve this desired effect. Butler (2000) in his book The Sensitive Nervous System comprehensively describes such tech niques in detail and these are therefore not included in this text. THE ROLE OF MOBILIZATION AND MANIPULATION IN REHABILITATION

Sports injuries and trauma

Sports injuries can be considered in two categories: the 'over-use', 'misuse' or 'abuse' category, and the trauma category. Patients who have their cause in the over-use, misuse or abuse category form a special group because people competing in any sport subject their bodies to the maxi mum level they can achieve to fulfil their genetic poten tial. By continuous training and competing they may place a greater stress on some structures than they are able to stand. This extra stress superimposed on an 'overuse' situation will result in symptoms. The treat ment of the symptoms requires many forms of physio therapy of which manipulative physiotherapy is one. It is not necessarily the main one, but it is an aspect of overall management which is neither adequately recog nized nor used. However, it does play a major role in prophylaxis. The trauma category relates to injuries caused by blows and falls, particularly in the heavy contact sports. Other traumas under this heading include injuries sustained as a result of car accidents, machin ery and other industrial-related injuries and even post surgical trauma. All comprise damage to what may otherwise have been healthy tissue. As with the first group of sports injuries, many forms of phYSiotherapy, including manipulative phYSiotherapy, have a role to play in treatment. What many people do not seem to realize is that passive movement treatment can achieve desired clinical changes which other forms of physio therapy cannot. For example, achieving maximum range of joint movement and muscle length, achieving best results from the effects of pain inhibition, and helping to clear a protective muscle spasm may be best attained by mobilization. Creating an ideal environment for healing

Early movement after injury appears to be what is needed to achieve the best possible recovery (Butler 2000). This may well include passive mobilization in

conjunction with advice on active exercise and other forms of physiotherapy. Quite often patients are reluc tant to move actively after an injury. Early use of gentle passive movement may be the means by which an ideal functional environment can be maintained. Passive movement will also create an ideal environment for the damaged tissue to maintain adequate nutrition and metabolic activity (Salter 1989). The hypoalgesic and sympathetic effects of mobilization (Sterling et al 2000) will also provide much needed pain relief and influence the immune responses to injury (Gifford 1997). Complementing the healing process

Rehabilitation after injury or a prolonged inflammatory response, as in a 'flare-up' of arthritis, needs to be tai lored to the injury/inflammatory response and to the functional requirements of the patient. The desire to restore pain-free, stiffness-free and spasm-free full range movements may be enhanced by graded passive stretch ing to influence collagen alignment and tissue compli ance (Frank et al 1984) and to maximize the tensile strength of the damaged tissue (Hunter 1994). Making sure that the joint's 'functional corners' are pain-free and full range, for example, may well enhance the ability of the muscles to regain their normal strength and endurance by ensuring that residual swelling or pain is not inhibiting the neurophysiological reflex arc. Examples of this phenomenon may be seen in patients who only regain full strength in the quadriceps muscles when the post-meniscectomy knee can fully extend without pain or the improvement in the rotator cuff muscle strength after mobilization and stretching of the shoulder into the 'quadrant' or 'locking position' (Chapter 11). Kick starting the healing process by removing barriers to recovery

Patients often consult phYSiotherapists or are referred to physiotherapists long after an injury because their symptoms and functional restrictions persist - they say that they just do not seem to be getting any better. It is therefore the task of the physiotherapist to identify and deal with the reasons for lack of progression of the disorder through its natural history. There may well be cognitive or emotional reasons for this which need to be considered but there are also likely to be move ment impairments which need to be treated in order that the healing process may recommence. In this way the symptoms and restrictions can resolve. Take for example the footballer who has strained his groin making a tackle, yet several weeks after the injury he still experiences pain in his groin and cannot run flat out. A thorough neuromusculoskeletal examination may

34

MAITLAND'S PERIPHERAL MANIPULATION

[ reveal the injury has left him with minor but very painful limitation of hip flexion/adduction (Chapter 14). After one or two treatment sessions of sustained stretching with minimal oscillations into hip flexion/ adduction he reports that he was very 'sore' in his groin for several days after treatment but he feels that this has done the trick and his pain has gone and he can run faster. The physiotherapist should not be happy with this until any muscle imbalance, neurodynamic restric tion, spinal or other lower limb impairments have been identified and dealt with, thus making sure that the patient can maximize his movement potential. Retain an optimal functional environment to attain maximization of movement potential

This may apply to the sportsman who is involved in full contact sports or who pushes himself to the limit and is constantly injuring himself, or to the patient with arthritis who experiences repeated or periodic 'flare-ups' of the condition. Such patients may need constant reappraisal of their ranges of movement in order to retain an optimal level of mobility for their functional requirements. Take for example the javelin thrower who is repeatedly exposing his elbow to 'overuse' and 'abuse' resulting in stiffness and pain in elbow extension abduction/ adduction and flexion adduction/ abduction (Chapter 12). Likewise, the patient with rheumatoid arthritis whose propensity to rest very painful joints in their most comfortable posi tion during an exacerbation of their condition may well lead to the development of joint contractures. The extended role of passive mobilization

Complementing proprioceptive rehabilitation after injury and enhancing active rehabilitation programmes Clinical science has shown that proprioceptors within joints are stimulated when passive movement is applied to the joint (Zusman 1986). Therefore passive movement may be a useful adjunct to rehabilitation which emphasizes the need for sound proprioceptive recovery. In rehabilitation after cruciate ligament repair of the knee, Barnett (1991) has highlighted the impor tance of proprioceptive training in the functional recov ery of patients undergoing cruciate ligament repair. Early movement, including passive movement, in con junction with recognized protocols of proprioceptive re-education may be of value.. Likewise, Butler (2000) suggests that passive mobilization may be of value as a means of providing input to enhance the full potential of active functionally based approaches. For example,

a patient may need to relearn the ideal position of the scapula as part of the process of regaining scapulo humeral functional stability. By repeatedly moving the scapula passively the therapist will help the patient to sense the ideal position which can then be reinforced actively. Complementing reconditioning of tissues and regaining trust in movement Other uses of passive mobilization include: •

•

•

complementing the reconditioning of tissues of the movement system after prolonged periods of disuse complementing the process of regaining trust in movement which may have been lost due to fear avoidance or activity intolerance complementing the process of gradually exposing the patient with chronic pain to movements which they do not trust.

Passive mobilization techniques performed in a skilled manner may be a means of introducing deconditioned tissues to movement. Structures that have not been used maximally for a long period of time may need to be gradually reintroduced to the forces which they need. Take for example the patient who has been in a coma for several weeks on an intensive care unit after contracting encephalitis. Afterwards the patient's shoulders are too sensitive and painful to move actively but passive mobi lization techniques allow the shoulders to be moved in a way that begins the reconditioning process. Active movement can then be introduced when the patient is ready. Passive mobilization techniques may also be one of the multidimensional strategies used by physiothera pists in the management of chronic pain disorders (Waddell 1998). However, the physiotherapist must take great care in choosing the correct patients, and selecting the timing and the duration of such interven tions. Passive mobilization techniques may be one method of enabling the patient with chronic pain to regain trust in movement that has been avoided because of fear of damage or fear of exacerbating pain. For example, pain-free passive mobilization techniques which are modifications of upper limb neurodynamic tests may be used to introduce the patient to pain-free movement in a limb that is chronically painful and sen sitive to movement after a severe nerve root entrap ment. If the therapist is skilled in handling the very painful limb the patient may be helped to regain trust in movement and trust in the therapiSt. The patient is then more likely to regain trust in their active functional movements.

Mobilization and manipulation

Passive movement treatment as a means to an end Passive mobilization techniques should be used clin ically as a means to an end, whether to regain optimal ranges of movement, or to ensure that a disorder pro gresses through its natural history in the best way, or to complement rehabilitation programmes. Passive movement techniques, therefore, should be part of the dynamiC, multidimensional process of 'homeostatic facilitation'.

EVIDENCE-BASED PRACTICE AND MOBILl ZATION/ MANI PULATION

There are many variations of the definition and descriptions of evidence-based practice or evidence based medicine. Evidence based medicine is:

. . . the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. Sackett et aJ

considered along with all the clinical information gath ered about the patient ill order to make the best thera peutic intervention for that person (Fig. 2.8). Scope of practice

Before discussing the evidence-base for mobilization and manipulation in clinical practice it is worth placing manipulative physiotherapy within the context of the physiotherapy professions as a whole. In the United Kingdom the Chartered Society of Physiotherapy Rules of Professional Conduct, Rule 1 , Scope of Practice (Bazin & Robinson 2002) states that:

Physiotherapy is an applied science, which possesses its own knowledge base, its own educational methods and practical application based on that knowledge. This is supported by the best available evidence of effectiveness. Physiotherapy research links theory and developing practice. This practice has, at the same time, retained its links to three core skills: •

• •

(1996)

In taking a broader, more realistic and comprehensive view of evidence-based practice, we define evidence as knowledge derived from a variety of sources that has been subjected to testing and has been found to be credible. Higgs & Jones (2000) The symbolic permeable brick wall separates the theo retical compartment from the clinical compartment in the physiotherapist's mind (Maitland 1991). Evidence based practice is essentially clinical decision making based on the philosophy of the symbolic permeable brick wall (see Fig. 1.3), i.e. all theoretical knowledge is

manual therapy (including massage, mobilization and manipulation) electrotherapy (electrophysical agencies) exercise and movement.

Mobilization and manipulation are well-established terms and physiotherapeutic core skills. However, there is still a mismatch between what highly trained and experienced clinicians experience every day (i.e. the clinical effectiveness of appropriately applied manipu lative physiotherapy) and the lack of clinical science and mature research evidence to support this. The lack of evidence and lack of appropriate patient-centred research focusing on the process rather than the modality does not mean that the use of mobilization and manipu lation within the physiotherapy profession should be used less or that training physiotherapists to a high

Figure 2.8 Evidence-based practice applied to the symbolic permeable brick wall.

Theoretical Compartment

Research evidence

- Clinical science

o

o

�

o

o

�

35

36

MAITLAND'S PERIPHERAL MAN IPULATION

L level of manipulative physiotherapy skill should not be important. In fact the physiotherapy profession should strive harder to answer the many research questions which still need to be asked about this physiotherapeu tic core skill. The evidence about mobilization and manipulation which is currently available can be categorized into evidence from: • • • • • •

systematic reviews randomized controlled trials clinical science single instance case studies expert opinion trial and error - within the safety margins of professional scope of practice.

Systematic reviews Systematic reviews and meta-analysis are considered to be the most reliable form of scientific evidence avail able. Their limitations are clear in that often the trials which they review are considered to be of poor quality in terms of their design and the statistical analysis of their results. Systematic reviews of mobilization and manipula tion are rarely conclusive one way or the other. Trials of mobilization and manipulation are fraught with difficulty in terms of population size, ethics, ran domization, reliable method and blinding. This proba bly means that such forms of scientific scrutiny are not suitable for patient-centred and process-orientated, rather than modality-orientated application of profes sional skills in the clinical setting.

Randomized controlled trials (Wrig ht Et Sluka 200 1 ) The jury i s still out! Manipulation of spinal joints has been the subject of many randomized controlled trials (RCTs). However, there have been few RCTs which specifically investi gate joint mobilization. Likewise, there is a lack of studies addreSSing the use of manipulation or mobiliza tion in treating peripheral joints. Early meta-analyses suggested beneficial effects of spinal manipulation and mobilization on measures of pain, flexibility and phys ical activity, although the effects were considered to be short term. Mobilization and manipulation appear to elicit short term beneficial effects in the management of low back pain of less than 3 weeks' duration and are probably of short-term benefit in the management of acute and sub acute neck pain and muscle tension type headaches.

In the context of rehabilitation, short-term relief of symptoms will enhance the patient's ability to stay active, on the one hand, and to help exercise pro grammes become more effective on the other. In this context, therefore, mobilization and manipulation become a means to an end rather than a quick fix.

Clinical science (Sterl ing et al 2000) Mobilization techniques applied to the cervical spine elicit concurrent changes in: • •

•

pain perception (hypoalgesia) autonomic function (increased skin conductance, decreased skin temperature) motor function (facilitation of deep neck flexor muscles).

These patterns of change are similar to the pattern of change elicited by direct stimulation of the periaque ductal grey region of the midbrain. Mobilization tech niques appear to exert a predominant influence on mechanical nociception (via dorsal periaqueductal grey modulation) rather than thermal nociception.

Single instance case studies Riddoch and Lennon (1991) have suggested that the single instance case study method of research is valid as long as the number of case studies related to a partic ular approach are sufficient to stand up to statistical analysis. Case studies in isolation have no value as research evidence but are of great value for other rea sons. Presentation of case shldies where manipulative physiotherapy has been used can be valuable in high lighting management strategies for some recognizable syndromes such as shoulder impingement or osteo arthritis of the hip. Discussions can provide useful learning opportunities about the selection and progres sion of mobilization techniques. There may also be opportunities to develop further research questions about the application of manipula tive physiotherapy to certain conditions. In a recent clinical seminar on anterior knee pain at a hospital in the UK a case study was used to emphasize the need for the physiotherapist treating such conditions to explore all avenues of therapeutic intervention. Such avenues included assessment of alignment faults in the lower limb, neurodynarnic evaluation, and hip and spinal examination as well as attention to the local structures around the knee. Consequently, a participant of the seminar went away, thought about her clinical practice for such conditions and applied some of the informa tion she had received. The result was that the next

Mobilization and manipulation

patient she saw with anterior knee pain, a 12-year-old girl, was successfully treated and managed using strate gies which previously were not within the physiothera pist's clinical repertoire. Expert opinion Expert opinion may include opmlOns of respected authorities, based on clinical evidence, descriptive studies or reports of expert committees (Moore & Petty 2001). Physiotherapists are increasingly being called upon as expert wih1esses in courts of law. They are asked to apply their knowledge, experience and skill to give expert evidence which is often used as admis sible evidence in cases relating to, e.g. accidents or medical negligence. Likewise, on a day-to-day basis, clinicians are more likely to follow a course of action based on advice from a more experienced colleague than pure research evidence. Clinical experience and highly skilled practitioners are vital to the infrastruc ture of a profession with its own body of knowledge. The passing on of that knowledge and the develop ment of innovative ways of applying it are crucial to the physiotherapy profession. To use the term guru in its seemingly derogatory sense (Muncy 2000) rather than the term expert opinion is not at all helpful to the day-to-day practice of many physiotherapists who need accessible guidance to help their decision making and clinical skills develop with confidence. Trial and error Scientific discovery has often been made by mistake. Because of the infinite uses of mobilization and manipu lation (the technique is the brainchild of ingenuity) and because of the individuality of each patient, physio therapists are often forced to use trial and error to

solve a person's clinical problems. Trial and error in manipulative physiotherapy is often within good clin ical reasoning parameters. It is also within the scope of physiotherapy practice and it often leads to innovative practices. The key to the use of trial and error is in the demands of this concept for continuous and repeated assessment of the clinical effects of mobilization/ manipulation techniques. Trial and error, therefore, is a valid method of solving clinical problems. Sometimes it is the best way and sometimes it is the only way. Take, for example, a patient with pain around the wrist during extension of the wrist and hand. The sequence of examination, treatment and reassessment may go something like this: •

•

•

•

•

•

•

•

wrist extension is painful, extension of the radiocarpal joint is most painful (Chapter 13) stretching radiocarpal extension - pain stays the same stretching radiocarpal extension with the joint distracted - more pain created stretching radiocarpal extension with joint compression - pain stays the same posteroanterior mobilization of the lunate bone - pain stays the same posteroanterior mobilization of the scaphoid bone - pain becomes less anteroposterior mobilization of the lunate - pain also becomes less anteroposterior mobilization of the lunate with posteroanterior mobilization of the scaphoid - pain becomes much less.

Therefore, by a sequence of trial and error test treat ments a solution has been found to a movement-related painful condition by the making of deliberate choices.

References Barnett, D. S. 1991. Proprioception and function after anterior crudate reconstruction. British Journal of Bone and Joint Surgery, 73B, 833-837 Bazin, S. & Robinson, P., eds. 2002. Chartered Society of Physiotherapy. Rules of Professional Conduct, 2nd edn. London: CSP Butler, D. S. 2000. The Sensitive Nervous System. Adelaide: NOI Group Difabio, R. P. 1992. Efficacy of manuaJ therapy. Physical Therapy, 72, 853-864 Frank, c., Akeson, W. H., Woo, S. L- Y, Arniel, D. & Coutts, R. 1984. Physiological and therapeutic value of passive joint motion. Clinical Orthopaedics and Related Research, 185, 1 13-125

Gifford, 1. S. 1997. Pain. In Rehabilitation of Movement: Theoretical Basis of Clin ical Practice, ed. J. Pitt-Brooke, pp. 196-232. London: W. B. Saunders Higgs, J. & Jones, M. 2000. Clinical Reasoning in the Health Professions, 2nd edn. Oxford: Butterworth-Heinemann Hunter, G. 1994. SpeCific soft tissue mobilisation in the treatment of soft tissue lesions. Physiotherapy, 80, 1 5-21 Maitland, G. D. 1987. The Maitland Concept: assessment, examination and treatment by passive movement. In Physical Therapy of the Low Back, Vol 13, ed. 1. T. Twomey & J. R. Taylor, pp. 135-155. Edinburgh: Churchill Livingstone Maitland, G. D. 1991 . Peripheral Manipulation, 3rd edn. London: Butterworth-Heinemann

37

J

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MAITLAND'S PERIPH ERAL MANIPULATION

L Moore, A. & Petty, N. 2001 . Evidence based practice - getting a grip and find ing a balance [editorial]. Manual Therapy, 6, 195-196 Muncy, H. 2000. The challenge of change in practice. In Topical Issues in Pain 2, Biopsychosocial Assessment and Management, Relationships and Pain, ed. L. Gifford, pp. 37-54. Falmouth: CNS Press Pitt-Brooke, J., ed. 1997. Neuromuscular therapeutic techniques. In Rehabilitation of Movement: Theoretical Basis of CLinical Practice, pp. 361-399. London: W. B. Saunders Riddoch, J. & Lennon, C. 1991 . Evaluation of practice: the single case study approach. Physiotherapy Theon; and Practice, 7, 3-11 Rocabado, M. 1985. Arthrokinematics of the temporomandibular joints. In Clinical Dysfunction of the Head, Neck and Temporomandibular Joints: Pain and Dysfunction. New York: W. B. Saunders Sackett, D. L., Rosenburg, W. M. & Gray, J. A. 1996. Evidence based medicine: what it is and what it is not. BM], 312, 71-72 Sahrmann, S. A. 2001 . Diagnosis and Treatment of Movement Impairment Syndromes. St Louis: Mosby Salter, R 1989. The biological concept of continuous passive motion in synovial joints: the first 18 years of basic

research and its clinical application. Clinical Orthopaedics and Related Research, 242, 1 2-25

Shacklock, M. 1995. Neurodynarnics. Physiotherapy, 81, 9-16 ShekeJJe, P. 1994. Spinal update, spinal manipulation. Spine, 19, 858-861 Sterling, M., Jull, G. & Wright, A. 2000. Cervical mobilisation: concurrent effects on pain, sympathetic nervous system activity and motor activity. In The 7th Scientific Conference of the IFOMT in conjunction with the MPAA, International Federation of Orthopaedic Manipulative Therapists, ed. K. P. Singer. Perth, p. 166 Van Wingerden, B. A. M. 1995. Connective Tissue in Rehabilitation. Vaduz: Scirpo Verlag Waddell, G. 1998. The Back Pain Revolution. Edinburgh: Churchill Livingstone Williams, P. L. & Warwick, R, eds. 1980. Gray's Anatomy, 36th edn. London: Churchill Livingstone Wright, A. & Sluka, K. 2001. Non-pharmacological treatments for musculoskeletal pain. Clinical Journal of Pain, 17, 33-46 Zusman, M. 1986. Spinal manipulative therapy - a review of some proposed mechanisms and a new hypothesis. Australian Journal of Physiotherapy, 32, 89-99

39

Chapter

3

Communication and the therapeutic relationship

THIS CHAPTER INCLUDES: •

Key words for this chapter

•

Glossary of terms for this chapter

•

A review of the relevance of the therapeutic relationship in physiotherapy literature

•

•

Aspects of communication and

•

interaction

•

communication Communication techniques

•

The importance of active and passive listening

KEY WORDS

communication, interaction,

Verbal communication, non-verbal

therapeutic relationship, critical

GLOSSARY OF TERMS Collaborative goal setting - the process in which the physiotherapist defines desired outcomes of treatment with the patient, rather than for the patient. This is an ongoing process throughout all sessions. It includes goals of treatment, selection of interventions and parameters to assess treatment results. Communication - verbal and non-verbal communication: communication may be considered as a process of the exchange of messages, which need to be decoded. A message may contain various aspects: the content of the message, an appeal, an indication

Process of collaborative goal setting

Verbal and non-verbal

•

Shaping of interactions

•

Critical phases in the therapeutic process

•

Verbatim examples of various phases in the therapeutic process.

phases of the therapeutic process.

of the relationship to the person to

information with regard to

whom the message is addressed,

diagnosis or assessment.

and revealing something about the

Furthermore, skipping may impede

sender of the message (Schulz

the therapeutic relationship as the

von Thun

1981). Watzlawick (1969) - 'non

et ai's axiom

communication does not exist' -

patient may not understand the purpose of certain procedures. Immediate-response questions - in

indicates that non-verbal

various phases of the process of

communication as well as the

information gathering (initial

absence of words can be a strong

sessions, reassessment procedures)

message. Critical phases of the therapeutic

the physiotherapist may need to gently interrupt the patient with

process - throughout the overall

an interceding 'immediate

physiotherapy process there are

response' question to seek

some specific 'critical' phases in

clarification of the information

which particular information needs

given by the patient. This is

to be sought or given. Skipping

particularly essential during the

some of the critical phases may

subjective examination in the

have a consequence that the

initial session and in reassessment

physiotherapist misses relevant

procedures where 'statements of

40

M A ITLAN D'S P E R I P H E R A L M A N I P U LAT I O N

fact' need to b e converted into

listening skills to allow the

which the physiotherapist follows

comparisons.

development of a climate in

the patient's line of thought rather

Key phrases, key words, key gestures need attention throughout the whole physiotherapy process. If picked up and reacted upon, the

which the patient feels free to

than letting the physiotherapeutic

reveal any information which

procedures of subjective

seems relevant. technique which may be

important information in

employed by the physiotherapist

Communication and the conscious

assessment and reassessment

to guide the patient to an

development of a therapeutic

increased awareness with regard

relationship are considered

be indicative clues to the patient's

to use of the body, posture or

important elements to enhance a

world of thoughts, feelings and

elements of the individual illness

climate in which the patient can

emotions, which may be

experience. Often starts off with,

learn, develop trust and recover full

contributing factors to ongoing

'I see you doing .. .' or 'I hear you

disability due to pain.

saying ... . Paralleling - an important communication technique, in

As described in former editions of Maitland's work (Maitland 1986, 1991), well-developed communication skills are essential elements of the physiotherapy process. They serve several purposes: They aid the process of information gathering with regard to physiotherapy diagnosis, treatment planning and reassessment of results. They may serve to develop a deeper understanding of the patient's thoughts, beliefs and feelings with regard to the problem. This information assists in the assessment of psychosocial aspects which may hinder or enhance full recovery of movement functions. Empathic communication with the above mentioned objectives also enhances the development of a therapeutic relationship.

THERAPEUTIC RELATIONSHIP Based on changing insights on pain as a multidimen sional experience, the therapeutic relationship is con sidered to have increasing relevance in physiotherapy literature. It is debated that interpersonal communica tion, next to academic knowledge and technical expert ise, constitutes one of the cornerstones of the art of health professions (Gartland 1984a). Furthermore, it is considered that the physiotherapy process depends strongly on the interaction between the physio therapist and the patient, in which the relationship

function. Yellow flags - psychosocial risk

'

INTRODUCTION

•

from a personal relationship.

procedures. Furthermore, they may

needs to develop passive and active

•

Therapeutic relationship - distinct

physiotherapist may receive

Listening skills - the physiotherapist

•

examination prevail.

Mirroring - communication

factors, which may hinder the process to full recovery of function.

may be therapeutic in itself (Stone 1991). The World Confederation of Physical Therapy (1999) describes the interaction between patient and physiotherapist as an integral part of physiotherapy, which aims to achieve a mutual understanding. Interaction is seen as a 'pre requisite for a positive change in body awareness and movement behaviours that may promote health and wellbeing' (WPCT 1999, p. 9). The physiotherapist may be seen as a treatment modality next to the physical agents applied (Charmann 1989), in which all the phys iotherapist's mental, social, emotional, spiritual and physical resources need to be used to establish the best possible helping relationship (Pratt 1989). It is recom mended that every health. professional establishes a therapeutic relationship with a client-centred approach, with empathy, unconditional regard and genuineness (Rogers 1980). In particular, empathy and forms of self disclosure by the therapist are seen as important ele ments of a healing environment (Schwartzberg 1992) in which markedly empathic understanding may support patients to disclose their feelings and thoughts regarding the problem for which they are seeking the help of a clinician (Merry & Lusty 1993).

The physiotherapist's role in the therapeutic relationship It is recognized that within the therapeutic process a phYSiotherapist may take on a number of different roles: • •

curative prophylactic

Communication and the therapeutic relationship

• • •

palliative (KNGF 1998) educational (French et a11994, KNGF 1998) counselling (Lawler 1988).

In relation to counselling it is argued that physiother apists may often be involved in counselling situations, without being fully aware of it (Lawler 1988). The use of counselling skills may be considered as distinct from acting as a counsellor, the latter being a function of psychologists, social workers or psychiatrists (Burnard 1994). However, it is recommended that every clinician learns to use counselling skills within their framework of clinical practice (Horton & Bayne 1998). It appears that over the years of clinical experience physiotherapists view their roles with regard to patients differently. As junior physiotherapists they may consider themselves more in an expert, curative role, providing treatment from the perspective of their professional expertise, while more senior physiother apists seem to endeavour to meet patients' preferences of therapy (Mead 2000) and engage more in social interactions with the patients (Jensen et al 1990), thus considering themselves more in the role of a guide or counsellor. The positive effects of a therapeutic relationship are seen in: •

•

•

•

•

•

actively integrating a patient in the rehabilitation process (Mattingly & Gillette 1991) patient empowerment (Klaber Moffet & Richardson 1997) compliance with advice, instructions and exercises (Sluys et a11993) outcomes of treatment, such as increased self efficacy beliefs (Klaber Moffet & Richardson 1997) building up trust to reveal information which the patient may consider as discrediting (French 1988) trust to try certain fearful activities again or re-establishing self-confidence and wellbeing (Gartland 1984b).

Notwithstanding this, the therapeutic relationship is often seen as a non-specific effect of treatment, meet ing prejudice in research and being labelled as a placebo effect, which needs to be avoided (Van der Linden 1998). However, it is argued that each form of treatment in medicine knows placebo responses, which need to be investigated more deeply and used positively in therapeutic settings (Wall 1994). These placebo effects seem to be determined more by charac teristics of the clinician than by features of the patients, such as friendliness, reassurance, trustworthiness, showing concern, demonstrating expertise and the ability to establish a therapeutic relationship (Grant 1994).

Research and the therapeutic relationship In spite of an increasing number of publications, rela tively few physiotherapy texts seem to deal explicitly with the therapeutic relationship when compared with occupational therapy or nursing literature. A CINAHL database search over the period 1993-1998 under the key words 'patient-therapist relationship' and 'therapeutic relationship' was performed: 5 out of 38 entries, and 6 out of 150 entries, respectively, were published in physiotherapy-related journals. Nevertheless, the World Confederation of Physical Therapy in the Description of Physical Therapy (1999) declared the interaction with the patient as an integral part of physiotherapy practice, and the Chartered Society of Physiotherapy in Great Britain, in the third edition of its Standards of Physiotherapy Practice, emphasizes the relevance of a therapeutic rela tionship and communication as key components of the therapeutic process (Mead 2000). These viewpoints seem to be shared by the majority of physiotherapists in Sweden. In a study with primary qualitative research and consequently a questionnaire with Likert-type answers, it was concluded that the majority of physio therapists attributed many effects of the treatment to the therapeutic relationship and the patient's own resources rather than to the effects of treatment techniques alone (Stenmar & Nordholm 1997). It is recommended that within a therapeutic rela tionship patients need to be treated as equals and experts in their own right, and that their reports on pain need to be believed and acted upon. Opportunities need to be provided to communicate, to talk with and listen to the patients about their problems, needs and experiences. In addition, independence in choosing personal treatment goals and interventions within a process of setting goals with rather than for a patient needs to be encouraged (Mead 2000). Various studies have been undertaken with elem ents of the therapeutic relationship among patients and phYSiotherapists. In various surveys of patients it was concluded that patients appreciated positive regard and willingness to give information next to pro fessional skills and expertise (Kerssens et aI1995), com munication skills and explanations on their level of thinking about their problem, and treatment goals and effects as well as confidentiality with the information given (de Haan et al 1995). In a qualitative study on elements of quality of physiotherapy practice, patient groups regarded the ability to motivate people and educational capacities as essential aspects (Sim 1996).

The therapeutic relationship and physiotherapy education and practice Indications exist that various dimensions of the thera peutic relationship are neglected in physiotherapy

41

42

M A I T LA N D ' S P E R I P H E R A L M A N I P U LAT I O N

L education and practice. I n a qualitative study i n Great Britain among eight physiotherapists offering low back pain education it was concluded that only one participant followed a patient-centred approach, with active listening to the needs of the patients, while the remaining physiotherapists followed a therapist centred approach (Trede 2000). In a survey among physiotherapists in The Netherlands it was concluded that almost all physiotherapists felt that insufficient communication skills training had been given during their undergraduate education (Chin A Paw et aI1993). Furthermore, in a qualitative study the participants felt that aspects of dealing with intimacy during daily clinical encounters between patients and physiother apists have been neglected (Wiegant 1993). In a qualita tive study among clinical instructors of undergraduate physiotherapy students it was noted that the clinical supervisors preferred to give feedback to the students on technical skills rather than on social skills (Hayes et aI1999). This may have the consequence that some students will never learn about the relevance of the therapeutic relationship in the physiotherapy process and later will not make the elements of this relation ship explicit in their clinical reasoning processes. Often physiotherapists consider communication as a by-product in therapy and don't consider this as 'work' (Hengeveld 2000); for example, 'every time the patient attended she had so many questions that it cost 10 minutes of my treatment time and I could not start working with her'. A study with interviews of 34 recipients of physio therapy treatment showed that patients not only appre ciate the outcomes of care but also the process in which therapy has been delivered. The following elements were identified as key dimensions that contribute to patient satisfaction with physiotherapeutic treatment: •

•

•

•

•

In order to develop a fruitful therapeutic relation ship, well-developed communication skills and an awareness of some critical phases of the therapeutic process are essential.

COMMUNICATION AND INTERACTION -===-=--=----:::11.

Most people consider that communication between two people who speak the same language is simple, routine, automatic and uncomplicated. However, even in normal day-to-day communications there are many instances in which misunderstandings occur. Even if the same words are being lIsed, they may have dif ferent meanings to the individuals involved in the communication. Communication may be seen as a process of send ing messages, which have to be decoded by the receiver of these messages. A message may contain various aspects: the content of the message, an appeal, an indication of the relationship to the person to whom the message is addressed, and revealing something about the sender of the message (Schulz von Thun 1981). This follows some of the axioms on communica tion as defined by Watzlawick in which it is discussed that 'non-communication does not exist' - in other

professional and personal manner of the therapist (friendly, sympathetic, listening, respectful, skilled, thorough, inspiring confidence) explaining and teaching during each treatment (identifying the problem, guidance to self management, process of treatment, prognosis) how the treatment was consultative (patient involvement in the treatment process, responses to questions, responsiveness to self-help needs) the structure and time with the therapist (e.g. short waiting time, open access and enough time) the outcome (treatment effectiveness and gaining self-help strategies).

It is concluded that it is essential to establish expect ations, values and beliefs with regard to physiotherapy treatment in order to optimize patient satisfaction with the delivered treatment (May 2001).

Figure

3.1

One of the problems of communication.

Communication and the therapeutic relationship

words, communication always takes place, whether the participants are aware of it or not. Every communi cation bears aspects of content and relationship, and human communication follows digital and analogue modalities, the latter referring to verbal and non verbal communication, which ideally should occur congruently (Watzlawick et aI1969). Many errors in communication occur as a result of different understanding and interpretation as well as to the selection of words. The cartoon depicted in Figure 3.1 highlights some of the difficulties which may occur during verbal communication. The last three lines in the cartoon bear greatest significance. This could be saying, 'What I said was so badly worded that it did not express the thought that was in my mind', or it is possible that the receiver tuned in, or listened closely only to those parts of the message that fitted their own way of thinking, and ignored other parts that did not. It is also possible that the receiver's expectations or frame of mind altered their perception. The feedback loop of Figure 3.2 indicates some of the coding errors wh.ich may occur during a communi cation between a 'sender' and a 'receiver' of a message. Communication, as any other skill in clinical work, is an ability which can be learned and refined by con tinuous practice. Attention to one level of communica tion (e.g. content and meaning of words) can be practised step by step, until a high level of skill in uncovering meanings is developed. A good way of dis covering more about an individual style of interview ing and communication is to record it on video or audiotape. Play it back to yourself and to constructive peers and supervisors. The skill must be developed to a high level if a patient's problem is to be understood without any detail being missed. The learning of this skill requires patience, humility, clarity and constructive self-criticism. Words, phrases and intonation need to be chosen care fully when asking questions to avoid being misunder stood, and patients must be listened to carefully so that the meanings of tlle words they use are not misinter preted (Maitland 1986). Attention needs to be given not only to what is said, but also to how it is said (Main 2004), including a careful observation of the body language of the patient. The physiotherapist should not be critical of the way a patient presents. The very presentation itself is a message, needing to be decoded in the same way as the many other findings that the subjective and phys ical examinations reveal. Various elements may lead to misinterpretation of the severity of the patient's symp toms and! or disability. The various ways that a person may experience pain or limitation of activities may lead to different

expressions of pain behaviour. Some may seem stoic and do not appear to experience much distress, while others seem to suffer strongly and have high anxiety levels. The way people express pain, distress or suffer ing may be due to learning factors, including the fam ily and the culture in which the person has been brought up. If patients are not fluent in the language of the examiner, their non-verbal expression to explain what is being experienced may be more exaggerated from the perspective of the examiner. Some patients will comment only on the symptoms tllat remain and do not comment on other aspects of the symptoms or activity levels that may have improved. The skilled physiotherapist can seek the positive side of the symp tomatic changes rather than accepting the more nega tive approach of the patient. Overall, it is essential for the physiotherapist to develop an attitude of uncondi tional regard towards the patient and the situation, as suggested by Rogers (1980), even if the physiother apist does not fully understand the patient's behaviour and marulers with regard to pain and disability.

Aspects of communication Communication consists of various components: • •

verbal components non-verbal components, such as tone of voice, body posture and movements and so on.

It is important that the physiotherapist creates a setting in which a free flow of communication is possible, allow ing an uncomplicated exchange of information. Atten tion to the physical distance to the patient, not too far and not too close, often enhances the process of informa tion gathering. At times a gentle touch will allow a quicker exchange of information, for example when the physiotherapist would like to know which areas of the body are free of symptoms. The physiotherapist may gently touch, for example, the knee of a patient in order to interrupt their somewhat garrulous dialogue, in order to become able to highlight an important aspect of tlle information given or to seek further clarification. Congruence of verbal and non-verbal communica tion is essential. Eye contact is important, as is a safe environment in which not too many outside disturb ances hinder the establishing of an atmosphere in which patients can develop trust to disclose information which they think might be compromising. It is important that the physiotherapist pays attention not only to what is said, but also to how it is said. Often tI1e body posture or the intonation of the voice or certain key words and phrases give indications of the individual illness experience, especially if certain words are used which may have a more emotional content (e.g. 'it is all

43

44

M A ITLA N D'S P E R I P H E R A L M A N I P U LAT I O N

1st process The reasoning behind the question which is to be asked The fundamental error that lies behind much poor questioning is having insufficient theoretical and clinical Error

knowledge to guide the precise information required from a patient

, 2nd process

3rd process

Wording the question The error occurs when the question asked does not clearly ask what the physiotherapist needs to know

r+

Hearing and understanding the questions Two errors can occur at this stage:

1. A word or words may be used which the patient does not understand 2. What the patient hears may be biased away from

Error

what he should have heard

,

Error

4th process Considering the repty Because the patient has particular thoughts about his complaint, he may assure different reasons for the question from those of the physiotherapist. Also his memory of facts which are involved in answering the question may be incomplete or inaccurate

�

6th process

5th process

Hearing and understanding the words used in the

PUlling the answer Into words

patients answer Patients may use descriptive words which are difficult to understand, particularly when describing bizarre symptoms. The error lies in assuming the meaning of them rather than asking questions to be certain Error

of the meaning

, 7th process tnterpreting the answer Because the physiotherapist does not have the patient's symptoms herself, she has to interpret the answer in the light of her own experiences (including her experiences with other patients). The interpretation may be wrong

Error

if the answer is not clarified

, 8th process Relating the answer to the question If the phYSiotherapist accepts the patient's answer as providing all the information, when the fact it does not, the subsequent examination will be open to Error

major errors

, 9th process Determining the next question If there was insufficient knowledge on which to base the first question, irrespective of the accuracy of the patient's answer, the basis for the second question must also be in error If there has been no error in any of the preceding

Error

eight processes there should be no error in this 9th process

Figure

3.2

Feedback loop.

Error

To translate thoughts related to answering the question

I+-

into words is even more difficult for the patient than for the physiotherapist because of the comparative lack of experience Error

Communication and the therapeutic relationship

very terrible'). These may be clues to the patient's world of thoughts, feelings and emotions, which may be con tributing factors to ongoing disability due to pain (Kendall et al1997). As expressed in Chapter 5, attention to these aspects often allows the physiotherapist to perform a psychosocial assessment as an integral part of the overall physiotherapy-specific assessment. As pointed out in the chapters on assessment and examination (Chapters 5 and 6), many details are asked in order to be able to make a diagnosis of the movement disorder and its impact on the patient's life. Critics may say that the patient will not be able to provide all this information. However, it has long been a principle of the Maitland Concept that the 'body has the capacity to inform'. If the phYSiotherapist carefully shapes the inter view, pays attention to details such as selection of words and body language and explains regularly why certain questions or interventions are necessary, the patient will learn what information is of special relevance to the physiotherapist and pay attention to this.

Shaping of interactions During the overall series of treatment, as well as in each session, it is important that the physiotherapist shapes the interaction deliberately, if a conscious nur turing of the therapeutic relationship seems necessary. As in other cOlmselling situations, each series of therapy, as well as each treatment session, knows three phases of interaction (Brioschi 1998): •

•

InitiaL phase a 'joining' between physiotherapist and patient takes place on a more personal level in order to establish a first contact; personal expect ations are established; the patient's questions may be addressed; the speCific objectives of physio therapy or of the session are explained; the spe cific setting is clarified (e.g. number of sessions, treatment in an open or closed room). The first subjective and physical examinations or the sub jective reassessment takes place. It is essential that in this phase the (ongoing) process of collabora tive goal setting has started. -

MiddLe phase - working on the treatment objectives and using interventions in a collaborative way; regular reassessment to confirm the positive effects of the selected treatment interventions. It is import ant that all aspects of goal setting, selection of inter ventions and reassessment parameters are defined in a collaborative problem-solving process between the physiotherapist and the patient.

•

End phase of the session or of the treatment series summary; attention to the patient's questions; recommendations, instructions or self-management

strategies including reassessment; addreSSing of organizational aspects. Often it is very useful to ask the patient to reflect on what has been particularly useful in the current treatment session or series and what has been learned so far. Often both the information and the end phase (includ ing the final analytical assessment in the last sessions of the treatment series) seem to be neglected, mostly due to lack of time. However, once the more explicit procedures of the session are finished, towards the end of the session the patient often reveals information on the individual illness experience which may be highly essential for the therapy. The following example high lights this aspect. A 72-year-old lady presents to the physiotherapist with a hip problem. Joint mobilizations in lying and muscle recruitment exercises in sitting and standing are performed. At the end of the session, when saying goodbye, the lady tells the physiotherapist that she was going to visit her daughter in another town. However, she was not confident in getting on a bus, as the steps were so high and the drivers would move off too quickly before she was even seated. On the levels of disability and activity resources as defined by the

InternationaL Classification of Functioning, Disability and Health (WHO 2001), it was more relevant to redefine goals of treatment on activity and participation levels and for the patient to practise actually walking to and finding trust on entering the bus, rather than working solely on the functional impairments in the physio therapy practice. This information was not given in the initial examination session, in spite of deliberate ques tioning by the phYSiotherapist. Shaping of a therapeutic climate: listening and communication In order to stimulate a safe environment in which a free flow of information can take place, the develop ment of listening skills is essential. Therapists may well hear what they expect to hear rather than listen ing to the words the patient uses. The following quota tion may serve to underline this principle:

Listening is itself, of course, an art: that is where it differs from mereLy hearing. Hearing is passive; listening is active. Hearing is voLuntary, Listening demands attention. Hearing is natural, Listening is an acquired discipLine. The Age (1982) It is essential to develop the skills of active and passive listening: •

Passive listening means showing that the therapist is listening, with body posture directed towards

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L

•

the patient, maintaining eye contact, and allowing the patient to finish speaking. Active listening encourages patients to tell their story and allows the therapist to seek further clarification.

Active listening may include clarifying questions such as 'Could you tell me more about this?', repetition and summary of relevant information such as 'If I have understood you correctly, you would like to be able to play tennis again and find more trust in riding your bicycle?', or asking questions with regard to the per sonal illness experience, for example, 'How do you feel about your back hurting for so long?' With active and passive listening skills the therapist can show that they have understood the patient. In order to shape a therapeutic climate of uncon ditional regard (Rogers 1980), it is essential that the responses and reactions of the therapist are non judgemental and neutral. Irony, playing the experience of the patient down, talking too much of oneself, giving maxims, threatening ('if you won't do this then your back will never recuperate') or just lack of time may jeopardize the development of the therapeutic relationship (Keel 1996, quoted in Brioschi 1998). If patients reveal personal information, it is essen tial that they are given the freedom to talk as much about it as they feel necessary. At all times the physio therapist should avoid forcing patients to reveal per sonal information which they would rather have kept to themselves. This may happen if the physiotherapist asks exploratory questions too aggressively. Some excellent publications with regard to 'sensitive prac tice' have been published, and are recommended for further exploration of this issue (Schachter et aI1999). Giving advice too quickly, offering a single solution, talking someone into a decision or even commanding may hinder the process of activating the patient's own resources in the problem-solving process. If pOSSible, it is better to guide people by asking questions rather than telling them what to do. This is particularly essen tial in the process of collaborative goal setting in which the patient is actively integrated in defining treatment objectives. In this process it is important to define treatment objectives on activity and participa tion levels (WHO 2001) which are meaningful to the patient. Too frequently it seems that the physiother apist is directive in the definition of treatment goals and in the selection of interventions (Trede 2000). Ideally the therapist may offer various interventions from the perspective of professional expertise to reach the agreed goals of treatment, and the decision is left to the patient to decide which solution may be best for the problem.

Communication techniques Communication is both a skill and an art. Various com munication techniques may be employed to enhance the flow of information and the development of the therapeutic relationship. •

•

•

•

•

•

Style of questions: - Open questions (e.g. 'What is the reason for your visit?') - Questions with aim (e.g. 'Could you describe your dizziness more?', 'What do you mean by pinched nerves?') - Half-open questions - as suggested in the subjective examination. The questions are posed with an aim, but they leave the patient the freedom to answer spontaneously. These questions often start with hmo, when, what, where (e.g. 'How did it start?', 'When do you feel it most?', 'What impact does it have on your daily life?', 'Where do you feel it at night?') - Alternative questions -leave the patient a limited choice of responses (e.g. 'Is the pain only in your back or does it also radiate to your leg?') - Closed questions -can only be answered with yes or no (e.g. 'Has the pain got any better?') - Suggestive questions -leave the patient little pos sibility for self-expression (e.g. 'But you are better, aren't you?') It may be necessary to employ a mixture of ques tion styles in the process of gathering information. Half-open questions and questions with aim may provide information concerning biomedical and physiotherapy diagnosis; frequently, however, they are too restricting if the physiotherapist wants to get an understanding of the patient's thoughts, feelings and beliefs with regard to the individual ill ness experience and psychosocial assessment. Such questions may provoke answers of social desirabil ity or the patient may not reveal what is actually being experienced. Modulation of the voice and body language - as described before. Summarizing of information - in the initial phase this technique is often useful during the subjective examination in various stages: after the completion of the main problem and 'body chart', after the establishment of the behaviour of symptoms, after completion of the history and as a summary of the subjective and physical examinations. Mirroring -in which the physiotherapist neutrally reports what is observed or heard from the patient. (Short) pauses before asking a question or giving an answer. Repetition (with a question) of key words or phrases.

47

Communication and the therapeutic relationship

Probably the first requirement during interviews with patients is that the physiotherapist should retain control of the interview. Even if the physiotherapist decides to employ forms of 'narrative clinical reasoning' rather than procedural clinical reasoning (Chapter 5), it is necessary that the physiotherapist keeps an overview of the indi vidual story of the patient and the given information which is particularly relevant to establish a diagnosis of a movement disorder and its contributing factors. It is essential to use the patient's language whenever possible, as this makes things that are said or asked much clearer and easier to understand. A versatile physiotherapist can develop various ways to stop or interrupt a more garrulous patient, by making statements such as 'I was interested to hear about X, could you tell me more?' Another possibility may be gently touching the patient's knee before stat ing, 'I would like to know more about this'. Interposing a question at a volume slightly higher than the patient's or with the use of non-verbal techniques such as rais ing a hand, making a note, or touching a knee, tends to interrupt the chain of thought and this may be employed if the spontaneous information does not seem to be forthcoming. More reticent patients need to be told kindly that it seems they find it hard to talk about their complaints but that it is necessary for them to do so. They should be reassured that they are not complaining, but informing. The following strategies are important to keep in mind during the interview: • • •

• • •

Speak slowly. Speak deliberately. Use the patient's language and wording, if possible. Keep questions short. Ask only one question at a time. Pose the questions in such a manner that as much as possible spontaneous information can be given (see above).

Paralleling When a patient is talking about an aspect of their prob lem, their mind is running along a specific line of thought. It is likely that the patient could have more than one point they wish to express. To interrupt the patient may make them lose their place in their story. Therefore, unless the physiotherapist is in danger of getting confused, the patient should not be stopped if at all possible while the therapist follows the patient's line of thought. However, a novice in the field may rather first practice the basic procedures of inter viewing, as paralleling is a skill which is learned by

experience. Paralleling may be a time-consuming pro cedure if the patient starts off with a long history of, for example, 20 years. It may then be useful to interrupt and ask the patient what the problem is now and why help is being sought from the physiotherapist now and from then on the physiotherapist may use the technique of paralleling. Paralleling means that, from the procedural point of view the physiotherapist would like to get information (e.g. about the localization of symptoms), whereas the patient is talking about the behaviour of the symp toms. However, using 'paralleling' techniques does not mean that the physiotherapist should let the patient talk on without seeking clarification or using the above-mentioned communication techniques.

-

Immediate-response questions At times the employment of immediate-response questions is essential. If during the first consultation a patient gives important information with regard to the planning of physical examination and treatment, immediate-response questions may be needed. Example: Patient: 'I feel it mostly with quick movements.' Therapist: 'Quick movements of what?' Following the patient's answer: 'In what direction?', or: 'Are you able to show me that quick movement now?' The informa tion on the area of the movement and the direction of the movement may be decisive in the selection of treatment techniques. During subsequent treatments in the reassessment phases, the physiotherapist is in a process with the patient of comparing changes in the symptoms and signs. Frequently, however, the patient may give infor mation which is a 'statement of fact'. The patient may say, 'I had pain in my back while watching football on television'. This is a statement of fact and is of no value as an assessment, unless it is known what would have happened during 'watching television' before starting treatment. This statement demands an immediate response question: 'How would you compare this with, for example, 3 weeks ago, when we first started treat ment?' The patient may respond that in fact 3 weeks ago he was not able to watch television at all, as the pain in his back was too limiting. Using immediate-response questions during this phase of reassessment prevents time being wasted and valuable information being lost. If the physiotherapist employs this technique kindly but consistently in the first few treatment sessions, the patient may learn to compare changes in his condition rather than to express statements of fact. At reassess ment, convert statements of fact into comparisons!

Furthermore, immediate-response questions may be needed with non-verbal responses. There are many

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L examples i n which the examiner must recognize a non verbal response either to a question or to an examin ation movement. The physiotherapist must qualify such expressions. For example, in response to a ques tion the patient may respond simply by a wrinkle of the nose. The immediate-response question, in combin ation with a mirroring technique may be: 'I see that you wrinkled your nose - that doesn't look too good. Do you mean that it has been worse?', etc. Key words and phrases During patients' discourses they will frequently make a statement or use words that could have great significance - the patient may not realize it, but the therapist must latch onto it while the patient's thoughts are moving along the chosen path. The physiother apist could use it either immediately by interjecting or by waiting until the patient has finished. For example, the therapist might say:

Q A

'You just mentioned your mother's birthday - what does that relate to?' 'Well, I can remember that it was on my mother 's birthday that I was first aware of discomiort in my shoulder when I reached across the table to pick up her birthday cake.'

By instantly making use of the patient's train of thought (paralleling) the development of the progres sive history of the patient's shoulder pain is easier to determine for both the therapist and the patient, because, in fact, the patient's mind is clearly back at the birthday party. As another example, having asked the question at subjective reassessment procedures, 'How have you been?', the patient may respond in a general and rather uninformative way. However, during subsequent state ments the patient may include, for example, the word 'Monday'. This may mean something to the patient and therefore it is often effective to use it and ask, 'What was it about Monday?', or 'What happened on Monday?' Bias It is relatively easy to fall into the trap of asking a ques tion in such a way that the patient is influenced to answer in a particular way. For example, the therapist may wish to know whether the last two sessions have caused any change in the patient's symptoms or activ ity levels. The question can be asked in various ways: 1.

'Do you feel that the last two treatments have helped you?' 2. 'Has there been any change in your symptoms as a result of the last two treatments?'

3.

'Have the last two treatments made you any worse in any way?'

The first and third questions are posed with aim, never theless they are suggestive. The first question, however, is biased in such a way that it may push the patient towards replying with 'yes'. The second and third questions are acceptable, as the second question has no specific bias and the third question biases the patient away from a favourable answer. Both questions allow the patient to give any spontaneous answer, even if the therapist is hoping that there has been some favourable change.

Purpose of the questions and assuming Purpose of the questions In efficient information gathering it is essential for the physiotherapist to be aware of the purpose of the questions - no question should be asked without an understanding of the basic information that can be gained (see Chapters 5 and 6). For beginners in the field it is essential to know which questions may support the generation of which specific hypotheses. Before asking a question it is vital for the physio therapist to be clear about several things: 1. 2. 3. 4.

What information is required and why. What is the best possible way to word the question. Which different answers might be forthcoming. How the possible reply to this question might influence planning ahead for the next question.

A mistake that often occurs with trainee manipulative physiotherapists is the accepting of an answer as being adequate when in fact it is only vaguely informative, incomplete or of insufficient depth. The reason for accepting an inadequate answer is usually that trainee phYSiotherapists do not clearly understand why they are asking the question and therefore do not know the number of separate answers they must. hear to meet the requirements of the question. The same reason can lead to another error: allowing a line of thought to be diverted by the patient, usually without realizing it.

Assuming If a patient says that pain is 'constant', it is wrong to assume that this means constant throughout the day and night. The patient may mean that, when the pain is present, it is constant, but not all day long. It is import ant to check the more exact meaning: is it 'steady' or 'unchanging in degree', 'constant in location' or 'constant in time'?

Communication and the therapeutic relationship

Assuming may lead to one of the major errors in clin ical reasoning processes: misinterpretation of informa tion, leading to overemphasis or blinding out of certain information. Therefore it is well worth remembering: never assume anything!

Pain and activity levels Sometimes the Maitland Concept is criticized for put ting too much focus on the pain experience and some may state that 'talking about pain causes some people to develop more pain'. If in examination and reassessment procedures the physiotherapist focuses solely on the pain sensation and omits to seek information on the level of activities, bias towards the pain sensation may occur and some patients may be influenced to focus mainly on their pain experience. It may then seem that they develop an increased bodily awareness and become more pro tective towards movements which may be painful. It is therefore essential that the physiotherapist estab lishes a balanced image of the pain including the con comitant activity linutations and resources. Sometimes the pain experience does not seem to improve and leaves the patient and physiotherapist with the impres sion that 'nothing helps'. However, if the level of activ ity normalizes and the patient may successfully employ some self-management strategies once the pain is expe rienced again, both the patient and physiotherapist may become aware of positive changes, if they look for them. Some physiotherapists prefer, with some patients, not to talk about pain and to focus only on the level of activity and may even make a verbal contract with the patient not to talk about pain any more and only about function (Hengeveld 2000). However, often this is not of much help, as it denies one of the major complaints for which the patient is seeking therapy, and in fact it denies the most important personal experience of the patient. Nevertheless, .in such cases it may be useful to use metaphors for the pain experience, wellbeing and activity levels. For example, rather than asking, 'How is yom pain?', the therapist may ask, 'What does yom body tell you now in comparison with before?' or, 'If the pain is like a high wave on the ocean in a storm, how is the wave now in comparison with before?' On the other hand, some patients prefer to focus on their activities rather than on the pain sensation alone. The following statement was once overheard in a clin ical situation:

Patient to physiotherapist: 'You aLways taLk about the pain. However it is Like having a filling of a tooth - if I give it attention, I wiLL notice it. However I still am able to eat normally with it.'

thus indicating that, to the patient, it is important to be able to function fully and that he will accept some degree of discomfort.

THE PROCESS O F CO L LA BO RATIVE GOAL SETTING As stated earlier, it is recommended that within a thera peutic relationship patients need to be treated as equals and experts in their own right. Within this practice following a process of collaborative goal setting is recommended (Mead 2000). There are indications that compliance with the rec ommendations, instructions and exercises may increase if treatment objectives are defined in a collab orative rather than a directive way (Riolo 1993, Sluys et a1 1993, Bassett & Petrie 1997). It is essential to consider collaborative goal setting as a process throughout all treatment sessions rather than a single moment at the beginning of the treatment series. In fact, ongoing information and goal setting may be considered essential elements of the process of informed consent. Various agreements between the physiotherapist and patient may be made in the process of collabora tive goal setting: •

•

•

•

Initially the physiotherapist and patient need to define treatment objectives collaboratively. Additionally, the parameters to monitor treatment results may be defined in a collaborative way. The physiotherapist and patient need to collaborate on the selection of interventions to achieve the desired outcomes. In situations where 'sensitive practice' seems especially relevant, some patients may need to be given the choice of a male or a female physiotherapist or may express their preference regarding a more open or an enclosed treatment room (Schachter et aI 1999).

Frequently, physiotherapists may ask a patient at the end of the subjective examination what would be the goal of treatment. Often the response will be that the patient would like to have less pain and no further clarification of this objective takes place. In some cases this approach may be too superficial, especially if the prognosis is that diminution of pain intensity and fre quency may not be easily achieved. This may be the case in certain chronic pain states or where secondary prevention of chronic disability seems necessary. Patients commonly state that their goal of treatment is 'having less pain'; however, after being asked some clarifying questions it often transpires that they wish to find more

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L control over their wellbeing with regard to pain, in order to be able to perform certain activities again. In the initial session during subjective examination various stages occur in which collaborative goal set ting may take place by the communication technique of summarizing: •

•

• •

after establishment of the main problem and the areas in which the patient may feel the symptoms after the establishment of the 24-hour behaviour of symptoms, activity levels and coping strategies after establishment of the history after completion of the physical examination (at this stage it is essential to establish treatment objectives collaboratively, not only in the reduction of pain, but also to define clear goals on the levels of activity which need to be improved and in which circumstances the patient may need self management strategies to increase control over wellbeing and pain).

The relatively detailed process of collaborative goal setting needs to be continued during each session in its initial phase. It is essential to clarify if the earlier agreed goals are still to be followed up. If pOSSible, it is useful to explain to the patient the diverse treatment options on how the goals may be achieved and then let the patient make the choice of the interventions. Another phase of collaborative goal setting takes place in later stages during retrospective assessment procedures. In this phase a reconsideration of treatment objectives is often necessary. Initially the physiother apist and patient may have agreed to work on improve ment of pain, pain control with self-management strategies, educational strategies with regard to pain and movement, and to treat impairments of local func tions, such as pain-free joint movement and muscular recruitment. In later stages it is essential to establish goals with regard to activities which are meaningful for the patient. If a patient is able to return to work after a certain period of sick leave, it is important to know about those activities which the patient seems most con cerned about and where the patient expects to develop symptoms again. For example, an electrician who needs to kneel down in order to perform a task close to the floor may be afraid that in this case his back may start to hurt again. It may be necessary to include this activity in the training programme in combination with simple self-management strategies which can be employed immediately in the work-place. This phase of retrospective assessment, including a prospective assessment with redefinition of treat ment objectives on activity and participation levels, is considered one of the most important phases of the

rehabilitation of patients with movement disorders (Maitland 1986). To summarize, the process of collaborative goal setting should include the following aspects (Brioschi 1998): • •

•

•

the reason for referral to physiotherapy the patient's definition of the problem, including goals and expectations clarification of questions with regard to setting, frequency and duration of treatment hypotheses and summary of findings of the physiotherapist, and clarification of the possibilities and limitations of the phYSiotherapist,

resulting in agreements, collaborative goal definitions, and a verbal or sometimes written treatment contract.

CRITICAL PHASES O F THE THERAPEUTIC PRO CESS In order to shape the therapeutic process optimally, special consideration needs to be given to the informa tion which is given to the patient and sought by the phYSiotherapist in specific phases of the therapeutic process. In fact, the educational task of the physiother apist may start at the beginning of the first session in which the expectations of the patient towards physio therapy need to be clarified. If some of these critical phases are skipped it is pos sible that the process of actively integrating the patient into the therapeutic process is impeded. Attention to these phases supports the development of mutual trust and understanding, enhances the therapeutic relationship and aids in the development of a treat ment plan. In these various stages regular interven tions of collaborative goal setting should take place, clarifying step-by-step: • • •

the goals of treatment what possibilities exist to achieve these goals where certain limitations may be present.

It is essential that the physiotl1erapist not only points out the possibilities of treatment, but also indicates, carefully and diplomatically, the possible limitations with regard to achievable goals. This is particularly essential in those cases where the patient seems to have almost unrealistic expectations of the physiotherapist, which it may not be possible to fulfil. Particularly with patients with chronic disability due to pain, it is fre quently necessary to point out that the physiotherapy interventions may not necessarily be able to reduce the pain, but that the physiotherapist can work with them

Communication and the therapeutic relationship

to find ways to establish more control over their well being and to normalize the level of activities which are meaningful to them. In general it is useful to pay attention to these critical phases in order to 'keep the patient on board'. It is stated that novices in the field tend to be more mechan ical in their interactions with patients in which their own procedures seem to prevail above the direct inter actions with the patient (Jensen et al 1990, 1992; Thomson et al 1997). However, it is essential that the patient understands the scope and limitations of physiotherapy as a movement science as well as the reason for certain questions and test procedures. At times it can be observed in supervision or examination situations that physiotherapists appear to be preoccu pied with their procedures of examination, treatment, recording and reassessment and seem to forget to explain to patients what they are doing and why. It may happen in such cases that the patient is not able to distinguish between a reassessment and a treatment procedure. Furthermore, by paying attention to the information of some critical phases, the physiotherapist may address some 'yellow flags', which may hinder the full recovery of movement function. Secondary preven tion of chronic disability may start with the welcoming and initial assessment of the patient's problem. The critical phases of the therapeutic process (Fig . 3.3) need specific consideration with regard to providing and gathering of information.

Welcoming and information phase After some 'joining' remarks to help the patient feel at ease as a first step towards development of a therapeutic relationship, it is important to inform the patient in

•

I

Referral

IW

t

examination

I

I am aware that your doctor has seen you and diagnosed your probLem as osteoarthritis of the hip and I have this diagnosis in the back of my head. However, my specific task as a physiotherapist is to examine and treat your movement functions. Maybe you have certain habits in your daily life, or you may have stiffjoints or muscles which react too Late. I need to ask some questions about this and I would like to look in more detail at your movements. Often when these movements improve, the pain of the osteoarthritis may aLso normalize. Is this what you yourself expected as a treatment for your probLem ? Starting a session in this manner often prevents the patient from developing irritation that the physiother apist starts off with an examination, as this may have already been done by the referring doctor. Further more, the patient may learn immediately that the physiotherapist follows a somewhat different perspec tive to problem-solving processes than a medical doc tor. Too often patients do not understand that each member in an interdisciplinary team follows a unique frame of reference which is specific to their profession (Kleinmann 1988).

t t t

Subjective

elcome/info

this phase about the specific movement paradigm of the physiotherapy profession - the 'clinical side' of the brick wall analogy of the Maitland Concept. The patient may have different beliefs or paradigms from the physiotherapist as to the causes of the problem and the optimum treatment strategies, which may create an implicit conflict situation if not clarified in time. The physiotherapist may explain this to the patient in the following way:

I

Planning physical examination Physical examination

I

Reassessments

Reflection on initial examination Treatment plan

I

t t

�

•

Final analytical assessment

Retrospective assessments Prospective assessment

Goals and interventions Figure

3.3

Critical phases i n the therapeutic process in which specific co nsid eration is given to the i n formation process.

J

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L Some questions with regard t o yellow flags may also be addressed with this information (Kendall et al 1997, Main 2004): • •

•

Is the patient expecting physiotherapy to help? Which beliefs does the patient have with regard to movement if something hurts? Does the patient feel that the problem has not been examined enough?

It is essential to be aware of certain key remarks indi cating these points, for example, 'Well, the doctor did not even bother to make an x-ray . . . '. If these points are addressed early enough in the treatment series, some patients may start to develop trust and carefully embark on a treatment, which they initially may have approached sceptically, especially if they have already had various encounters with many different health care practitioners (Main & Spanswick 2000).

Subjective examination The subjective examination serves several purposes as described in the chapters on assessment and examina tion (Chapters 5 and 6). It is essential to pay attention not only to what is said but also to how things are said by the patient. Key words, gestures and phrases may open a window to the world of the individual illness experience, which may be decisive in treatment planning. Furthermore, the physiotherapist needs to ensure that the patient understands the purpose of the questions - be they a baseline for comparison of treat ment results in later reassessment procedures or indicative of the physiotherapy diagnosis, including precautions and contraindications. Most essential are the various steps in collaborative goal setting, which preferably take place throughout the overall process of subjective examination. With information on the main problem and the 'body chart', the physiotherapist may develop a first general idea of the treatment objectives; with increasing information throughout the whole examination, this image of the various treatment goals should become more and more refined.

treatment objectives on which the patient and the physiotherapist have agreed so far. Furthermore, it is essential to explain to the patient the purpose of the physical examination.

Physical examination In order to integrate the patient actively in this phase of examination, it is recommended that the physio therapist explains why certain test procedures are per formed and to teach the patient to become aware of the various parameters which are relevant from the physiotherapist's perspective - for example, it may be important during active test movements to educate the patient that the physiotherapist is interested not only in any symptom the patient may feel but also in the range of motion, the quality of the movement and the trust of the patient in the particular movement test. During palpation sessions and the examination of accessory movements, the patient should be encour aged not only to describe any pain but also any sensa tions of stiffness at one level in the spine in comparison with an adjacent level. This is a procedure which requires highly developed communication skills; however, it can be an important phase in the training of the perception of the patient. Furthermore, it is recommended that physiotherap ists inform patients not only about those tests which serve as a reassessment parameter but also about the test movements that have been judged to be normal. Frequently it appears that physiotherapists are more likely to be deficit oriented in their examinations; however, to many patients it is a relief to hear from the therapist which movements and tests are considered to be normal. Sometimes patients may indicate their anxiousness with certain test procedures (e.g. SLR) based on earlier experiences. In such cases it is essential to negotiate directly with the patient how far the physiotherapist will be allowed to move the limb. In fact, 'trust to move' may become an important measurable and achievable parameter, which may indicate the first beneficial changes in the condition of the patient.

Ending a session Planning of the physical examination The planning phase between the subjective and the physical examination is crucial from various perspec tives. The main objective of this phase is the planning of the physical examination in its sequence and dosage of the examination procedures. However, it is import ant to surrunarize the relevant points of the subjective examination first and then to describe the preliminary

Sufficient time needs to be planned for the ending of a session. On the one hand the physiotherapist may instruct the patient about how to observe and compare the possible changes in symptoms and activity levels. Furthermore, the therapist may need to warn the patient of a possible exacerbation of symptoms in cer tain circumstances. A repetition of the first instruc tions, recommendations or self-management strategies

Communication and the therapeutic relationship

may be necessary in order to enhance short-term com pliance (Hengeveld 2003). As described in Shaping of interactions above, attention needs to be given to unexpected key remarks of the patient as these may be indicative of the individual illness experience and relevant treatment objectives .

Evaluation and reflection of the first session. including treatment pl anning This phase includes summarizing relevant subjective ' and physical examination findings, making hypoth eses explicit, outlining the next step in the process of collaborative goal setting for treatment and, if possible, collaboratively defining the subjective and physical reassessment parameters. If the physiotherapist is confronted with a recognizable clinical presentation, this phase may have occurred partially already during the examination process ('reflection in action'). How ever, in more complicated presentations or in new situations the physiotherapist may need more time to reflect on this phase after the first session ('reflection on action') before explaining the physiotherapy view points to the patient and suggesting a treatment plan (Schon 1983). In particular, trainees and novices in the field need to be given sufficient time to reflect before entering the next treatment session in order to develop comprehensive reflective skills (Alsop & Ryan 1996). The completion of a clinical reasoning form may aid the learning process of the students in the various phases of the therapeutic process.

Reassessments As stated earlier, it is essential that patients are able to recognize reassessment procedures as such and do not confuse them with a whole set of procedures in which they may not be able to distinguish between treatment and evaluation . Education of patients may be needed to observe possible changes in terms of comparisons, rather than statements of fact. Cognitive reinforcement at the end of a reassessment procedure may be helpful to support the learning processes of both the patient and the physiotherapist. If the physiotherapist employs educational strategies it may be necessary to perform a reassessment on this cognitive goal as well. Often it is useful to integrate questions with regard to self management strategies in the opening phase of each session during the subjective reassessments. However, from a cognitive-behavioural perspective the way a patient is asked if they are capable of doing their exer cises and to evaluate the effects of these can be decisive in the development of understanding and compliance.

Retrospective assessment In an earlier edition of Maitland's work it was stated that retrospective assessments are crucial aspects of the Concept . In retrospective assessment in particular, the physiotherapist evaluates patients' awareness of changes to their symptoms as one of the most important elements of evaluation. The only way to get this infor mation is with skills in communication and awareness of possible changes in symptoms, signs, activity levels and illness behaviour. The physiotherapist evaluates the results of the treatment so far, including the effects of self-management strategies. In this phase it is essen tial to (re)define collaboratively with the patient the treatment objectives for the next phase of treatment, preferably on levels of activity and participation (WHO 2001) ('prospective assessment') and leading to an optimum state of wellbeing with regard to move ment functions (Chapters 4 and 5).

Final analytical assessment This phase includes the reflection of the overall thera peutic process, when assessment is made of which interventions have led to which results. Often it is use ful to reflect with the patient what has been learned so far. In order to enhance long-term compliance the phys iotherapist may anticipate collaboratively with the patient on possible future difficulties in activities or work and which self-management interventions may be useful if there is any recurrence (Sluys et aI 1993).

VERBATIM EXAM P LES Although communication with a patient is a two-way affair, the main responsibility for its effectiveness lies with the therapist rather than with the patient. The therapist should be thinking of three things (Maitland 1991): I should make every effort to be as sure as is possible that I understand what the patient is trying to tell me. 2. I should be ready to recognize any gaps in the patient's communication, which I should endeavour to fill by asking appropriate questions. 3. I should make use of every possible opportunity to utilize my own non-verbal expressions to show my understanding and concern for the patient and his plight . 1.

The following verbatim examples in this text are used to provide some guidelines which will, it is hoped,

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help the physiotherapist t o achieve the depth, accur acy and refinement required for good assessment and treatment. The guidelines should not be interpreted as preach ing to the ignorant - they are given to underline the essence of careful and precise communication as an integral part of overall physiotherapy practice.

Welcoming and information phase As described above, the welcoming and information phase may be an essential stage to 'get a patient on board' in the physiotherapy process. This phase needs an explanation on the paradigms in physiotherapy, which can be understood easily by the patient. It is essential to find out if the patient can be motivated to physiotherapy and to develop trust in what is lying ahead in the therapy sessions. In this phase it is also important to find out if a patient has already consulted a number of different specialists in the medical field for the problem. Often the patient may have received various opinions and viewpoints and is left confused, especially if they seem to have a more externalized locus of control with regard to their state of health (Rotter 1966, Harkapaa et a1 1989, Keogh & Cochrane 2002, Roberts et al 2002). A patient may indicate by certain key phrases the expectation of a single cure according to the biomedical model, whereas the physiotherapist expects to treat the patient according to a movement paradigm in which self-management strategies may play an important role: 'I have seen so many specialists - everybody says something different. Why don't they find out what is wrong with me and then do something about it?' There are many ways to respond to such a state ment but it is crucial that such a key remark is not ignored. The phYSiotherapist may respond in various ways, for example:

Q Q

'What would you think that they would need to do about it?' 'Now you have come to me - there is a chance that I might also have a different opinion, like all the others. How would you feel about that?'

Initial assessment: subjective examination As stated above, in this phase it is vital to concentrate on both the patient's actual words and how they are deliv ered. Furthermore, during the overall process of subjec tive examination the process of collaborative goal setting should take place, in which treatment objectives are defined in a balanced approach to symptom con trol and normalization of activities, thereby enhancing overall wellbeing.

'First question' - establishing main problem When the physiotherapist starts off the subjective examination, the first thing to be determined is the main problem in the patient's own terms. It is import ant that patients be given every opportunity to express their reasons for seeking treatment, for example with the first question being: 'As far as you are concerned . . . [Pause . . ] (the pause helps the patient t o realize that the therapist is specifically interested in the patient's own opinion) . . . what do you feel . . . [Pause . . ] is your main problem at this stage?' The patient may start off by answering, 'The doctor said I've got tennis-elbow', or, 'Well, I've had this problem for 15 years'. In this case the physiotherapist may gently inter rupt with an 'immediate-response' question such as: .

.

Q A Q

'What made you go to tl1e doctor?' 'Well, because my shoulder hurts of course.' 'Ah, okay, it's your shoulder hurting' (and tl1en immediately making a note of this answer, which indicates to the patient that this is the information the physiotherapist is seeking).

After this answer the physiotherapist may determine the perceived level of disability. At this stage it is also essential to pay attention not only to what is said, but also to how it is said. The use of more emo tionally laden words ('it's all very terrible and annoy ing, I can't do anything anymore'), the non-verbal behaviour of expressing the main problem (e.g . looking away from the area of the symptoms while indicating this, a deep sigh before answering) or a seeming dis crepancy between the level of disability and the expected impairments or areas of symptoms may guide the physiotherapist to the development of hypotheses with regard to 'yellow flags' which may facilitate or hinder full recovery of function. In the determination of the localization of symp toms, at times it is important to ensure that certain areas are free of symptoms, in a sense if 'not even half of 1 %' exists. In this case 'immediate-response' questions need to be asked:

Q A Q

'Do you have any symptoms in your leg?' 'Not really.' 'Do you mean, nothing at all?'

The response to the examiner's first question with regard to the patient's main problem will guide the next question in one of two directions: the behaviour of the symptoms and the activities of daily living 2. the history of the problem. 1.

Communication and the therapeutic relationship

Behaviour of the symptoms Without experience in the choice of words or phrasing of questions, an enormous amount of time can be taken up in determining the behaviour of a patient's symptoms. Unfortw1ately, it needs time if the skill is to be learned, for nothing teaches as well as experience. The information required relative to the behaviour of a patient's symptoms is: •

•

•

• •

the relationship that the symptoms bear to rest, activities and positions the constancy, frequency and duration of the intermittent pain and remission, and any fluctuations of intensity ('irritability') the ability of the patient to control these symptoms and promote wellbeing (coping strategies) the level of activity in spite of the symptoms defining of first treatment objectives on activity and participation levels, as well as further coping strategies.

The following is one example that provides a guide as to the choice of words and phrases that will save time and help the therapist avoid making mistaken inter pretations and incorrect assumptions. The conversa tion that follows is with a man who has had 3 weeks of buttock pain. The text relates only to the behaviour of the buttock pain (adapted from Maitland 1986):

(ET, Examiner's thoughts; Q, question; A, answer) ET Earlier in the interview he said his buttock pain was 'constant'. 'Constant' can mean 'constant for 24 hours of the day' or 'constant when it is present' as compared with the momentary sharp pain. This is borne out by the fact that a surprising number of patients say their pain is constant, yet when you ask them, immediately prior to testing the first move ment, 'Do you feel any symptoms in your back at this moment?', they will answer 'No'. The 'constant ache' and 'no symptoms' are incompatible. To avoid misinterpreting his use of 'constant', it is essential that it be clarified. It may be possible to gain a more positive manner by tackling the ques tion from the opposite direction Q 'At this stage, are there any moments in which you do not feel your backache?' A 'No, it's there all the time.' ET The next question is to ask him is if he has any ache if he awakens during the night, because this is the most likely time for him to be symptom-free. Q 'How does it feel if you waken during the night?' A 'All right.' Q 'Do you mean it is not aching then?' A 'That's right.'

'Do you mean it is not aching at all?' 'That's right.' 'So you do have some stages when it is not aching?' 'Only at night. It aches all day.' That's now clear. His thinking processes at the moment relate to 'no symptoms in bed' and 'it aches all day'. I need to know the answers to two associated aspects of the daytime: 1. Does the ache vary during the day? (And if so, how much, why, and how long does it take to subside?) 2. Does he have any stiffness and/or pain on get ting out of bed first thing in the morning? To make use of his current train of thought, the following question should quickly be asked in response to his answer ' . . . it aches all day': Q 'Does the ache vary at all during the day?' A 'Yes.' ET Well, that doesn't help me much, but it does pro vide a point from which to work further. There are many ways I can tackle the next few questions. Basically, what I want to know is, does it increase as the day progresses or does it depend on particular activities or positions he may adopt? How can I get the answer most quickly? I'll try this first: Q 'What makes it worse?' A 'It just gets worse as the day goes on.' Q 'Do you mean there is nothing you know of which makes it worse - it just gets worse for no obvious reason?' ET Assessment and reassessment in particular are easier if there is something he can do to increase or to decrease his ache. I need to ask a more leading question: Q 'Is there anything you can do, here and now, which you know will hurt your buttock?' A 'Well, I know that while I have been sitting here it has ached more.' Q 'Do you mean, sitting normally makes you ache?' A 'If I sit and watch television it aches.' ET Good, this gives me more information with regard to physical examination and reassessment of treat ment. However I would like to know two things: 1. What can he do by himself to influence the pain? (This will provide me with information with regard to self-management strategies and phy sical examination.) 2. Are there any activities he performs which cause aching? (This information will also be helpful in later reassessment stages.) I first continue with his current line of thought sitting and watching TV cause ache. Q 'Once your back is aching during watching tele vision, is there anything you can do by yourself to influence the ache?' A 'I just get up and walk around for a while.'

Q A Q A ET

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L Q A Q A Q A

'Do you happen to perform any particular movements?' 'I am not aware of this.' 'Are you having any ache right now?' 'Yes.' 'What would you like to do right now to reduce it?' 'I would like to get up and walk a few steps.' (patient

gets up and PT observes) 'How is it now?' 'It's still there, but certainly better than just before.' 'Well, since this improves it a bit, I would suggest that getting up and moving around for a few moments is certainly a good thing to continue, whenever your back is aching more.' ET Well, 1 observed him getting up and supporting his back with his hands and he seemed to be having difficulty in straightening his back. This indicates a lumbar movement disorder rather than a hip dis order. In the latter case I would have expected him to have difficulty with walking rather than straight ening his back. He could also have moved his leg more to reduce the pain if the hip was a cause of his movement dysfunction. Now I would like to find out if there are some activities rather than positions which provoke his symptoms. 1 can combine this with one step of goal setting: Q 'So, if 1 understand you correctly, you would like sitting while watching television and getting up after sitting to improve, am I correct?' A 'Oh sure, that's right.' Q 'How do you feel when you first get out of bed in the morning?' A 'I have difficulty putting my socks on, 1 feel stiff and it aches in my buttock.' ET The greater value of this answer is the use of the spontaneous key word 'stiffness'. Stiffness in the morning may fit a recognizable clinical pattern of an inflammatory disorder, which can be deter mined by further questioning. Q 'How long does the stiffness last?' A 'Only a few minutes. I'm still aware of it when 1 lean over the wash-basin to wash my face, but by breakfast it has already gone.'

Q A Q

Some readers may consider the above answers are too good to be true. However, as the physiotherapist learns to ask key questions to elicit spontaneous answers, the responses become more informative and helpful in understanding both the person and his problem, hence the development of a therapeu,tic relationship and a dif ferentiated baseline for later reassessment procedures. The behaviour of the patient's symptom of stiffness may also be Significant when there is some pathology involved. For example, during the early part of the

examination the physiotherapist may develop the hypothesis that ankylosing spondylitis may be the back ground of the patient's movement disorder. The conver sation and thoughts may be something like this: ET 1 want to know if his back feels stiff on getting out of bed in the morning. If he has ankylosing spondyli tis, his back should be quite stiff and probably painful. Even if it is not very painful, does the stiff ness take longer than 2 hours to improve to his normal degree of limited mobility? To gain the maximum value from his answer 1 must avoid any suggestive questions. Q 'How does your back feel when you first get out of bed in the morning?' A 'Not so good.' Q 'In what way isn't it good?' A 'It's stiff.' ET This is a statement, and all statements need to be made factual if they are to be used for prognosis and assessment purposes. Q 'How stiff?' A 'Very stiff.' Q 'How long does it take for this stiffness to wear off?' A 'Oh, it's fairly good by about midday.' ET His job may involve shift work, so 1 must not assume immediately that his stiffness lasts for about 5 hours. Q 'What time do you get up in the morning?' A 'About 7 o'clock.' ET That means that he's stiff for at least 4 hours. That's too long for any ordinary mechanical movement disorder. History of the problem History taking is discussed in detail in Chapter 6. The discussion here relates to communication guidelines. Especially in those patients in whom the disorder is of a spontaneous onset, many probing questions are needed to determine the predisposing factors involved in the onset. The following text is but one example of the probing necessary in the history taking of this group of patients: ET If 1 start with open questions, which are vaguely directed, his spontaneous answers may help me considerably to understand those parts of his his tory that are important to him. Those parts which are important to me 1 can seek later, if they do not unfold spontaneously. Q 'How did it begin?' ET This may also provide me with information on when it began. A 'I don't know. It just started aching about 3 weeks ago and it isn't getting any better.' ET It is necessary to know what precipitated the pain and whether this was mechanical or not. If there

Communication and the therapeutic relationship

Q ET

A ET

Q A ET

Q A ET

Q A ET

was an incident or episode, it was either so trivial that he does not remember, or he doesn't associate it with his symptoms. Before sorting this out, it may save time for me to know if he has had any previous episodes. If he has, they may provide the key to rec ognizing the historical pattern of a particular move ment disorder, as well as the key to this kind of precipitating onset for the present symptoms. 'Have you ever had this, or anything like this before?' 1 have to be alert here because he may say 'No' on the basis that previous episodes have been called 'lum bago' and therefore he does not associate them with his present problem, which has been called 'arthritis'. 'No.' 1 can now direct my questions in several ways, but probably the most informative may be verifying this 'No' answer, as his present thoughts are directed now along 'past history'. 'Do you mean you've never had a day's backache in your life?' 'No, not really.' Ah . . . 'Not really' means to me that he has had something, so 1 must clarify this. 'When you say "Not really", it sounds as though you may have had something.' 'Well, my back gets a bit stiff if 1 do a lot of garden ing, but then everyone has that, don't they?' Now it's coming out. What I need to know is whether the degree of stiffness is related to the degree of gardening. 'How long does it take you to recover from a certain amount of gardening?' 'It might take 2 or 3 days to get back to normal after a whole weekend in the garden.' This is very useful information. It helps me to know what his back can tolerate, at least in previous episodes. 1 don't know yet if his back is about the same in this episode or if it's deteriorating, but to save time I'll go back to the 'here and now' and return to the gardening issue later - provided 1 do not forget about it! 1 will need to know the stability of the current disorder as it will guide me in the vigour of treatment and prognosis. The answer may come during other parts of the examination. W hat 1 need to know now is how this episode began. His initial vagueness indicates 1 am going to have to ask some searching questions to find the answers.

There are many ways the questions can be tackled, and the answer to each will take about the same length of time.

Q A

'You said that this episode started about 3 weeks ago. Did it come on suddenLy?' 'Yes, fairly quickly.'

ET Fairly quickly means 'suddenly' to him, but it's not precise enough for me, so I'll need to probe deeper. Q 'What were you first aware of?' A 'It just started aching.' Q 'During the morning or the afternoon?' A 'I don't remember: Q 'Do you remember if it came on in one day? In other words, did you have no ache one day and have an ache the next day?' After a delay, while he ponders the question, the answer comes: A

'Yes, 1 think so.' Q 'Do you happen to remember which day it was?' ET To pursue this line of thinking 1 will guide his memory, which may help him to remember something that might otherwise be lost. A 'It was a Thursday: Q 'Was it aching when you wakened that day or did it come later that day?' A 'I think 1 wakened with it, yes. Yes, I'm sure 1 did because 1 remember saying to my wife during breakfast that my back was aching.' Q 'And when you went to bed the night before, was your back aching then?' A 'No, then 1 did not feel anything.' ET That's part of the question solved, or at least as much as 1 need at the moment. Now to find out what provoked it. The first thing is to make him think about whether there was any trivial incident which occurred during the day before the backache started. If this proves negative, then I'll ask about 'predisposing factors'. Q 'Did you do anything at all on Wednesday that hurt your back even in a minor way, or made you aware of your back in any way?' A 'No, I've been trying to remember if 1 did anything, but 1 can't remember any time 1 could have hurt it: ET So now 1 have to resort to the 'predisposing factors' referred to above. While his mind is orientated towards physical activity, if I continue with ques tions associated with activities, he will probably be able to answer more quickly. And the answer may be more reliable. To ask him about the non physical activity 'predisposing factors' (fatigue, disease, etc.) will force him to change his train of thought and it may take more time. I will keep paralleling to his train of thought, as long as I do not lose the overview and don't forget about the other questions. Q 'Did you do any unusual work on that Wednesday or about that time?' A 'No.'

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'Have you been doing any heavier work than usual?' 'No.' 'Any work that was longer than usual?' 'No.' 'Anything changed at work, like new furniture?' 'No.' So there isn't any obvious physical activity which has provoked this ache. The next step is to investi gate the other 'predisposing factors' - there must be a reason for the onset of aching on the Thursday morning. Q 'At that time, were you unwell, or overtired or under any stress?' A 'Well, yes I was pretty tired. I'm overdue for holi days and we have had two men off work sick - and now you mention it, we have been working longer hours than usual to meet a deadline - I'd forgotten about that - and I was involved in a lot of lifting and carrying that day.' ET It often takes quite a long time (which is reason able) for a person to retrieve pieces of information, so rather than thinking, 'Why didn't you say that when I asked you earlier ', I'd be better to think, 'Well at least I didn't miss out on that piece of information' . Q 'And that is unusual for you, isn't it?' A 'Well, yes it is. I do have to do quite a bit of lifting, but the pressure was really on at that particular time.' ET Thank you very much, that's just what I was look ing for. Now that it makes sense, the history and the symptoms are compatible. Now I would like to know, as his train of thought is still '3 weeks ago', if he considered doing any self management interventions during the day he was lifting so much. Q 'During that Wednesday when you were lifting so much, did you think of doing any exercises in between to protect your back - or have you learned some things previously?' A 'Oh no, I was so busy, I did not think of anything other than getting the job done.' ET Okay, that's something I can understand. It pro vides me however with hypotheses regarding management - it could be a lumbar movement dysfunction, without prematurely excluding other sources. If it is lumbar, he may need to learn exten sion movements during the day to compensate for the bending activities. I'll keep that in mind and come back to this later. Q A Q A Q A ET

As already mentioned, when interviewing more gar rulous patients, trying to keep control of the interview is chalJenging. During history taking these patients

tend to go off at tangents and give a lot of detailed information. This may need to be skilfully interposed by gently increasing the volume of your voice and Simultaneously touching the patient gently. However, the important thing is that the examiner can retain con trol of the interview without insulting or upsetting the patient. Nevertheless, every effort should be made to make patients feel that they are not complaining, rather they should be told that they are informing 'What you don't tell me, I don't know.' For example the opening question and answer might be as follows: Q A

'When did it start?' 'Well, I was on my way to visit an old aunt of mine, and as I was getting onto . . . .'

This is often a difficult situation - is this the patient's train of thought, which may provide the therapist eventually with valuable spontaneous information, or is it better to interrupt? Some intervening questions to keep control of the interview may be as follows: Q l 'What happened?' Q2 'Did you fall?' Q3 'How long ago was this?'

Initial assessment: physical examination After a summary of the main findings of the subjective examination and agreed treatment objectives, it is essential that the patient is informed about the purpose of the test movements to allow the patient an active role in the procedures. This may be worded as follows:

'We have agreed that we would try to work on activities like bending over and standing. I've understood that it is important to you that you feel capable ofjogging again soon and inviting people to your home. Am I correct? (patient agrees). Now I would like to Look more specifically at your movements of your shoulder and neck, in order to see if they all meet the basic requirements to fulfiL such tasks. ' While performing the test procedures, the purpose of active test movements, as well as the parameters rele vant for reassessment procedures can be explained: Q A Q A Q A

'While standing here now, what do you feel in your neck and arm?' 'The whole lot.' 'Equally throughout?' 'No, the upper arm isn't so bad.' 'Your neck and forearm are more painful, aren't they?' 'Yes.'

Communication and the therapeutic relationship

Q 'Which is worse?' A 'They're about the same.' ET Right, that's dear. Now 1 would like to test neck flexion. The patient is asked to bend his head forward and then return to the upright position. 'Did your pain change?' 'Yes, the pain in my upper arm increased.' 'Did your forearm change?' 'No.' 'And nothing else changed either?' 'No.' 'Good. And now, has the upper arm pain subsided back to what it was before?' A 'Yes.' Q 'Did that happen immediately you started to come up, or did it take a while to subside?' A 'It hurt more while 1 was fully bent forwards.' ET That's ideal answering. 1 now have a complete picture of how the symptoms behave with for ward flexion of the neck. 1 have seen his range and quality of movement 1 wonder if he observed this as well. Q 'I want you to remember this movement - we will use it as a test later on to measure progress. Could you tell me something about how you perceived the way you moved - could you bend as much and as easily as YOLi are L1sed to?' A 'Can 1 do it again?' Q 'Yes.' A 'It feels much stiffer and 1 think I normally come further down.' Q 'I would like you to remember how the pain feels, but also to remember the way you feel able to move. Let's test the next movement now . . . Could you carefully bend your head backwards?'

Q A Q A Q A Q

-

Patient does this and makes a grimace. 'Up you go. Where was it?' 'In my upper arm again.' 'How is it now?' 'Back to normal again.' 'How did you feel about the movement itself?' 'I did not feel free; 1 did not fully trust myself to go further back. 1 did not go as far as normal.' Q 'Which movement was more problematic: bending forwards or backwards?' A 'Backwards; it hurts more and 1 did not trust myself fully.' Q 'I would like you to remember this movement also. We will compare this one later on as well.' ET Now 1 would like to perform the other neck move ment, if the 'present pain' has not yet increased. Q A Q A Q A

This example demonstrates how much dose attention the pain responses to the movement deserve. The physiotherapist usually simultaneously observes the quality and range of movement. However, often it is necessary to guide the patient to this observation in order to teach him all the essential parameters of a test procedure. Furthermore, it is important for the patient to understand that the physiotherapist wants to use these movements in later reassessment procedures to observe if any beneficial changes have occurred. To many patients this is a strange procedure, as they often naturally would want to avoid the painful move ments. To omit precision in this area would be a grave mistake. Once the behaviour of the pain is established and the patient w1derstands the purpose of these test procedures, the treatment techniques can be suitably modified and the appropriate care given to treatment and reassessmen t. The intonation of the patient's speech can also express much to the physiotherapist. During the con sultation every possible advantage should be taken of all avenues of both verbal and non-verbal communica tion. The more patients one sees, the quicker and more accurate the assessment becomes. Q

'Now let me see you bending your head to the left side.'

And so the examination continues. The examples given should show how it is possible to determine very precise, accurate information about the responses to movement without great expenditure of time. Obviously it is not always as straightforward as the example given, but it is nearly always possible to achieve the precision. Some patients become quickly irritated in subse quent treatment sessions by being asked the same questions in the same detail. The physiotherapist who is tuned into the patient's non-verbal communication will quickly get this message. One way around this, without losing precision, is to vary the question: 'Upper arm again?' or, 'Only upper arm?', or, 'Same?' Palpation

During palpation sequences and examination of acces sory movements it is important to actively integrate the patient in the examination as well. Often the patient will be asked to comment only on any pain. However, if the patient is guided towards giving infor mation on his perception of the tissue quality and com paring the movements of various levels of the spine, he learns that many more subtle parameters may be relevant to reassessment procedures and hence to his wellbeing.

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L While performing, for example, accessory move ment of the cervicothoracic junction the following ver bal interactions may take place. Physiotherapist performs accessory movements of the C5-7 segments: Q A Q A Q

'How does it feel when 1 move on these vertebrae?' 'The lower one especially hurts.' (performs central PA movement on C7) 'So this one hurts you the most?' 'Yes.' 'If 1 move it a little bit less?' (moves less deep into the

direction of movement) A Q

A Q A

'Now it's less?' 'Yes.' 'And if 1 move so far (goes back to the point where she suspected the pain to start again), then it flares up again?' 'Yes.' 'And like this it is less again?' 'Yes.'

With this method of questioning the patient may learn several things: first, that the physiotherapist is truly interested not only in finding the painful segments of the spine, but also that the therapist does not want to hurt him unnecessarily. Second, the patient may develop trust in the physiotherapist. The physiotherapist examines now Tl-4, which are not painful, but have a very limited range of motion. Q A Q A Q

'If 1 move in this area, how is this?' 'Good.' 'Does anything hurt?' 'No.' 'Do you notice any difference in elasticity in this area compared with above?' (moves gently in Tl-4

area and then back to a more mobile, but pain-free area of the cervical spine) A Q

'Well, it's hard to say. It somehow seems much stiffer.' 'That's what 1 felt as well. 1 think that this area (C7) may have become so painful because these adjacent areas are stiff. 1 would like to gently move those painful areas in your neck with these fine move ments; however 1 would not like to go into the pain

(gently shows the movements on the neck of the patient).

This area (shows now at Tl-4) 1 would like to treat a bit later, as soon as 1 know how your neck reacts to these little movements. Could you sit up again, and we will quickly look at bending forwards and backwards - just to see if your neck has liked these little movements.'

Summarizing the first session: collaborative treatment planning and goal setting At the completion of the first session, after a subjective and a physical examination as well as a first probation ary treatment, including reassessment, it is essential to summarize the main points. This is relevant to train the clinical reasoning processes of the physiotherapist and to inform the patient about the viewpoints of the therapist, to clarify the goals of treatment once more and to define the interventions to achieve these objec tives. Furthermore, the parameters which indicate any beneficial treatment effects need to be defined collab oratively with the patient. The process of collaborative goal setting requires skill in communication as well as in negotiation. At times a patient may Simply expect to have 'less pain', although it seems in the prognosis that reduction in pain intensity and frequency may not be easily achieved. It may even be more challenging if the patient states that 'first the pain has to disappear and then 1 will think of work and activities'. Almost always it is relevant to define goals with control of pain and wellbeing, includ ing normalization of activities, as fear avoidance behav iour has been described as one of the major contributing factors to ongoing disability due to pain (Klenermann et al 1995, Vlaeyen & Linton 2000). However, not only the avoidance of activities but also the avoidance of social contacts and interesting stimuli such as going to a theatre are important contributing factors (Philips 1987). Furthermore, a lack of relaxation or lack of bodily awareness during activities of daily living may be rele vant contributing factors and may need to be included in the collaborative goal-setting process. The following interaction could take place: Q A Q A Q A Q A

Q

'What would be your main goal of the treatment with me?' 'To have less pain.' 'I understand that. If you had less pain, what would you do again that you are not doing now?' 'Well, 1 would like to work in the garden, 1 love roses.' 'Are there any other things that you would like to do again?' 'I would like to invite people to my house again.' 'What keeps you from doing this now?' 'Well, if 1 invite people to the house and cook for them, then 1 am afraid that the pain just comes at that time. And 1 cannot expect much help from my husband in that case.' 'So if 1 understand you correctly, if you could have a bit more control over your pain, for example with simple movements, you would invite people to

Communication and the therapeutic relationship

A Q

A Q

A Q

A Q

A

Q

A Q

your house again and work in the garden with your roses again?' 'Oh certainly!' 'When would you be satisfied with your pain? 1 mean, if your pain was like a wave on the ocean, now it is a very high wave, but does the water need to be totally flat?' 'Oh no, 1 certainly can accept some pain! It just should not get worse than it is right now.' 'Do you mean, that now your pain is acceptable, but it should not get worse?' 'Yes, that's right!' 'So if 1 understand you correctly, you would like to perform these activities again, but you do not trust yourself fully to do this?' 'Yes, 1 am afraid to do these things again.' 'What seems more important to you: having more trust in doing these things and controlling the pain a bit, or do you need to be fully pain free?' 'Oh no, 1 don't mind a bit of pain. If possible 1 would like to be able to cook again, to ride a bicycle and to work in the garden - just those things which make life so much more enjoyable.' 'How about trying to work together on activities like cooking and working in the garden and see if we find ways to control the pain, if this should flare up?' 'Well, yes . . . that would be wonderful of course.' '1 suggest that on the one hand 1 might perform some movements on your back to loosen it up a bit, as 1 did before. However, 1 also think we should find some simple exercises together which you could perform in your daily life, exactly when you may get more pain. Is that something you would be willing to try?'

Initially in this interaction it seems that the patient only seeks 'freedom from pain' in its intensity; however, after a few probing questions it becomes clear that the woman is more probably looking for a sense of control over her pain and developing trust in activities that she has avoided so far. The use of a metaphor for the pain (as in this example 'a wave on the ocean') frequently shows that in fact the patient is seeking control rather than simply reduction of pain and improvement in wellbeing. Often it is useful to take the time for this process of clarifying treatment goals as unrealistic expectations may be identified and the patient some times learns that there are other worthwhile goals to be achieved in therapy as well. Furthermore, it aids reassessment purposes as both the phYSiotherapist and patient learn to pay attention to activities which serve as parameters - for example, trust to move, and control over pain rather than sensory aspects of pain alone (e.g. pain intensity, pain localization and so on).

At times phYSiotherapists think they are involved in a collaborative goal-setting process; however, they may be more directive than they are aware (Chin A Paw et al 1993). In order to enhance compliance with the agreed goals, ideally it is better to guide people by asking questions rather than telling them what to do. The following example may highlight this principle: The patient is a 34-year-old mother of three little children who takes care of the household and garden, nurses her sick mother-in-law, and helps her husband in the bookkeeping of his construction business. She is complaining of shoulder and arm pain. The physio therapist is treating her successfully with passive movements in the glenohumeral joint. However, the pain is recurrent and the physiotherapist developed the hypothesis that lack of relaxation and lack of awareness of tension development in the body and during move ments may be very important contributing factors as to why the pain is recurring. The phYSiotherapist would like to start to work on relaxation strategies which could be easily integrated into the patient's daily life activities and subsequently would like to start to work on bodily awareness of relaxed movement during daily life functions (see also example on p. 65). Directive in teraction Q

A

'1 think you need more quiet moments during your day. Because you work so much, your shoulder can never recuperate. 1 suggest that you just take some time off every day for yourself.' 'Yes, 1 think you're right. I should do this.'

This directive way may develop an agreed goal of treat ment; however, the patient is not provided with any tools on how to achieve this goal. This may impede short-term compliance (Sluys & Hermans 1990). Furthermore, it has been shown that compliance with suggestions and exer cises may increase if goals are defined in a more collabo rative way (Bassett & Petrie 1997). Another approach may be: Collaborative goal setting b y asking questions

Q A Q

'1 think you must be quite stress resistant when 1 see all the things that you are doing in your daily life.' 'Oh, well, yes . . .' (reluctant) 'Yes?' (makes a short pause and looks the patient in

the eye) A Q A

'Oh well, sometimes it is a little bit too much.' 'What are you able to do, when you feel it is becom ing a bit too much?' 'Well, in 3 months' time my husband and 1 are going for a long weekend to Paris without the kids.'

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L Q

A

Q

A Q

A Q

'Wow, that's wonderful! Hope you enjoy it! How ever, Paris is still a long time to go. What could you do in the meantime, when things get a bit too much? Have you discovered anything which you could do just during the day?' 'I don't know. 1 don't do anything special. 1 am not used to doing anything special for such things. Also at home when 1 was a kid we always worked a lot in our parents' business.' 'I think it would be useful if you could find some moments in the day in which to tank up a bit of energy again, before you continue with all your tasks. 1 think that your shoulder may benefit a lot from this.' (waits a moment and observes the patient) 'I have been thinking about that as well.' 'How would it be if we search for simple things which you could integrate into your daily life in which you can tank up a bit of energy? Maybe you already do very useful things in this regard, but if they're not done consciously, they may not be done frequently enough.' 'That's okay.' 'Could you describe a situation where you think it was all a bit too much for you in which your shoulder was hurting as well?'

Beginning of a follow up session : subjective reassessment Reassessment

In follow-up sessions spontaneous information about reactions to the last treatment is usually sought first, before a comparison to the parameter of the subjective examination is pursued explicitly. If the physiothera pist has suggested some self-management strategies to influence pain, it is also essential to address this some where in the subjective reassessment. It is important to remember at all times that statements of fact need to be converted into comparisons. The following communi cation could take place: 'Well now, how have you been?', or, 'How do you feel now compared with when you came in last time?' A 'Not too bad.' ET That tells me nothing, so . . . Q 'Any different?' A 'I don't know if this is usual, but I've been terribly tired.' ET Well, it seems that his symptoms have not been sig nificantly worse. However, 1 should not just assume that if they had been he would have said so straight away. The tiredness can be related and it can be a Q

favourable sign, so the response to his answer should be: Q 'Yes, it's quite common and it can be a good indica tor. How have your back and leg been?' A 'A bit worse.' ET Most responses need qualifying, but for 'worse' clarifying is mandatory: In what way?, Which part?, When?, Why? Spontaneous answers are still important, so I'll keep my questions as non directive as possible. 1.

In what way?

Q A Q A ET

what way is it worse?' 'My buttock has been more painful.' 'Sharper or more achy?' 'It's more difficult to get comfortable in bed.' That's not really answering my question, but it's telling me something about an activity, which I'm going to accept for the moment as being enough of an answer. 'In

2. Which part? ET Because he may have a nerve root problem 1 should determine if his calf pain has changed, and it would be better to do this before finding out the 'when' and 'why' of his increased buttock pain. Because 1 hope his calf hasn't worsened too, 1 am going to ask the question in a way that will influence him to say 'yes'. Q 'Do you mean your calf?' A 'No, that's about the same.' ET That's makes the answer to what 1 wanted to know very positive. 3. Q A Q A Q

A

When? 'When did you notice your buttock worsening?' 'Last night.' 'How about the night before?' 'No different from usual.' 'So there was no change from the time you left here after treatment until last night?' 'That's right.'

4. Why? ET It is essential to know if this increase was caused by treatment or other causes. 1 still don't know about his other activities. He may have done much more with his structures that he was not able to do before. Then it may even be a favourable response. At no time should 1 stop the subjective reassessment in this phase! Q 'Do you think it was what 1 did to you that made it worse?' A 'Not really, because the night before last was all right. And, actually, when 1 left here 1 felt better and 1 think 1 even had a better night than usual.'

Communication and the therapeutic relationship

ET That's a good answer - I know treatment did not make him worse, he even felt better. Let me check on that asterisk of sitting. Q 'So, you felt better after treatment and the night seemed better. How was sitting compared to before the treatment?' A 'Actually I think on the first day after treatment I could sit longer at work before it became uncom fortable as usual. However, yesterday I had to sit in an uncomfortable chair for 2� hours at a meeting during the evening - my buttock was quite sore during the last hour.' Q 'So after this sitting you felt the ache in your buttock more?' A 'Yes.' Q 'Did you feel anything in your calf then?' A 'No, only my buttock.' ET Well, the worsening seems related to his sitting, which was already a problem. I have already sug gested that he tries out a self-management exercise if his pain increases. I am aware that behaviour does not change over night, but I am curious to find out if he thought of trying out this exercise last night after the meeting, or if he stuck to his old habits. Q 'Were you able, last night, to try out that exercise I showed you last time?' A 'Exercise? No, I was so busy, I did not even think of it.' ET Okay, that's acceptable in the beginning - I have dif ficulty in changing my habits as well. But it shows me I have to repeat this exercise today during the session and I want to emphasize particularly the necessity of him trying it out, especially at those times when he has more symptoms. Now I want to know if he has recuperated to his initial state after this episode of sitting. Q 'After you went to bed and finally became comfort able, how was your night?' A 'I slept well, in fact I did not wake up at all last night.' Q 'Is that unusual?' A 'Well, it's at least 3 weeks since I could sleep a whole night. This is the first time since my buttock and leg started to hurt.' Q 'And how were you this morning compared with other mornings?' A 'I think about the same, back to what it was. A bit stiff for about 10 minutes and some difficulty put ting socks on.' Q 'Thank you. I'd like to summarize what I've heard, but please correct me if I'm wrong. Last night you had more difficulty getting comfortable in bed, but that this may be due to the longer period of sitting?' A 'Yes I think so.'

Q

A Q

A Q

'I can imagine that. It would be helpful the next time to try out that exercise of straightening your back to see if you can influence it.' 'Okay.' 'So last night you were more uncomfortable in your buttock, but your calf was the same. Immediately after treatment 2 days ago you felt better and you may have slept better. And last night YOLl could sleep the whole night for the first time for 3 weeks?' 'Yes that's correct. Overall I think I am a bit better.' 'Okay, now I would like to compare a few of the test movements of last time before we continue with treatment.'

If the physiotherapist had stopped this reassessment procedure relatively early in the conversation, impor tant information would have been lost and in fact the therapist may have stopped with the impression that the patient's situation had worsened. Especially in the beginning it takes questioning in much depth before the patient knows which details to observe and com pare. The phYSiotherapist needs to have a clear picture in mind of all the possible indicators of change, both in the subjective and in the physical examination. Too fre quently it can be observed in clinical situations that lack of in-depth questioning leads the physiotherapist to the interpretation that the situation has remained unchanged or worsened, but in fact the disorder has improved somewhat already. The questioning may also alert the patient to the necessity of trying out the self-management strategies the moment he starts to feel an increase in his symp toms, provided the exercises have been chosen with that objective. It is not unusual for patients to forget these self-management suggestions. However, this should not be interpreted as lack of discipline or moti vation; from a cognitive-behavioural perspective the education of self-management strategies deals with change of movement behaviour and habits, which usually do not change overnight.

Effects of self-management strategies

The way the physiotherapist reassesses the self management strategies may be crucial for the learning process of the patient and the initialization of change in movement behaviour. Random questions will often lead to random answers (Sluys et aI 1993): Q A Q A

'Have you been able to do your exercises?' 'Yes.' 'What did they do? Did they help?' 'No, not really.'

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L reassessed the lifting of your arm, it seems that your body liked the treatment as you could move the arm higher up and move it with more ease. The pain has not increased, but came on a little bit later in the range of movement. That's a good sign! Could I now check the other movements?

I n comparison with for example: Q

A Q

A Q

'Last time I recommended you try out two exercises - have you been able to think of these?' 'Yes, I've done them in the morning and in the evening.' 'Very good! You told me that you had symptoms in your shoulder and neck after writing at your com puter. Have you thought of doing the exercises then as well?' 'No, not at that particular moment. Maybe I should do them then as well.' 'Yes, that's a very good idea. It seems strange, but just at the time that something hurts it might be helpful to try this out. Maybe you can tell me next time what the effects were - are you going to work at your computer again?'

Reassessments of physical examination tests To determine the effect of a technique both the subjec tive and the physical parameters need to be assessed. The patient is asked if he feels any different from the treatment intervention. The following conversation shows how this can be done quickly, without sacrific ing the depth of information required. 'How do you feel now compared with when you were last in?' A 'About the same.' ET So subjectively he is about the same - now to check the movements. Q 'Do you remember a few of the test movements we did before?' A 'Yes, I lifted my arm, didn't I?' Q 'Yes - please could you compare that with before? How does your arm feel now?' ET I think he has gained about 20° in range before he made a grimace and the quality of the movement looked better. A 'It did not make my upper arm worse this time.' Q 'And now that your arm is down again, is it any worse as a result of lifting it?' A 'No.' Q 'Did you notice any difference in the way you moved?' A 'I think I could lift it a bit higher?' Q 'Yes, that's what I saw as well. You could move your arm higher before the pain started. How did it feel with regard to the quality of the movement? Did it feel any heavier or more difficult to move up?' A 'No, I think I could lift my arm a bit more easily.' Q 'Good. I would now like to summarize: we did these mobilization movements of your arm, which were not painful this time, and now that we have Q

It may be useful, especially if the patient feels that the symptoms have not changed, to ask if he feels that the quantity or quality of the movement has changed. There are at times situations where the patient starts to move more freely with more range, but the pain is still the same, so the patient experiences everything as being the same, although parts of his movements are already changing. By asking patients about these other aspects of the movement, they may learn about this and concentrate more on the aspects of the test move ment as well. Summarizing the information gained out of the reassessment frequently reinforces this learning process.

During a treatment intervention It is essential while performing a treatment technique such as passive mobilization to maintain communica tion. On the one hand, the physiotherapist wants to assess any changes in resistance to movement or motor responses - on the other hand, the therapist needs to know of any changes in symptom reaction to the movement. There may be no pain, or no pain to start with, but soreness may occur as the technique is con tinued; alternatively, while performing the technique there may be soreness or reproduction of the patient's symptoms, which behave in various ways: The symptoms decrease and disappear (they may increase during the first 10--20 seconds and then decrease). 2. The symptoms may come and go in rhythm with the rhythm of the technique. 3. An ache may build up which is not in rhythm with the technique. 1.

The communication issues associated with determin ing the behaviour of symptoms during the perform ance of the technique are related to trying to help the patient understand what the differences might be, so that he can give a useful answer: ET Now that I have started performing the technique I must know straight away what is happening to the patient's symptoms. Q 'Do you feel any discomfort at all while I am doing this?' A 'No, I can't feel any discomfort at all other than the stretching.'

Communication and the therapeutic relationship

ET This state of affairs may change fairly quickly, so in about 10 seconds I will ask again. Q 'Still nothing?' A 'No, I can feel a little in my left buttock now.' Q 'And that wasn't there when I started?' A 'Yes it was there, it's always there.' Q 'Has it changed since I started?' A 'Yes, it's slightly worse.' ET What I need to know now is whether this is a grad ual build-up into an ache, or whether it is going to 'come and go' in rhythm with the technique. To make it easier for him, the question is better asked in such a way that he can choose between two statements. Q 'Does it come and go in rhythm with the move ment, or is it a steady ache?' A 'It's just a slight ache.' ET What I need to determine as quickly as possible is whether it is going to increase with further use of the technique, whether it will remain the same, or whether it will decrease and go.

Directive communication Q

'You should not sit like this. That will certainly provoke pain. I think it is better that you take care in your daily life not to sit in so much tension. I will show you the exercise once again and I sug gest you do this exercise three times a day and, of course, when it hurts as well.' (shows the patient

once again how to relax the shoulders more towards a neutral position) A Q

'Okay.' 'I'll see you then next time.'

Next session: Q A Q

A Q A

'How have you been since last time?' 'I still have pain.' 'Have you been able to do that exercise I showed you last time?' 'Yes.' 'Could you show me once again?' 'Em . . . , I don't know if I have done it right, could you show me again?'

After a further 10 seconds, the question is asked:

In

Q 'Is it just the same or increasing?' ET The question in asked in this way because it is hoped that the symptoms will be decreasing and therefore it is better to influence the answer towards what is not wanted rather than to get a false answer suggested by me. A 'It's about the same.'

Mirroring, guiding by asking questions, including reassessments

Ten seconds later: Q A

'How is it now?' 'It's less, I think.'

In another 10 seconds: Q 'And now?' A 'It's gone.' ET That's an ideal response. I also had the impression that I could move further into the range. I will record this response later.

such cases the physiotherapist may be disappointed that the patient seems to have forgotten the exercise. However, this may be due to the timing within the ses sion (in the last few minutes of the session) and the quality of communication.

Q A Q A Q

A

not change anything immediately) Q A Q

Treatment and education of bodily awareness Communication is important not only during the application of passive movement techniques, but also during education of bodily awareness. The 34-year-old patient described in the communication examples of collaborative goal setting had a tendency to pull her shoulders in protraction and elevation. Although it may seem time consuming, a different communication technique may have immediate effects on understanding and compliance.

'How are you now?' 'It hurts at my shoulder.' 'Do you notice anything different about your posture?' 'No.' 'I see that you have pulled your shoulder forwards and up.' (mirrors the positions) (observes herself now) 'Oh yes, that's right.' (but does

A Q A Q A Q A Q

'Would you be able to change something?'

(pulls shoulders very far down and in retraction) 'Like this?' 'Maybe a little bit less. (guides the movement) How does it feel now?' 'That feels fine.' 'Anything that hurts you right now?' 'No.' 'You mean nothing of the shoulder pain that you had right before?' 'No.' 'Could you please pull your shoulder up and for wards, as you did before?' (performs the movement) 'How does it feel right now?'

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A

'That hurts at my shoulder.' (but does not change

automatically) Q

'How about trying to relax your shoulder again.'

(guides the movement, tactile) A Q A Q A

'Now it's gone.' 'Could you please do that again?' (pulls the shoulder up again) 'That hurts again.' 'And if you change the position again?'

A Q A Q A Q

A

'I suggest you monitor yourself a bit during the daytime, this afternoon and tomorrow. Maybe you'll notice that you pull up your shoulder quite frequently. We all often move automatically, with out thinking - I notice that with myself as well. Shall I explain what happens to your body when you perform such movements?' 'Yes please.'

(explains the principle of the bent finger; McKenzie 1 981) 'Aha!' 'Could you imagine that similar things happen in your shoulder?' 'Oh well, yes.' 'I have explained a lot to you - however I'm not sure if I've done a good job. Would you mind explaining to me in your own words what you've understood?' 'If I am sitting in such a tensed position the blood circulation is in trouble. If I move differently it is better. '

This has been a reassessment on a cognitive level. If the patient is invited to explain in her own words, the physiotherapist immediately understands if the expla nation 'touched ground' and in the patient herself deeper understanding may be enhanced. Q

Q A

Q A

(performs the movements without the aid of the physio therapist) 'Now it is much better again.'

In this case the reassessment is not only the evaluation of the symptom responses, but also the patient auto matically changing her movement behaviour as hap pened in the third repetition. To follow the sequence with cognitive reinforcement and explanation will often be useful. Q

Next session:

'Then I would like to suggest that you focus on your shoulder a few times during the day, to check if you are pulling it up, particularly when you feel it is hurting again. Maybe you could try this simple exercise then. If this helps you, then we come closer to understanding your pwblem. However, if it does not help, then we have to look for alternatives. So please try it and feel free to tell me if you think it is successful or not.'

'How have you been since last time?' 'I have noticed that I have this silly habit of pulling my shoulder up. I've paid more attention to this and I feel it's getting better already.' 'How did you notice that?' 'It does not hurt so much now and I am able to complete all the tasks that I have to do during the day.'

Retrospective assessments (after three to five treatments) Frequently it is necessary to assess the progress in the patient's symptoms and signs compared Witll those at the first visit. The physiotherapist may also have employed various interventions, the effects of which need to be determined. Furthermore, it needs to be clarified collaboratively with the patient if the agreed treatment objectives are still relevant or if new goals need to be defined. The latter becomes especially important if the patient is supported towards resum ing activities at work or in hobbies. A valuable question is: 'How do you feel compared with before we began?' The answer enables ilie phys iotherapist to see the progress in its proper perspec tive. It sometimes happens that a patient reports at each successive treatment to be feeling a bit better, yet at the fourth treatment session may say, 'Well . . . I'm not any worse.' It is for reasons such as this that retrospective assessment must be made a routine part of the thera peutic process. Sometimes the patient may be asked to define the percentage of progress: Q

'What do you think the percentage of improvement has been compared with when we began?'

For some patients it is difficult to think in these terms, in which case they may be asked : Q

A

'Do think you are less than halfway to being com pletely better?' 'Oh no, I'm more than half better, thank you.'

The communication may then continue, for example, as follows: Q

A

'That sounds good, tell me in what way are you better?' 'The aching doesn't bother me during ilie day now and when I get out of bed in ilie morning I don't feel stiff any more. Also I can put my socks on wiiliout any difficulty.'

Communication and the therapeutic relationship

'That's good. Any symptoms left? How is your day?' 'I still feel it a bit after I've been sitting for a long time.' 'Sitting for how long?' '2-3 hours.' 'Anything you can do about it then, once it comes on?' 'Well, as you suggested, I move my back or I put my arm or a pillow in my back while I'm sitting or I stand up and do this straightening exercise.' 'Do you feel this allows you to sit for longer?' 'Yes, then I can get on with my work again.' 'How's that in comparison with the first treatment?' 'Oh, then I could sit for only 10 minutes, so I think that's quite a step forward, isn't it?'

A : ' I would like t o play golf and tennis again.' Q 'Are there any particular movements that you think may be difficult?' A '1 think at golf only the bending down to pick up a ball. At tennis I'm not so sure, the quick changes and the deep reaching at forehand - I don't know.' Q 'Let's take these movements into the reassessment procedures and I think we should start to train them. Could you bring in a golf club with you the next time?'

After the assessment of the symptoms, activity levels and the employment of self-management strategies, it is essential to assess the subjective effects of the treat ment. The physiotherapist may ask, for example:

In this phase it is the objective not only to evaluate the overall therapeutic process so far, but also to anticipate possible future difficulties in order to enhance the patient's long-term compliance with the suggestions, instructions and self-management strategies (Sluys 2000). Similar questions may be posed as described in retrospective assessment. The anticipation of future difficulties may take place as follows:

Q

A Q A Q

A

Q A Q

A

Q

'I have done various things in the first few sessions. Is there anything that you think has been especially helpful - is there anything that you feel I certainly should not do to again?'

Furthermore, it is often useful to reflect on the learning process: Q

A

Q

A

'From all the things we have discussed and done, which has been particularly useful for you? In other words, what have you learned from the therapy so far?' 'I understand now that my being in the same posi tion for a long time may provoke pain. I've been working so hard over the last 2 years that I did not have time for my usual sports and when I was working I was concentrating so hard that I forgot about the stress on my body.' 'Is there anything that is particularly useful to you to do now for this?' 'Well, I feel it is really useful to think of the move ments of my back once I'm at work and I am already thinking of returning to my sports again.'

After having established this, a prospective assess ment in which treatment objectives are redefined may be useful: Q

A Q

'On which activities should we work together in the next period of treatment?' 'Well, I don't know, you're the therapist.' 'You told me you wanted to go back to your sports which sports?'

Similar questions need to be asked with regard to working situations, before reassessing the physical examination tests.

Final analytical assessment

Q

A Q

A Q A Q A

Q

A

Q

'We have now looked back at the therapeutic process. I'm glad that I've been able to help you so far. In the future, where would you anticipate diffi culties may arise again?' 'I don't know. 1 think if 1 stick to the exercises you taught me I should be in good shape, 1 guess.' 'I think so. However, we are all only human, so it may be that you forget some of the exercises over time. Which exercise would you do first, just in case your back started to hurt again?' 'I guess I would start with the straightening exercises.' 'When would you do them particularly?' '1 believe I would think of them after sitting or bending over.' 'Anything else?' 'Well, if 1 bend over for a longer period, it is also helpful to tuck my belly in, so 1 think 1 should not forget about that one too.' 'Are there any working activities which you think could cause you difficulties?' 'Well, 1 help out with a gardener at times - in spring we often put up fences and then 1 may lift a lot and may use a heavy sledgehammer.' 'Oh, that may be important. Can you show me the way you would do this?'

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L CONCLUSION Although this discussion about communication and its problems may seem lengthy, it merely touches the surface of the subject. Communication and the establishment of a therapeutic relationship nowadays

have been declared an integral part of physiotherapy (WPCT 1999, Mead 2000). However, communication is both an art and a skill which needs careful attention and ongoing training in order to enhance the assess ment and treatment process between the patient and the physiotherapist.

References Alsop, A. & Ryan, S. 1996. Making the Most of Fieldwork Education - A Practical Approach. London: Chapman and Hall Bassett, S. E & Petrie, K J. 1997. The effect of treatment goals on patient compliance with physiotherapy exercise programmes. Physiotherapy, 85, 130-137 Brioschi, R 1998. Kurs: die therapeutische Beziehung. Lei tung: R Brioschi & E. Hengeveld. Fortbildungszentrum Zurzach, Mai 1998. Burnard, P. 1994. Counselling Skills for Health Professionals. London: Chapman and Hall Charmann, R A. 1989. Pain theory and physiotherapy. Physiotherapy, 75, 247-254 Chin A Paw, J. M. M., Meyer, S., De Jong, w. et al. 1993. Therapietrouw van cystic fibrosis patienten. Nederlands Tijdschrift voor Fysiotherapie, 105, 96-104 de Haan, E. A., van Dijk, J. P., Hollenbeek Brouwer, J. et al. 1995. Meningen van clienten over de kwaliteit van fysiotherapie: verwachting en werkelijkheid. Nederlands Tijdschrift voor Fysiotherapie, 105, 18-22 French, S. 1988. History taking in the physiotherapy assessment. Physiotherapy, 74, 1 58-160 French, S., Neville, S. & Laing, J. 1994. Teaching and Learning - A Guide for Therapists. Oxford: Butterworth Heinemann Gartland, G. J. 1984a. Communication skills instruction in Canadian physiotherapy schools: a report. Physiotherapy Canada, 36, 29-31

Gartland, G. J. 1984b. Teaching the therapeutic relationship. Physiotherapy Canada, 36, 24-28

Grant, R 1. E., ed. 1994. Manual therapy: science, art and placebo. In Physical Therapy of the Cervical and Thoracic Spine. New York: Churchill Livingstone Hiirkiipiiii, K, Jarvikoski, A., Mellin, G. et al. 1989. Health locus of control beliefs in low back pain patients. Scandinavian Journal of Behavioural Therapy, 18, 107-118 Hayes, K. w., Huber, G., Rogers, S. & Sanders, B. 1999. Behaviors that cause clinical instructors to question the clinical competence of physical therapist students. Physical Therapy, 79, 653-667, discussion 668-671 Hengeveld, E. 2000. Psychosocial Issues in Physiotherapy: Manual Therapists' Perspectives and Observations. MSc Thesis. London: Department of Health Sciences, University of East London Hengeveld, E. 2003. Compliance·und Verhaltensiinderung in Manueller Therapie. Manuelle Therapie, 7, 1 22-132 Horton, J. & Bayne, R, eds. 1998. Counselling and Communication in Health Care. Counselling and

Communication Skills for Medical and Health Care Practitioners. Leicester: BPS Books.

Jensen, G., Shepard, K E & Hack, 1. M. 1990. The novice versus the experienced clinician: insights into the work of the physical therapist. Physical Therapy, 70, 314-323 Jensen, G. M., Shepard, K E, Gwyer, J. & Hack, 1. M. 1992. Attribute dimensions that distinguish master and novice physical therapy clinicians in orthopedic settings. Physical Therapy, 72, 711-722 Kendall, N. A. S., Linton, S. J., Main, C. J. et al. 1997. Guide to Assessing Psychosocial Yellow Flags in Acute Low Back Pain: Risk Factors for Long-Term Disability and Work Loss.

Wellington, New Zealand: Accident Rehabilitation & Compensation Insurance Corporation of New Zealand and the National Health Committee Keogh, E. & Cochrane, M. 2002. Anxiety sensitivity, cognitive biases, and the experience of pain. Journal of Pain, 3, 320-329 Kerssens, J. J., Jacobs, c., Sixma, H. et al. 1995. Wat patienten belangrijk vinden als het gaat om de kwaliteit van fysiotherapeutische zorg. Nederlands Tijdschrift voor Fysiotherapie, 105, 168-173 Klaber Moffet, J. & Richardson, P. H. 1997. The influence of the physiotherapist-patient relationship on pain and disability. Physiotherapy Theory and Practice, 13, 89-96 K1einmann, A. 1988. The Illness Narratives - Suffering, Healing and the Human Condition. New York: Basic Books K1enermann, 1., Slade, P. D., Stanley, 1. M. et al. 1995. The prediction of chronicity in patients with an acute attack of low back pain. Spine, 20, 478-484 KNGE 1998. Beroepsprofiel Fysiotherapeut. Amersfoort l Houten: Koninklijk Nederlands Genootschap voor Fysiotherapie/Bohn Stafleu van Loghum Lawler, H. 1988. The physiotherapist as a courisellor. In Physiotherapy in the Community. Cambridge: Woodhead Faulkner Main, C. J. 2004. Communicating about pain to patients. Schmerzen, alles klar? Zurzach, Switzerland Main, C. J. & Spanswick, C. C. 2000. Pain Management An Interdisciplinary Approach. Edinburgh: Churchill Livingstone Maitland, G. D. 1986. Vertebral Manipulation, 5th edn. Oxford: Butterworth-Heinemann Maitland, G. D. 1991. Peripheral Manipulation, 3rd edn. Oxford: Butterworth-Heinemann. Mattingly, C. & Gillette, N. 199 1 . Anthropology, occupational therapy and action research. American Journal of Occupational Therapy, 45, 972-978

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May, S. 2001. Patient satisfaction with management of back pain. Part 1: What is satisfaction? Review of satisfaction with medical management; Part 2: An explorative, qualitative study into patients' satisfaction with physiotherapy. Physiotherapy, 87, 4-20 McKenzie, R. 1981. The Lumbar Spine: Mechanical Diagnosis and Therapy. Waikanae, New Zealand: Spinal Publications Mead, J. 2000. Patient partnership. Physiotherapy, 86, 282-284

Merry, T. & Lusty, B. 1993. What is Patient-Centred Therapy? A Personal and Practical Guide. London: Gale Publications Philips, H. C. 1987. Avoidance behaviour and its role in sustaining chronic pain. Behaviour Research and Therapy, 25, 273-279

Pratt, J. W. 1989. Towards a philosophy of physiotherapy. Physiotherapy, 75, 114-120

Riolo, L. 1993. Commentary to Sluys, Kok & van der Zee (1993). Physical Therapy, 73, 784-786

Roberts, 1., Chapman, J. & Sheldon, F. 2002. Perceptions of control in people with acute low back pain. Physiotherapy, 88, 539-548

Rogers, C. R. 1980. A Way of Being. Boston: Houghton Mifflin Rotter, J. 1966. Generalized expectancies for internal versus external control of reinforcement. Psychological Monographs, General and Applied, 80, 1-5

Schachter, C. 1., Stalker, C. A. & Teram, E. 1999. Towards sensitive practice: issues for physical therapists working with survivors of childhood sexual abuse. Physical Therapy, 79, 248-261

Schon, D. A. 1983. The Reflective Practitioner. How Professionals Think in Action. Aldershot: Arena Schulz von Thun, F. 1981. Miteinander Reden - Stonmgen und Kliirungen. Allgemeine Psychologie der Kommunikation.

Reinbek bei Hamburg: Rowohlt Taschenbuch Verlag Schwartzberg, S. 1. 1992. Self-disclosure and Empathy in Occupational Therapy. Invited Paper at Occupational Therapy Conference, Trinity College, Dublin Sim, J. 1996. Focus groups in physiotherapy evaluation and research. Physiotherapy, 82, 189-198

Sluys, E. 2000. Therapietrouw door Voorlichting - Handleiding voor Patientenvoorlichting in de Fysiotherapie. Amsterdam: Uitgeverij SWP Sluys, E. & Hermans, J. 1990. Problemen die patienten ervaren bij het doen van huiswerkoeferungen en bij het opvolgen van adviezen. Nederlands Tijdschrift voor Fysiotherapie, 100, 1 75-179

Sluys, E. M., Kok, G. J. & van der Zee, J. 1993. Correlates of exercise compliance in physical therapy. Physical Therapy, 73, 771-786

Stenmar, 1. & Nordholm, 1. A. 1997. Swedish physical therapists' beliefs on what makes therapy work. Physical Therapy, 77, 414-421

Stone, S. 199 1 . Qualitative research methods for physiotherapists. Physiotherapy, 77, 449-452 The Age. 1982. 21 August Thomson, D., Hassenkamp, A. M. & Mainsbridge, C. 1997. The measurement of empathy in a clinical and non clinical setting. Does empathy increase with clinical experience? Physiotherapy, 83, 1 73-180 Trede, F. V. 2000. Physiotherapists' approaches to low back pain education. Physiotherapy, 86, 427-433 Van der Linden, M. 1998. Therapeutische relatie: een specifieke of een non-specifieke factor. NBMF-Nieuws, 1, 12-15

VJaeyen, J. & Linton, S. 2000. Fear avoidance and its consequences in chronic pain states: a state of the art. Pain, 85, 317-332

Wall, P. D. 1994. The placebo and the placebo response. In Textbook of Pain, ed. P. D. Wall & R. Melzack. Edinburgh: Churchill Livingstone Watzlawick, P., Beavin, J. & Jackson, D. J. 1969. Menschliche Kommunikation. Bern: Huber Verlag. WCPT. 1999. Description of Physical Therapy. London: World Confederation of Physical Therapy WHO. 2001. ICF - International Classification of Functioning, Disability and Health. Geneva: World Health Organization Wiegant, E. 1993. Tussen intimiteit en sexueel rnisbruik. FysioPraxis, 16, 24-27

69

71

Chapter 4

Contemporary perspectives in physiotherapy practice

THIS CHAPTER INCLUDES: • • •

•

Key words for this chapter Glossary of terms for this chapter Some contemporary perspectives in physiotherapy and the influence on and by the Maitland Concept of manipulative physiotherapy Paradigms in physiotherapy

KEY WORDS Biopsychosocial paradigms, movement

GLOSSARY OF TERMS Body of knowledge - theory which underpins clinical practice. Research in principle should contribute to the body of knowledge of a profession by generating and testing theories. Currently the body of knowledge of the physiotherapy profession is embedded in a biopsychosocial movement paradigm. The 'movement continuum theory' (Cott et al 1995) may serve as the model of practice and research in which all concepts of physiotherapy may find a place. Clinical reasoning - 'The thinking and decision-making processes associated with clinical practice' (Higgs Et Jones 2000). In a more

•

•

Movement as the central core in physiotherapy, including physiotherapy diagnosis The International Classification of

• •

•

Functioning, Disabilities and Health and its role in physiotherapy diagnosis

•

The pain revolution The role of movement in the treatment of pain Research and the body of knowledge of physiotherapy Clinical reasoning, research and assessment.

paradigms, physiotherapy diagnosis, quantitative and qualitative research,

clinical reasoning.

phenomenological perspective clinical reasoning concerns not only the medical diagnosis but also the patient and the personal illness experience. It is more than applied science; it is more likely 'applied phenomenology'. During a therapeutic session a clinical judgement is made about causes, ways to treat and how to integrate the patient actively in the rehabilitation process. The therapist may not always be explicitly aware of all the decisions made during this process (Mattingly Et Fleming 1994). Physiotherapists engage in complex forms of clinical reasoning in which they follow different paradigms. Individual illness experience - the personal experiencing of bodily

processes and the impact of social and cultural influences on this experience (Kleinmann 1988). Paradigm - model of practice or research. Kuhn (1962) had a formative influence on the awareness of paradigms in medical practice and research. By looking at the history of scientific developments he recognized that in each scientific community a set of presuppositions existed which guided the research of that group. Within a paradigm, assumptions, problems, research strategies, criteria and techniques are shared and often taken for granted by the community. Kuhn argued that a set of overt disagreements between natural scientists and social scientists existed about the nature

72

MAITLAND'S PERIPHERAL MANIPULATION

L

of legitimate scientific problems and methods, in which each group may be unaware of the paradigms of the other group. Paradigms function as maps or guides which dictate the kinds of issues to address, theories which are acceptable and procedures to solve the defined problem (Kuhn 1962). A shift in paradigm will take place if certain phenomena do not fit, are contradictory or cannot be explained by the existing dominant paradigm. Phenomenology - developed as a counter-movement to positivism in

the 18th century, this challenges the appropriateness of a positivist approach to research by stating that humans cannot be reduced to measurable units that would exist independently of their historical, cultural and social context. The topics of research within the philosophy of phenomenology are the values and the matters which seem to be significant to individuals within a certain context (Parry 1991). Salutogenic perspective Antonowsky (1987) suggests not only focusing on pathogenic

INTRODUCTION

•

stressors in research but also on those factors which promote health. A sense of coherence is described as an important contributing factor to a sense of health. He suggests that health is not a static state, but that it needs to be defined on a 'dis-ease' to ' ease' continuum. Physiotherapists may guide patients from an individual health experience and illness behaviour towards a sense of wellbeing and health-promoting behaviour with regard to movement functions.

An increasing number of physiotherapists have become

engaged

in

profession-specific

research

The physiotherapy profession saw widespread devel

underpinning physiotherapy practice and contribut

opment over the last four to five decades of the 20th cen

ing to the body of knowledge of the profession.

tury. Physiotherapists seemed to identify with a variety of the concepts and treatment methods that evolved

•

rather than with a common denominator. However,

ing physiotherapy practice and research. This devel

over the years there was a recognition of the need to: •

opment has brought forward physiotherapists who concern themselves with the philosophy of clinical

define and describe the specific role of physio

practice and research.

therapists in the medical landscape and in society (Hislop 1975, Parry 1991, Rothstein 1994, Belanger

•

1998) •

researchers, health-care policy makers, administra

identify common denominators in all the concepts

tors, etc. on the scope of current physiotherapy practice.

APTA 1988, KNGF 1992, Parry 1997, WCPT 1999) describe the specific body of knowledge to which research efforts should contribute (Hislop 1975, Parry 1991, Cott et al 1995, NPI 1997). Due to many professionalization efforts, physiotherapy has been going through an emancipation process in which it has become an increasingly autonomous pro fession. The development has encompassed various aspects: •

In many countries physiotherapists have moved away from an auxiliary status to direct-contact practitioners and increasingly assume their roles as equal partners in interdisciplinary teams.

•

The publication of descriptions of the physio therapy profession to inform clinicians, educators,

that constitute physiotherapy practice (Hislop 1975,

•

Within this context, discussions have been initiated regarding which specific paradigms should be guid

Based on a review of former editions of Maitland's pub lications, it may be concluded that these developments were not unobserved by Maitland, since he started prac tising in the 1950s. On the other hand Maitland himself, among others, by his numerous publications and lectur ing, contributed to the development of the identity of the physiotherapy profession. In particular, the follow ing aspects of the 'Concept' may have been of influ ence on certain achievements in the above-mentioned professionalization process. •

'Brick wall' analogy

(Chapter 1) - in the brick wall

analogy it is suggested that physiotherapists fol low a different decision-making process from that of other professionals (e.g. medical doctors) with

Higher degree courses have become available in

regard to the shaping of treatment. In this pro

many countries worldwide.

cess physiotherapists employ various paradigms

Contemporary perspectives in physiotherapy practice

•

simultaneously, as delineated in the clinical and

the results of research should contribute and within

theoretical sides of the brick wall analogy.

which paradigms clinical practice and research should

Assessment

-

one

of

the

first

publications

by

Maitland addressed the relevance of examination and assessment before embarking on a treatment process. It was emphasized that the specific clinical presentation of symptoms and signs (of movement dysfunctions) should guide the clinician in making decisions regarding treatment rather than the bio medical diagnosis itself. Although theories may change over the years, the primacy of clinical evi dence - in which the physiotherapist should prove if the chosen path of treatment is beneficial to the patient - will always remain a core element of clin ical practice (Chapter 5). •

be conducted (Shepard 1987, Jensen 1989, Parry 1991, Stone1991, Hullegie1995, NPl1997, Parry1997). It appears that the dualistic biomedical paradigm, dominant in both medical and physiotherapy practice since the 19th century, is increasingly being questioned as the basis for clinical practice and research. Within physiotherapy practice and research it is argued that

physiotherapists traditionally seem

to

adhere to a biomedical paradigm. This is explained from a historical viewpoint in which the founders of the physiotherapy profession in the19th and 20th centuries accepted medical hegemony and adopted the current biomedical perspectives on their work in exchange for professional recognition and permission to practise

The art of manipulative physiotherapy - in concert with

(Parry 1991, Barclay 1994, Welti1997). However, various

other founders of the International Federation of

physiotherapists believe that the dominant biomed

who

ical model should be replaced by a profession-specific

worked tirelessly for the integration of the 'art of

Orthopaedic

Manual

Therapists

biopsychosocial model of practice (Pratt 1989, Moon

manipulative

1990, Barclay 1994, Parry 1995, Carpenter 1997, Koke

physiotherapy'

(IFOMT),

(including

passive

movement and treatment progression) into the core

1997, Welti 1997, Wright 1999a).

skills of physiotherapists, passive movement may be considered as a 'kick-start' to active movement and may be an essential intervention in the overall rehabilitation process of patients. • •

Commitment to the patient

-

The biomedical model has been challenged by Engel

see Chapters 1 and

Communication and the therapeutic relationship

3. - the

Concept emphasizes the importance of communica tion and the development of a therapeutic relation ship at an early stage in the physiotherapist's personal professional development (Chapter

Biopsychosocial model

3).

(1977), who argues that the model places too much emphasis on explaining illness and disease by devi ations in biological processes. The biomedical model creates, according to Engel, a dichotomy with organic elements of a disease on the one hand and, on the other, the psychosocial elements of human malfunc tion, which are often too easily associated with causal

With the brick wall analogy Maitland moved away from

principles such as psychopathology or psychosocial

the biomedical diagnosis as the primary basis for deci

problems.

sions regarding the selection and application of physio

From a biopsychosocial perspective it is suggested

therapy treatments. Furthermore, he accentuated the

that various factors may contribute to the develop

necessity of independent decision-making processes by

ment and maintenance of disease, pain and disability:

physiotherapists in order to provide the best manipula tive physiotherapy care possible. However, Maitland

•

biological processes

emphasized that manipulative physiotherapy should

•

emotional aspects

always occur under the umbrella of recognized medical

•

cognitive aspects

and health-care practice (Maitland 1995).

•

social factors

•

cultural factors

•

behavioural factors.

PARADIGMS AN D THEORETICAL MODELS From biomedical to biopsychosocial frameworks Currently the medical and physiotherapy communities

Engel's ideas seem to receive increasing attention and acceptance in various fields of medical practice as dif ferent authors suggest following a biopsychosocial para digm, for example in the assessment and treatment of

have started to question the paradigms underlying

whiplash-associated disorders (Ferrari & Russel 1999),

clinical practice and research. In the field of physiother

in the management of low back pain (Waddell1987), in

apy, with the increasing wealth of profession-specific

the treatment of headaches (Holroyd et al1999) as well

research, it has been asked to which body of knowledge

as in the treatment of rheumatoid arthritis (Teasel &

73

74

MAITLAND'S PERIPHERAL MANIPULATION

Merskey 1997) or in the support of cancer patients (Turk et al 1998).

which promote a move forward towards an experi

Within the biopsychosocial model, the phenomeno logical construct of the 'individual illness experience' plays a central role. This relates to the personal experi encing of bodily processes and the impact of social and cultural influences on this experience (Kleinmann 1988). The following aspects are emphasized: •

The illness experience is always culturally shaped appropriate illness behaviour, on the personal biog raphy of the person, and on psychological processes, meanings and relationships, so that the social world is always linked with the inner experience of feel ing ill. In this experience powers may exist that can either amplify or reduce suffering and disability, includ ing the

•

behaviours of others as relatives or clinicians.

Every professional is trained to

transLate the

illness

experience of an individual into theoretical terms of disease and into a profession-specific taxonomy and nomenclature. •

Interpretation of the narratives of this individual experience should be a core task in medical prac tice. Neglect of the individual account of the per sonal experience may lead to an alienation of the patient or the caregiver.

The

saLutogenic viewpoints of

Antonowsky (1987) may

experience as proposed by Kleinmann (1988). Based on a critical appraisal of research outcomes, which have a tendency to focus on pathogenic factors, the introduc tion of a salutogenic perspective - which follows up questions as to why certain people stay healthy in spite of many stressors - has been suggested. salutogenic

perspective

emphasizes

various

aspects: •

merits attention in the

Loeser 1982, Pilowsky 1997). Behaviour may be con and sociocultural processes and will be influenced by earlier learning experiences. Fordyce (1982) suggests assessing pain and disability not only by verbal report and physical examination, but also by observing behaviour. In fact, it is argued that many health professionals observe and react to the behav iour of their patients without being explicitly aware of this (Fagerhaugh & Strauss 1977). Fordyce argues that humans and the complex behaviours they display can only be understood by considering their biomedical, genetic, psychological and environmental or social contexts. He suggests following up questions as to

why

certain behaviours take place rather than questioning which nociceptive processes lead to a certain kind of behaviour, thus leaving space for the interpretation of pain and disability from a pathobiological perspective as well as from emotional, cognitive and sociocultural viewpoints. Behavioural factors may be an essential element in the development of disability due to a pain experience (Philips & Jahanshani 1986, Klenermann 2004). Various

physiotherapists

suggest

integrating

cognitive-behavioural approaches in clinical practice, as many efforts will be undertaken to guide patients in changing their habits and (movement) behaviour (French 1988, Harding & Williams 1995, Lockwood 1996, Solomon 1996, Martinez et aI1997). In may be concluded that, in both medicine and physiotherapy, psychOSOcial aspects of pain, disability and illness (rightly) receive more attention now than before. However, it needs to be emphasized that the

certain people remain healthy and others get ill in

psychopathological processes or social problems. The

A sense of coherence

-

this appears to be an important

factor for successful coping with stressors and maintaining a sense of health.

states or disability are

not

necessarily indicators of

psychosocial aspects need to be considered as variables of the human experience and are more likely to be

contributing factors to ongoing pain and disability than causative ones (Kendall et aI1997).

Health and disease - these should be defined on two extreme ends of a dynamic continuum.

•

illness behaviour

presence of psychosocial variables in ongoing pain

the presence of certain stressors?

•

In particular,

more holistic biopsychosocial paradigm (Fordyce 1982,

Reflection on the basic viewpoints on health and disease which factors may be decisive as to why -

•

Schliffel et aI1998).

et al 1995, Pilowsky1997, V laeyen & Linton 2000, Waddell

complement the perspective of the individual illness

A

ence of health or wellbeing (Antonowsky 1987,

sidered as the result of biological, cognitive, emotional

and is dependent on what a society regards as

•

illness. Furthermore, the caregiver also seeks factors

Physiotherapy-specific paradigms

Following both pathogenic and saLutogenic paradigms, in

Although it appears that phYSiotherapists would read

which the caregiver seeks those factors which may

ily accept a biopsychosocial paradigm, it has been sug

lead to a move backwards towards an experience of

gested that this model should only be adopted within

Contemporary perspectives in physiotherapy practice

75 J

Figure

Person Subcellular

Tissue

in environment

Person

Movement continuum

knowledge of physiotherapy. The

in society

levels are interdependent, functions of one level influence movement

External factors

( ( (

4.1

theory: suggested model of body of

--

capacity of other levels. This model should incorporate all concepts of

--'___-i-- Internal factors __

physiotherapy practice. Reproduced

Individual/environment interface

by kind permission from Cott et al

(1995).

Micro Macro Continuum of movement

the specific framework of physiotherapy (Roberts

practice

According to Grant

(1995), a primary physiotherapy

paradigm may be defined in the maintenance and

1994, Grant 1995).

The need to formulate physiotherapy-specific para

restoration of function, in which clients are helped to

digms may be seen in the context of professionalization

return to an optimal functional activity and an enhanced

processes: it is argued that it is within physiotherapy's

appreciation of health and a healthy lifestyle.

own responsibility to identify physiotherapy-specific paradigms for clinical care, education and research,

Colt et al

(1995) have elaborated on Hislop's model

with the movement continuum theory of physiotherapy

which are required to be subjected to systematic study

(Fig.

(Tyni-Lenne

organ systems, body parts, the person in the envir

1989) in order to become an authority on physiotherapy's own body of knowledge (Parry 1991, Welti 1997).

4.1). Interrelated levels of molecules, cells, tissues,

onment and the person in the society are of influence on the movements of a person. It is recognized that external, social and cultural factors, as well as internal,

Physiotherapy paradigms: movement as the common denominator

physiolOgical and psychological factors will influence

It appears that, within phYSiotherapy, movement and its

and a movement potential, which ideally should be the

rehabilitation is considered the core of clinical prac tice and the common denominator to all concepts in phYSiotherapy, and various authors worldwide have contributed to this viewpoint. Hislop

(1975) proposed the formulation of a specific

paradigm for physiotherapy research within a concept of motion and pathokinesiology, in which motion was considered at different interrelated levels of cells, tis sues, organs, systems, persons and family. Sahrmann

(1993) argues that physiotherapists are

specialists in movement disorders, comparable to other medical specialists (e.g. cardiologists). She argues that movement should be considered as a specialized physio logical system just like all other systems. She recom mends

developing

a

classification

of

movement

dysfunctions and impairments as a basis for inclusion and exclusion criteria in physiotherapy research. Rothstein (1994) considers that physiotherapy should be in the domain of rehabilitation sciences and should enhance meaningful functioning in the lives of persons who seek the help of phYSiotherapists, while DeVries & Wimmers

(1997) argue that physiotherapy should be a

part of movement sciences.

the movement functions at each level of the movement continuum. Each level has a current movement capacity same. In this movement continuum all the different con cepts and methods of physiotherapy should find their place.

PROFESSIONAL DECLARATION S AN D THE MOVEMEN T PARADIGM The development of a specific movement paradigm in physiotherapy is increasingly reflected in the work of numerous professional associations in different countries. Their descriptions of the profession place

movement and movement functions attention (CSP

at the centre of

1990, CPA 1992, KNGF 1998, APTA

2001). The World Confederation of Physical Therapy also recommends following a movement paradigm and adheres to Cott et aI's movement continuum theory by pointing out that:

[Physiotherapy] is concerned with identifying and maximizing movement potential within the spheres of promotion, prevention, treatment and rehabilitation. This is achieved through interaction

76

MAITLAND'S PERIPHERAL MANIPULATION

Participation - social roles

Individual illness experience

Pathobiological processes Stages of tissue healing

connective tissue

viscera

Fi gure 4.2 Hengeveld

Model of ICF with the integration of a manual therapy specific taxonomy of impairment analysis. Adapted from

1999, with permission.

between physical therapist, patients or clients and caregivers, in a process of assessing movement potential and in working towards agreed objectives using knowledge and skills unique to physiotherapy.. . . It places full and functional movement at the heart of what it means to be healthy. wePT (1999, p. 7)

describe aspects of movement which cannot be directly observed with the regular clinical examination tools of the physiotherapist. Therefore, diagnosis in physiotherapy may be expressed in terms of movement dysfunctions using the levels of disability as described in the InternationaL Classification of Functioning, Disabilities and Health (ICF) (WHO 2001):

Physiotherapy diagnosis

Within the professionalization process and the declar ation of the specific body of knowledge, it has been debated over the last two decades that physiotherapists should make a specific diagnosis of the disorders they examine (Rose 1988, 1989; Sahrmann 1988; Guccione 1991; Delitto & Snyder-Mackler 1995; Wiarda et al 1998). The World Confederation of Physical Therapy takes a clear stance with regard to physiotherapy diagnosis and movement functions:

Diagnosis arises from the examination and evaluation and represents the outcome of a process of clinical reasoning. This may be expressed in terms of movement dysfunction or may encompass categories of impairments, functional limitations, abilities/ disabilities or syndromes. wePT (1999, p. 7) International Classification of Functioning, Disabilities and Health (ICFj

While the movement continuum theory (Cott et al 1995) eventually may become the theoretical model which underpins clinical practice and guides research efforts, in daily practice it may not be suitable for making a physiotherapy diagnosis, as the micro levels

•

Functions are the physiological or psychological

•

Body structures are anatomical parts of the body

functions of body systems

•

•

• •

•

•

such as organs, limbs and their components Impairments are problems in function or structure such as significant deviation or loss Activity is the execution of a task or action by an individual Participation is involvement in a life situation Activity limitations are difficulties an individual may have in executing activities Participation restrictions are problems an individual may experience in involvement in life situations EnvironmentaL and personal factors make up the physical, social and attitudinal environment in which people live and conduct their lives.

One suggestion is to incorporate the rCF in the basic taxonomy of physiotherapy and manual therapy prac tice (Hengeveld 1998, 1999) to allow follow-up of treat ment goals beyond impairment levels, as debated by Dekker et al (1993) and Van Baar et al (1998a). The analysis of impairments of movement function has been the specific domain of manual therapists. Figure 4.2 delineates a model in which manual ther apists can integrate their specific taxonomy of analysis

Contemporary perspectives in physiotherapy practice

Figure Physiotherapy process from a phenomenological perspective

4.3

A phenomenological

approach to the rehabilitatio n o f movement dysfunctions may guide p hysiotherapists i n a

Individual i1lnesl experience, behaviour

Experience of health maintaining behaviour

(Kleinmann 1988)

(Antonowsky 1987)

•

Movement sensitivity, activity intolerance

•

Impairments, activity limitations,

•

•

Illness behaviour (e.g. avoidance, help-seeking)

•

Suffering, distress

•

Pathobiological processes

t reatment objectives.

Symptoms, signs (Impairments) Trust. use of body, forgetting Body during activities

participation restrictions •

comprehensive planning of

•

•

Level of activity, participation Prevention/prophylactic measures awareness of use-of-self

•

Control: Knowing what to do/doing if recurrences occur (active coping

© Hengeveld 1999

strategies) - control over well being

of the components of movement impairment into a model of the ICF. This model may further serve in the definition of comprehensive treatment goals at all levels of disablement, in which the individual illness experience (Klemmann 1988) may determine the prior ities of goal setting at each level of disablement. In rehabilitation, the specific strengths of the different professions may be better utilized: for example, gener alist physiotherapists and occupational therapists have developed many skills in rehabilitation on the levels of activities and participation, whereas manual ther apists may give their special contribution to a team with the analysis and treatment of movement impair ments and pain.

The phenomenological approach to the movement paradigm

Within the movement paradigm, physiotherapists fre quently translate the individual illness experience (Klemmann 1988; see Biopsychosocial model above) of patients into their profession-specific taxonomy of movement dysfunctions and resources. From a phenom enological point of view physiotherapists may guide patients on the continuum as proposed by Antonowsky (1987) from 'dis-ease' to 'ease' or, in other words, physio therapists may guide patients towards a 'sense of health or wellbeing' and health-promoting behaviour with regard to movement function (Hengeveld 2003). In treatment planning, physiotherapists may 'think from the end' and consider the possible ideal state of movement functions if all treatment objectives could be achieved. In defining treatment goals with the patient, consider which aspects are missing in the

'ideal state' that could be followed up in treatment (Fig. 4.3): •

•

•

•

•

•

Which movement impairments should be improved, if an ideal state could be achieved? Which activities have to improve? Do any activities regarding participation need to be followed up? Does the patient seem confident (trusting) in moving the body in daily life? (If not, how can the manipulative physiotherapist guide the patient to the experience?) Does the patient move with an increased bodily awareness (and guarding) or seem to 'forget' the body during meaningful activities? Is the patient aware of any preventive measures and the way their body is used in daily life situations? Control - does the patient seem to have an adequate sense of control of the pain or wellbeing? If not, which measures should be undertaken? (See Appendix 2.)

Summary: paradigms and theoretical models

To summarize, the changing i nsights in paradigms, theoretical models and their consequences may be expressed in this concept of manipulative physiother apy as follows: •

•

The term 'nature of the person' and the specific frame of reference relate to the biopsychosocial paradigm, in which it is recognized that a patient's thoughts, beliefs, feelings and earlier learning processes may be important contributing factors to the disorder and need to be respected in treatment (Chapter 1). The 'art of manipulative physiotherapy' has con cerned itself principally with movement impairments.

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[ Fi gure 4.4 Theoretical aspects

Clinical aspects

ICD

ICF

(International Classification

(International Classification of

of Diseases)

Functioning, Disabilities and Health)

Biomedical diagnosis

Physiotherapy diagnosis:

Some of the current developments

of physiotherapy practice and research expressed in the 'brick wall' anal o gy.

Symptoms and signs of movement dysfunctions Commitment to patient:

Phenomenological perspective: illness experience and illness behaviour �� sense

of health or wellbeing and

health promoting behaviours with regards to movement functions

In the movement continuum theory it may find its place predominantly on the level of movement of 'body parts'. The treatment of these impairments with passive movement plays a central role in many movement disorders; however, physiotherapists have to consider if the treatment leads to improve ment of functioning on activity and participation. If this does not take place, appropriate interventions need to be taken (see Figure A2.1, Appendix 2). •

•

•

Physiotherapists increasingly assume 'movement', with all its dimensions, as a core commitment to patient care. The symptoms and signs which guide the therapeutic process are in fact symptoms and signs of movement dysfunctions and contribute to the specific physiotherapy diagnosis. Within the principle of 'commitment to the patient', a phenomenological approach to treatment may be followed with the concept of the illness experience. From this perspective, physiotherapists may guide patients with regard to movement from an 'individ ual illness experience and illness behaviour' towards an 'individual sense of health and health maintaining behaviours' (see Fig. 4.3). Some of the above-mentioned aspects may be expressed in the 'brick wall' analogy (Fig. 4.4).

THE PAIN REVOLUTION With the publication of the 'gate control theory' in 1965 (Melzack & Wall 1984) the traditional biomedical para digm seems to have been challenged. In this paradigm pain was considered as a symptom directly related to the extent of bodily damage, with the consequence that treatment was focused on removing or normalizing the underlying pathology of the pain. In the absence of

bodily damage the mind was assumed at fault and psy chopathology was inferred (Vlaeyen & Crumbed 1999). The gate control theory appears to have catalysed a shift towards a biopsychosocial paradigm in the research, assessment and treatment of pain, and pro posed that cortical processing was involved in the integration of both sensory-discrirninative and affec tive-motivational aspects of pain. The implication of this theory was that cognitive, emotional, behavioural, social and cultural dimensions were identified as essential con tributing factors to the pain experience of a person. From a neurophysiological perspective the gate control theory implied that pain was not only the result of nociceptive information ascending from peripheral structures but also that pain could be modulated by descending path ways in the central nervous system. This theory further proposed that pain could be a result of processing in neuronal networks rather than a consequence of tissue damage alone. However, it is argued that pain should be ascribed to diverse mechanisms of the nociceptive sys tem in neuronal networks rather than to a single neuro physiological pain mechanism (Cervero & Laird 1991) and to elements of neuroplasticity or learning processes (Loeser & Melzack 1999). Cervero and Laird (1991 ) suggested that to assess pain with its underlying neurophysiological pain mech anisms it is necessary to distinguish between: • • • •

nociceptive mechanisms peripheral neurogenic mechanisms central nervous system modulation autonomic nervous system influences.

The modulatory influence of the central nervous system on transmission of nociceptive impulses has received increasing attention in the physiotherapy literature, in which it is recommended that the central nervous system is viewed as an integrated cyclical system

Contemporary perspectives in physiotherapy practice

rather than a simple cause-and-effect system distin guishing between afferent and efferent aspects of func tion (Wright 1999b). For further reading see Gifford (1998a) and Butler (2000). Pain as a dynamic phenomenon

It is argued that the interpretation of neurophysiological pain mechanisms may be too linear and does not acknowledge the dynamics of the pain experience of a person suffiCiently. It is suggested that a pain experience often changes over time as a result of interactions between the illdividual, the environment and medical professionals (Delvecchio Good et al 1992) and also due to the increasing influence of cognitive, emotional and behavioural factors (Vlaeyen & Crombez 1999). An increasing sense of distress or suffering may contribute to the experience over time, if aspects such as a sense of helplessness, worthlessness and impaired self-esteem also start to play a role in the pain experience and dis ability (Corbin 2003). If the dynamics of a pain experi ence starts to change over time, there needs to be an explicit distinction between symptoms and signs of pain and disability. Furthermore, the interventions of a physio therapist have to be adapted with the incorporation of, for example, self-management and/or educational strategies. From a neurophYSiolOgical perspective different models are proposed in which the dynamics of a pain experience may be expressed. Gifford (1998b) with the mature organism model and Shacldock (1999) with the processing model suggest explaining the pain experience from the perspective that input to the central nervous system will be processed in the central nervous system, which consequently may influence output systems of the body. From a biological point of view, the brain or central nervous system may be seen as a discrimination centre which continuously scans the environment, the body and relevant past experiences (Gifford 1998b). Central nervous system processing may be influenced by biological factors, cognitive and emotional aspects, sociocultural meanings and previous learning experi ences. It is suggested that this processing of the central nervous system may be of major influence on efferent physiological systems, such as muscle tone, autonomic responses and endocrinological and immunological systems, as well as on behavioural reactions such as expression, movement or activities ('output mech anisms') (Gifford 1998b, Shacklock 1999). The role of movement in the treatment of pain

Over the last two decades of the 20th century many industrialized countries saw a dramatic rise in the number of individuals receiving compensation due to

pain-related disability (Waddell 2004). The changing insights on pain as well as the rise in the number of individuals with chronic pain have led to changes in paradigms regarding the treatment of pain. Within a cognitive-behavioural approach it is argued that disability due to pain pertains to performance behav iour (Fordyce 1997) and at times may be considered as a form of avoidance behaviour to activities or social con tacts (Philips 1987). It needs to be determined if the avoidance behaviour is adaptive and directly related to nociceptive processes or if it has become maladaptive due to cognitive and affective learning processes and sociocultural influences (Pilowsky 1997). However, in the presence of maladaptive behaviour, do not implicitly blame the patient, but take a multidimensional perspec tive in the treatment of pain and consider all possible influences in the assessment and treatment of patients in pain (Kendall et al 1997). Within this context, a favourable development regarding the specific role of physiotherapists in the medical world appears to have taken place: an increas ing number of papers have been published which focus on the role of movement in the treatment of pain and dis ability, in order to influence or prevent the (maladap tive) avoidance of activities and long-term disability due to pain: •

•

•

•

Fordyce (1995) suggests focusing on activity intol erance rather than on pain in the rehabilitation of many pain states. The terms mechanosensitivity and movement sensitiv ity should be used if movements provoke pain. The Paris Task Force describes the role of activity in the treatment of low back pain and suggests an approach of reduced activity rather than bed rest in acute pain states and that patients should be guided in resuming their full activity potential at an early stage (Abenhaim et aI2000). In the treatment of degenerative osteoarthritis, a dynamic approach is suggested by Bullough (1984), with a focus on normalizing joint mobility, muscu lar control, movement patterns and aerobic condi tion (Dieppe 1998). In fact exercise therapy has been found to have beneficial effects on pain and disabil ity in degenerative hip and knee osteoarthritis (Van Baar et aI1998b).

Some of the aforementioned publications describe activity or exercise therapy in the treatment of pain, implying a dominant role for active movements. However, if this refers to movement, rather than to activ ity or exercises, it may leave more room in clinical deci sion making for all forms of movement, as it is the

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[ opmlOn of the authors that both active and passive movement can assume their place in the treatment of many patients with pain and disability. Summary: the pain revolution

Symptoms and signs as described in the brick wall analogy in fact should relate to the multidimensional aspects of a pain experience. Physiotherapists should distinguish explicitly between the constructs of pain, disability and distress, define hypotheses with regard to these constructs and shape the treatment, communi cation and educational strategies accordingly. Over a short period of time after an acute nociceptive onset, cognitive and affective factors may start to play a role in the pain experience (VIaeyen & Linton 2000), which physiotherapists may address with, for example, con scious reassessment procedures, educational strat egies, communication and self-management strategies (Chapters 3 and 5, Appendix 2). Within this context a tendency to 'hands-off' treatment may be observed. However, the essence of manipulative physiotherapy as a hands-on profession and the power of therapeutic touch in the reintegrative role of bodily awareness and sense of self should not be underestimated (Rey 1995, Ledermann 1996, Van Manen 1998). The dynamic models as described by Gifford (1998b) and Shacldock (1999) may be an adequate learning and teaching tool for physiotherapy practice as they allow for explanations on the relevance of cognitive behavioural approaches, information strategies and the therapeutic relationship of physiotherapy practice. They may provide a framework for decision-making processes regarding the selection of physiotherapist directed interventions such as passive movement and the education of self-management strategies, bodily awareness and proprioception and gradual exposure to activities by, for example, medical training programmes or other forms of movement. With regard to primacy of clinical evidence, educa tional programmes as well as changes in therapeutic approaches based on insights of pain should lead to better functioning and wellbeing. Only by profound assessment procedures can the clinical evidence be delivered and these goals be achieved (Chapter 5).

RES E ARCH For some years, physiotherapy - like other health professions - has been under pressure to identify its added value to society and to justify its treatment methods by research processes. Within the profession alization process physiotherapists have increasingly

assumed their responsibility to conduct research which validates clinical practice. Currently, clinical practice seems characterized by an era of expert evaluation and evidence-based practice (Ritchie 1999) in which movement is increasingly becoming a core principle (Sahrmann 2002) as an expression of the specific body of knowledge of phYSiotherapists. In fact incorporating movement classifications as inclusion and exclusion criteria in phYSiotherapy-specific research has been proposed (Maluf et al 2000). Over the years a substantial body of publications has grown, supporting the use of both pas sive and active movement in many disorders (Chapter 2). Further within the ranks of physiotherapy, the debate has started as to which paradigms for clinical practice and research should be followed. It has been argued that within the art and science of physiother apy, science originally was concerned with the rational, deductive and measurable aspects of practice (quanti tative research) and the art as the intuitive, inductive and non-measurable part of practice (Shepard 1987). This approach to physiotherapy science as the sole contribution to the physiotherapy knowledge base has been questioned by many authors. Pratt (1989) argues that frequently physiotherapists tend to a more orthodox selection and presentation of what is seen as relevant areas of knowledge, i.e. an objective approach to clinical care, dealing with natural orders, probability, causality and experimental testing. However, daily practice is not related to an objective approach to patients: the setting, meanings and per sonal intentions play a relevant role in daily practice. With the application of predominantly biomedical knowledge, generated from an empirico-analytical paradigm, physiotherapists may have insufficient comprehension of the patient's subjective understand ing and experience of illness and their resulting behav ioural responses (Sim 1990). The practice of physiotherapy is more than the application of techniques - modalities of treatment and the clinical setting in which the technique is applied, together with other contextual factors are inte gral to the evaluation of the effectiveness of treatment. Physiotherapy research should therefore adhere to multiple paradigms and employ different approaches to research (Parry 1991, 1997). Ritchie (1999) considers that a pronounced emphasis on a scientific mission of bringing evidence may reduce the essence of the humanistic approach of health care. The input from personal, subjective dimensions has to be incorporated in research and clinical practice. The more traditional model of quantitative research may not be fully applicable to the clinical setting, and other forms of research (e.g. qualitative research) may be more responsive (Shepard 1987).

Contemporary perspectives i n physiotherapy practice

Within this debate, an increasing number of researchers recommend incorporating qualitative as well as quantitative research methods in physiotherapy research, in order to make a comprehensive contribu tion to the knowledge base of the profession in which theories and concepts can be generated as well as tested (Shepard 1987, Jensen 1989, Stone 1991, Shepard et al 1993, Parry 1995, Sim 1996, Smith 1996, Carpenter 1997). The following definition of research (DePoy & Gitlin 1998) underlines an open approach to research and the application of evidence-based practice, which on the one hand should be inductive in generating theories and, on the other, deductive in questioning and testing theories:

Research is a group of multiple, systematic strategies that generate knowledge about human behaviour, human experience, and human environments in which the thought and action processes of the researcher are clearly specified so they are logical, understandable, confirmable and useful. Evidence-based practice

Evidence-based practice is defined by Sackett et al as:

The conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. It is emphasized that evidence-based medicine is not 'cook book' medicine and the clinician needs a mastery of patient interviewing and physical examination skills (Sackett et al 1998, pp. 2, 3, IX). Although compliance with evidence-based practice is highly recommended, at times it may put clinicians in a dilemma in making decisions based on the 'best avail able external clinical evidence'. Part of the dilemma is caused by the fact that factors other than selecting treat ment procedures play an important role in providing optimal care. Schon (1983) argues that concern exists about the increasing gap between research-based knowledge and the professional knowledge that guides everyday activities in which practitioners need to interpret incomplete and ambiguous information in order to make decisions with regard to practice. In the rehabilitation of painful movement disorders the way that treatment is applied, the communication between the physiotherapist and the patient and aspects such as motivation, beliefs, learning experiences, collab oration, education, setting, individual concerns and so

on may influence the results of the treatments applied (Linton 1998). The inclusion and exclusion criteria for many stud ies form another dimension of the dilemma. Physio therapists may not always recognize their 'own' patients as they are presented in clinical studies: inclu sion criteria may be based on pathobiological diag noses rather than on movement disorders (Maluf et al 2000) or outcome measures used in the studies may not reflect the relevant clinical outcome measures of pain and movement function of the phYSiotherapist (Jones & Higgs 2000). Above all, many of the problems encountered in daily physiotherapy practice are multicomponential and multidimensional movement disorders, whereas many studies deal with problems which are unistruc tural in nature in which it is assumed that the prob lems have a single cause and need a single treatment approach. As a consequence of these dilemmas physiother apists are frequently left to their own devices in making the best decisions with and for their patients in daily practice. They often need a balanced and pragmatic approach towards clinical practice and results from 'evidence-based practice'. Not only will physiother apists need a mastery of patient interviewing and physical examination skills (Sackett et al 1998), but they will also need a proficiency in the application of various treatments,

including communication abilities and clinical reasoning skills. Only the application of consequent reassessment procedures allows for reflection on the decisions made with regard to treatment, be they arriving from the experiential knowledge base or from a propositional knowledge base as evidence-based research findings. Only the clinical results will indicate if the suggestions of the 'best evidence' are indeed applicable to the indi vidual patient (Chapter 5). Nevertheless, evidence-based practice is an essen tial skill to enhance clinical practice; however, it can only be applied successfully with an increased aware ness of clinical reasoning processes (Jones & Higgs 2000) and consequent assessment procedures. Here evidence-based practice correlates with one of the main pillars of this concept of physiotherapy: the primacy of clinical evidence (Wells 1996). Different research methods : quantitative and qualitative research

As stated above, various researchers recommend fol lowing different paradigms in research and applying both quantitative and qualitative research methods to underpin clinical practice. In particular, qualitative

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research methods may make implicit approaches, meanings and assumptions explicit, which in later stages may be put under the scrutiny of quantitative research methods. Some authors claim that clinical practice 'per defin ition' would be lagging behind science (Van den Ende 2004). Frequently this may be the case with the applica tion of insights from evidence-based practice (Linton 1998). However, insights or unusual observations from numerous clinical situations have led to meaningful research questions, which later could be generalized in overall practice (e.g. application of neurodynamics). In such cases clinical practice may walk ahead of science. In fact, it is noted by Parry (1991, p. 437) that many physiotherapists who contributed to current clinical practice employed forms of qualitative research with out expliCitly referring to this:

Current practice owes its diversity and vitality to qualitative observation....Bobath, Knott, Maitland and others who have contributed in no small amount to the knowledge and practice of physiotherapy went through a process, which is characteristic of ethnog raphy, to develop their concepts and techniques.... observed patients and own handling systematically, constantly analysing the effects, . . . keeping a written record, making comparisons with other records, and using insights from experience to modify techniques .. . .In this way physiotherapy can run ahead of science for decades before research in the biomedical sciences begins to provide objective supporting evidence. In the interim many innovations will be rejected as well as disseminated according to practitioners' judgement of their effectiveness. In order to allow for future innovative practice and not just to scrutinize existing practice, in times to come physiotherapy practice will need clinicians with a bal anced approach to the application of research findings and an open mind to clinical presentations which seem at odds with the current actual theoretical models and clinical frameworks. A critical testing of research find ings is needed in daily encounters with patients. This requires precise observational abilities, critical self reflection, lateral thinking, profound assessment and consequent reassessment procedures, and a refined and systematic documentation system which can describe both regular and uncommon clinical observa tions in sufficient detail.

CLINICAL REASONING Clinical reasoning undoubtedly has always been employed by clinicians; however, for the past three

decades clinical reasoning has received more attention in educational and research processes. A conscious con sideration of clinical reasoning processes has been rec ognized as a critical skill, which is central to the practice of professional autonomy (Higgs & Jones 2000) and enables profound clinical practice (Elstein 1978). Clinical reasoning is defined in various ways, for example, 'the thinking and decision-making processes associated with clinical practice' (Higgs & Jones 2000). The anthropologist Mattingly and occupational ther apist Fleming take a more phenomenological perspec tive in which they explain that clinical reasoning is mainly a tacit, half-conscious, complex problem solving process. In this process not only the medical diagnosis, but also the patient with his personal illness experience, is at the centre of attention. It is more than applied science; it is more likely 'applied phenomen ology'. During a therapeutic session a clinical judgement is made about causes, ways to treat and how to inte grate the patient actively in the rehabilitation process. The therapist may not always be explicitly aware of all the decisions made during this process (Mattingly & Fleming 1994). Physiotherapists employ highly complex clinical reasoning processes in which various paradigms to practice and different forms of clinical reasoning are followed (Hengeveld 2000): •

•

•

In some instances it will be a form of biomedical reasoning, in which the physiotherapist considers pathobiological processes mainly to detect precau tions and contraindications to treatment. Within the specific physiotherapy movement para digm, physiotherapists will follow a pathogenic perspective in which any abnormalities to move ment are examined. In the salutogenic perspective, measures are under taken or taught to maintain and promote health with regard to movement functions of an individual.

Various forms of clinical reasoning are described: •

• •

considering movement impairments, activity limitations and participation restrictions and their contributing factors, as well as pathobiological processes.

Diagnostic reasoning

-

Theoretical reasoning theory guiding clinical decisions. -

Procedural reasoning thinking about disease or dis ability and deciding on the procedures of assess ment and treatment which may be employed to restore the patient's movement functions. In exami nation and treatment multiple hypotheses may be generated based in cue acquisition and tested by -

Contemporary perspectives in physiotherapy practice

83

J reassessment procedures. Decisions may be based on hypotheses generated or the recognition of clini cal patterns. In manipulative physiotherapy prac tice this is probably one of the best known forms of clinical reasoning (Chapter 5). •

Interactive reasoning - takes place during the direct encounters between therapist and patient. It may be employed to: - understand the patient better - convey trust and acceptance - engage the patient in the treatment session - understand the disability from the patient's perspective - individualize treatment to the specific needs and abilities of the patient - use humour to relieve tension - construct a shared language of actions and meanings - inform the patient about the specific procedures and reasons for these in examination, treatment and reassessment (see also Chapter 3).

•

•

Conditional reasoning - more likely to be used by therapists with a phenomenological approach to practice. It is being employed in a wider social and temporal context. The therapist thinks about the overall condition of the patient, including the per sonal illness experience and context, and considers how the future condition and the patient's life might change as a result of the selected interventions. In treatment planning and during treatment, the thera pist interprets the meaning of the problem in the context of a possible future for the patient. Narrative reasoning - 'reasoning by telling stories'. Various forms of narrative reasoning are described: - the patient gives an account of the individual story, rather than being controlled by procedural questions; the therapist attempts to understand the patient's individual story ('narrative') (see also 'Psychosocial assessment', Chapter 5) the encounter between therapist and patient unfolds like a story, which may make an observer curious about how it unfolds later on therapists engage in story telling among col leagues, in order to make sense of the individual illness experience of their patients therapists may use stories to educate patients in a broader context, the therapist may enter the life story of the pa tient. Over the years of clinical experience clinicians seem to encapsulate their theoretical knowledge and may be strongly guided in the decision-making processes by the stories which they have experienced

with individual patients ('illness scripts') (Schmidt & Boshuyzen 1993). • • • • •

Practical reasoning Ethical reasoning Pragmatic reasoning Collaborative reasoning Teaching as reasoning

(Adapted from: Mattingly 1991 , Ryan 1995, Munroe 1996, Higgs & Jones 2000.) Clinical reasoning skills and science have become important aspects in professional declarations (WCPT 1999) and clinical reasoning is referred to regularly throughout this text. Clinicians being trained in this concept of manipu lative physiotherapy may recognize aspects of hypoth eses in inductive and deductive procedural clinical reasoning, as it has been one of the principles of the brick wall analogy to formulate hypotheses about the condition of the patient. Furthermore, some elements of interactive clinical reasoning may be recognized, following the emphasis on developing communication skills to enhance the exchange of information and understanding (Maitland 1986). However, it is essen tial to make the implicit processes which guide clinical decisions explicit, in order to guarantee independent practice Oones 1995), to guide novices on the path to expertise (Ryan 1995) and to support the overall devel opment of the profession (Grant 1995). It is recommended that physiotherapists consciously reflect on the individual clinical reasoning processes and on the hypotheses being generated, modified and tested during the therapeutic process (Grant et al 1988). Categorization of the hypotheses generated may enhance efficiency and the recollection of relevant information (Thomas-Edding 1987). Within this con cept of manipulative physiotherapy, therapists are encouraged to reflect on their hypotheses in some crit ical phases as well as in the planning stages of the thera peutic process, as described in Chapters 3 and 6. Clinical reasoning may be summarized as 'wise action' Oones 1997), in which phYSiotherapists endeav our to integrate three areas into their deCision-making processes (Butler 2000): 1. 2.

the best of science the best of current therapies with good assessment procedures and varied treatment strategies

3. the best of the patient-therapist relationship, with a client-centred approach with empathy, unconditional regard and genuineness (Rogers 1980), communica tion, educational strategies and an awareness of the possibilities of a cognitive-behavioural approach to the overall therapeutic process (Chapter 3).

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It can be concluded that clinical reasoning processes support the professionalization process of physiother apy, as summarized in the following quote by Grant (1995, p. 6):

Physiotherapy is both [an art and a science), and paradigms by their very definitions allow for both the art of clinicaL practice and the deveLopment of theory underLying such art through clinicaL reasoning and research, to develop the science of physiotherapy. CONCLUSION It has been acknowledged that Maitland - with the unfolding of the principles as outlined in this book has made a significant contribution to the develop ment of the declarative knowledge and identity of physiotherapy (Refshauge & Gass 1995). The Maitland Concept has progressed into one that meets the demands of current times as well as one that incorpo rates rather than excludes new methods and tech niques of assessment and treatment, provided they prove to be clinically valid (Wells 1996). The current era in physiotherapy seems to be determined by (biopsy chosocial) movement paradigms guiding the specific body of knowledge of physiotherapists, in which

evidence-based practice, clinical reasoning and vari ous forms of research play an important role in both research and clinical practice. Changing insights in the factors contributing to the pain experience of patients challenge physiotherapists to reflect upon their habit ual approaches to clinical practice and to integrate cognitive-behavioural perspectives and educational strategies into the art of manipulative physiotherapy. Nevertheless, it may be summarized that the unique approach to clinical practice with the principles as worked out by Maitland more than four decades ago still seems applicable at the beginning of the 21st century. It may be appropriate to conclude with the following quote from Professor Lance Twomey, Vice Chancellor, Professor of Physiotherapy, Curtin Univer sity of Technology, Perth, Australia:

Maitland's emphasis on very carefuL and comprehensive examination Leading to the precise application of treatment by movement and followed in turn by the assessment of the effects of that movement on the patient, forms the basis for the modern clinical approach. This is probabLy as close to the scientific method as is possible within the clinical practice of physical therapy and serves as a modeL for other areas of the profession. Twomey in Foreword to Refshauge & Gass (1995)

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Corbin, J. M. 2003. The body in health and illness. Qualitative Health Research, 13, 256-267 Cott, C. A., Finch, E., Gasner, D. et al. 1995. The movement continuum theory for physiotherapy. Physiotherapy Canada, 47, 87-95 CPA. 1992. Description of Physiotherapy. Toronto: Canadian Physiotherapy Association CSP. 1 990. Standards of Physiotherapy Practice. London: The Chartered Society of Physiotherapy Dekker, J., van Baar, M. E., Curfs, E. C. & Kerssens, J. J. 1993. Diagnosis and treatment in physical therapy: an investi gation of their relationship. Physical Therapy, 73, 568-580 Delitto, A. & Snyder-Mackler, L. 1995. The diagnostic process: examples in orthopedic physical therapy. Physical Therapy, 75, 203-211 Delvecchio Good, M. J., Brodwin, P. E., Good, B. J. & Kleinmann, A., eds. 1 992. Pain as Human Experience. An Anthropological Perspective. Berkeley: University of California Press DePoy, E. & Gitlin, L. 1998. Introduction to Research. Understanding and Applying Multiple Strategies. St. Louis: Mosby De Vries, C. D. L. & Wirnmers, R. H. 1997. Is fysiotherapie gevolgengeneeskunde? Fysiopraxis, 6, 10-13 Dieppe, P. 1998. Osteoarthritis: time to shift the paradigm. BMt 318, 1 299-1300

Contemporary perspectives in physiotherapy practice

Elstein, A., Shulman, L. S. & Sprafka, S. A. 1978. Medical Problem Solving: An Analysis of Clinical Reasoning. Cambridge, MA: Harvard University Press Engel, G. L. 1977. The need for a new medical model: a challenge for biomedicine. Science, 176, 129-136 Fagerhaugh & Strauss (1977) quoted by French, S. 1994. Psychosocial Aspects of Physiotherapy. Oxford: Butterworth Heinemann Ferrari, R & Russel, A. S. 1999. Whiplash: heading for a higher ground. Spine, 24, 97-98 Fordyce, W. E. 1982. A behavioural perspective on pain. British Journal of Clinical Psychologlj, 21, 3 1 3-320 Fordyce, W. E. 1995. On pain, illness and disability. Journal of Back and Musculoskeletal Research, 5, 259-264 Fordyce, W. E. 1997. On the nature of illness and disability. Clinical Orthopaedics and Related Research, 336, 47-51 French, S. 1988. History taking in the physiotherapy assessment. Physiotherapy, 74, 158-160 Gifford, L. 1998a. Pain, the tissues and the nervous system: a conceptual model. Physiotherapy, 84, 27-36 Gifford, L., ed. 1998b. The mature organism model. In Topical Issues in Pain - Whiplash: Science and Management. Fear Avoidance Beliefs and Behaviour. Adelaide: NOr Press Grant, R 1995. The pursuit of excellence in the face of constant change. Physiotherapy, 81, 338-344 Grant, R, Jones, M. & Maitland, G. 1988. Clinical decision making in upper quadrant dysfunction. In Physical Therapy of the Cervical and Thoracic Spine, ed. R Grant. New York: Churchill Livingstone Guccione, A. 1991. Physical therapy diagnosis and the relationship between impairments and function. Physical Therapy, 71, 499-504 Harding, V. R & Williams, A. C. d. C. 1995. Extending physiotherapy skills using a psychological approach: cognitive-behavioural management of chronic pain. Physiotherapy, 81, 681-688 Hengeveld, E. 1998, 1999. Gedanken zum Indikationsbereich der Manuellen Therapie. Part 1, Part 2. Manuelle Therapie, 2, 176-181; 3, 2-7 Hengeveld, E. 2000. Psychosocial Issues in Physiotherapy: Manual Therapists' Perspectives and Observations. MSc Thesis. London: Department of Health Sciences, University of East London Hengeveld, E. 2003. Das biopsychosoziale Modell. Angewandte Physiologie, Band 4. Schmerzen Verstehen und Beeinflussen, ed. F. v.d. Berg, Kapitel 1.4. Stuttgart: Thieme Higgs, J. & Jones, M., eds. 2000. Clinical Reasoning in the Health Professions, 2nd edn. Oxford: Butterworth Heinemann Hislop, H. J. 1975. The not-so-impossible dream. Physical Therapy, 55, 1069-1080 Holroyd, K. A., Malinoski, P., Davis, K. M. & Lipchik, G. L. 1999. The three dimensions of headache impact: pain, disability and affective distress. Pain Forum, 80, 425-431 Hullegie, W. 1995. Fysiotherapie, een Wetenschapstheoretische en VakJilosoJische Analyse. Utrecht: De TIjdstroom Jensen, G. M. 1989. Qualitative methods in physiotherapy research: a form of disciplined inquiry. Physical Therapy, 69, 492-500

Jones, M. 1995. Clinical reasoning and pain. Manual Therapy, 1, 1 7-24 Jones, M. 1997. Clinical reasoning: the foundation of clinical practice. Part 1. Australian Journal of Physiotherapy, 43, 167-171 Jones, M. & Higgs, J. 2000. Will evidence-based practice take the reasoning out of practice? In Clinical Reasoning in the Health Professions, ed. J. Higgs & M. Jones. Oxford: Butterworth-Heinemann Kendall, N. A. S., Linton, S. J., Main, C. J. et al. 1997. Guide to Assessing Psychosocial Yellow Flags in Acute Low Back Pain: Risk Factors for Long-Term Disability and Work Loss. Wellington, New Zealand: Accident Rehabilitation & Compensation Insurance Corporation of New Zealand and the National Health Committee Kleinrnann, A. 1988. The Illness Narratives - Suffering, HeaLing and the Human Condition. New York: Basic Books Klenermann, L., Slade, P. D., Stanley, 1. M. et al. 1995. The prediction of chronicity in patients with an acute attack of low back pain. Spine, 20, 478-484 KNGF. 1992. Visie op Fysiotherapie. Amersfoort: Koninklijk Nederlands Genootschap voor Fysiotherapie KNGF. 1998. BeroepsproJiel Fysiotherapeut. Amersfoort/Houten: Koninklijk Nederlands Genootschap voor Fysiotherapie/Bohn Stafleu van Loghum Koke, A. J. A. 1997. Andere aanpak lage rugpijnklachten. Fysiopraxis, 8, 16-18 Kuhn, T. 1962. The Structure of Scientific Revolutions. Chicago: University of Chicago Press Ledermann, E. 1996. Fundamentals of ManuaL Therapy PhysioLogy, Neurology and Psychology. New York: Churchill-Livingstone Linton, S. 1998. In defence of reason. Meta-analysis and beyond in evidence-based practice. Pain Forum, 7, 46-54 Lockwood, S. 1996. How can physiotherapists influence chronic pain behaviour negatively and positively? New Zealand Journal of Physiotherapy, 13-16. Loeser, J. D. 1982. Chronic Low Back Pain. New York: Raven Loeser, J. D. & Melzack, R 1999. Pain: an overview. Lancet, 353, 1607-1609 Maitland, G. D. 1986. Vertebral Manipulation, 5th edn. Oxford: Butterworth-Heinemann Maitland, G. D. 1995. The development of manipulative physiotherapy. S VMP B ulletin, 10, 3-5 Maluf, K., Sahrmann, S. & Van Dillen, L. R 2000. Use of a classification system to guide nonsurgical management of patients with low back pain. Physical Therapy, 80, 1097-1111 Martinez, A., Simmonds, M. J. & Novy, D. M. 1997. PhYSiotherapy for patients with chronic pain: an operant behavioural approach. Physiotherapy Theory and Practice, 13, 97-108 Mattingly, C. 1991. What is clinical reasoning? American JournaL of OccupationaL Therapy, 45, 998-1005 Mattingly, C. & Fleming, M. 1994. Clinical Reasoning: Forms of Inquiry in a Therapeutic Practice. Philadelphia: F. A. Davis Melzack, R & Wall, P. 1984. The Challenge of Pain. Harmondsworth: Penguin

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[ Moon, M. 1990. Rehabilitation and chronic musculoskeletal pain: a bio-psychosocial approach. New Zealand Journal of Physiotherapy, 4, 23-27 Munroe, H. 1996. Clinical reasoning in occupational therapy. British Journal of Occupational Therapy, 5, 196-202 NPl. 1997. 'Evidence-based' paramedische zorg. Een balans tussen 'consensus based evidence' en 'research based evidence'. Issue 4, 44 Parry, A. 1991. Physiotherapy and methods of inquiry: conflict and reconciliation. Physiotherapy, 77, 435-439 Parry, A. 1995. Ginger Rogers did everything Fred Astaire did backwards and in high heels. Physiotherapy 81, 310-319 Parry, A. 1997. New paradigms for old: musing on the shape of clouds. Physiotherapy, 83, 423-433 Philips, H. C. 1987. Avoidance-behaviour and its role in sustaining chronic pain. Behaviour Research and Therapy, 25, 273-279 Philips, H. C. & Jahanshani, M. 1986. The components of pain behaviour. Report. Behaviou r Research and Therapy, 24, 117-124 Pilowsky, I. 1997. Abnormal Illness Behaviour. Chichester: John Wiley Pratt, J. W. 1989. Towards a philosophy of physiotherapy. Physiotherapy, 75, 114-120 Refshauge, K. & Gass, E. 1995. Musculoskeletal Physiotherapy. Oxford: Butterworth Heinemann Rey, R 1995. The History of Pain. Cambridge, MA: Harvard University Press Ritchie, J. 1999. Using qualitative research to enhance evidence-based practice of health care providers. Australian Journal of Physiotherapy, 45, 251-256 Roberts, P. 1994. Theoretical models of physiotherapy. Physiotherapy, 80, 361-366 Rogers, C. R 1980. A Way of Being. Boston: Houghton Mifflin

Rose, S. 1988. Musing on diagnosis. Physical Therapy, 68, 1665 Rose, S. 1989. Physical therapy diagnosis: role and function. Physical Therapy, 69, 535-537 Rothstein, J. 1994. Disability and our identity. Physical Therapy, 74, 375-378 Ryan, S. 1995. The study and application of clinical reasoning research. British Journal of Therapy and Rehabilitation, 2, 265-271 Sackett, D., Richardson, W. S., Rosenberg, W. & Haynes, R B. 1998. Evidence-based Medicine - How to Practice and Teach EBM, 2nd edn. Edinburgh: Churchill Livingstone Sahrmann, S. 1988. Diagnosis by the physical therapist a prerequisite for treatment. Physical Therapy, 68, 1703-1706 Sahrmann, S. 1993. Movement as a Cause of Musculoskeletal Pain. Congress Proceedings of MPAA, Perth, Australia Sahrmann, S. 2002. Diagnosis and Treatment of Movement Impairment Syndromes. St. Louis: Mosby Schmidt, H. & Boshuyzen, H. 1993. On acquiring expertise in medicine. Educational Psychology Review, 5, 205-221 Schon, D. A. 1983. The Reflective Practitioner. How Professionals Think in Action. Aldershot: Arena

Schiiffel, w., Brucks, U. & Johnen, R, eds. 1998. Handbuch der Salutogenese - Theorie und Praxis. Wiesbaden: UListein Medical Shacklock, M. 1999. Central pain mechanisms: a new horizon in manual therapy. Australian Journal of Physiotherapy, 45, 83-92 Shepard, K. E 1987. Qualitative and quantitative research in clinical practice. Physical Therapy, 67, 1891-1894 Shepard, K. E, Jensen, G. M., Schmoll, B. J. et al. 1993. Alternative approaches to research in physiotherapy: positivism and phenomenology. Physical Therapy, 73, 88-101 Sim, J. 1990. The concept of health. Physiotherapy, 76, 423-428 Sim, J. 1996. Focus groups in physiotherapy evaluation and research. Physiotherapy, 82, 189-198 Smith, S. 1996. Ethnographic inquiry in physiotherapy research. Part 1, Part 2. Physiotherapy, 82, 342-352 Solomon, P. E. 1996. Measurement of pain behaviour. Physiotherapy Canada, 48, 52-58 Stone, S. 1991. Qualitative research methods for physiotherapists. Physiotherapy, 77, 449-452 Teasel, R W. & Merskey, H. 1997. Chronic pain and disability in the workplace. Pain Forum, 6, 228-238 Thomas-Edding, D. 1987. Clinical Problem Solving in Physical Therapy and its Implications for Curriculum Development. Proceedings of the 10th International Congress of the World Confederation of Physical Therapy, Sydney, Australia Turk, D. c., Sist, T. c., Okifuji, A. et aJ. 1998. Adaptation to metastatic cancer pain: role of psychological and behavioural factors. Pain, 74, 247-256 Tyni-Lenne, R. 1989. To id �ntify the physiotherapy paradigm: a challenge for the future. Physiotherapy Theory and Practice, S, 169-170 Van Baar, M. c., Dekker, J. & Bosveld, W. 1998a. A survey of physical therapy goals and interventions for patients with back and knee pain. Physical Therapy, 78, 33-42 Van Baar, M., Dekker, J. & Oostendorp, R. A. 1998b. The effectiveness of exercise therapy in patients with osteoarthritis of the hip or knee: a randomized clinical trial. Journal of Rheumatology 25, 2432-2439 Van den Ende, E. 2004. Editorial: Van kloof tot greppel. Nederlands Tijdschrift voor Fysiotherapie, 114; 1 Van Manen, M. 1998. Modalities of body experience in illness and health. Qualitative Health Research, 8, 7-24 Vlaeyen, J. & Linton, S. 2000. Fear avoidance and its consequences in chronic pain states: a state of the art. Pain, 85, 317-332 Vlaeyen, J. w. S. & Crombez, G. 1999. Fear of movement/(re)injury, avoidance and pain disability in chronic low back pain patients. Manual Therapy, 4, 187-195 Waddell, G. 1987. A new clinical model for the treatment of low back pain. Spine, 12, 632-644 Waddell, G. 2004. The Back Pain Revolution, 2nd edn. Edinburgh: Churchill Livingstone

Contemporary perspectives in physiotherapy practice

WCPT. 1999. Description of Physical Therapy. London: World Confederation of Physical Therapy Wells, P. 1996. The Maitland Approach to the Assessment and Treatment of Neuro-musculo-skeletal Problems. IFOMT '96 The 6th International Conference, Lillehammer, Norway. Lillehammer, Norway: IFOMT Welti, S. R. 1997. Massage und HeilgtjYnnastik in der ersten Hiilfte des 20. Jahrhunderts. Sempach: Schweizerisches Rotes Kreuz (SRK), Schweizerischer Physiotherapeuten Verband (SPV)

WHO. 2001. ICF - International Classification of Functioning, DisabilihJ and Health. Geneva: World Health Organization Wiarda, v., Heerkens, Y., Vogels, E. M. H. M. et al. 1998. Project fysiotherapeutische diagnose. Fysiopraxis, 3, 27-29 Wright, A. 1999a. Editorial. Manual Therapy, 4, 185-186 Wright, A. 1999b. Recent concepts in the neurophysiology of pain. Manual Therapy, 4, 196-202

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Chapter

5

Principles of assessment

THIS CHAPTER INCLUDES: •

Key words for this cha pter

•

Glossary of terms for this cha pter

•

The physiotherapy process assessment procedures to monitor the therapeutic process

•

In itia I assessment - aims

•

Reassessment

•

•

Assessment d u ring treatment -

development a n d recognition,

interventions

prognosis, i n teractive a n d

throughout the physiotherapy

•

Aspects of clinical reasoning

process.

science - hypotheses generation a n d testing, clinical pattern

retrospective assessment, a nalytical assessment, clinical reason i ng,

further than assessment. Assessment cou l d be performed as a mechanical process to prove the value of a technique. An alytical assessment im plies a nalysing one's thoughts about all aspects of the patient's disorder, treatment decisions a n d i nteractions to arrive at clearly defined a nswers. As well as enforced discipline, it requires an agile, sceptical a n d methodical mind. It involves the process of 'think', 'plan' and 'execute' (to) 'prove'. Assessment - i n cludes all proced u res which are undertaken to mon itor

Psychosocial assessment

Final a n alytical assessment

KEY WORDS

Analytical assessment - goes a stage

•

•

Assessment, reassessment,

GLOSSARY OF TERMS

n a rrative reasoning

Retrospective a nd prospective assessment

the therapeutic process t h roughout

psychosocial assessment.

Final analytical assessment -

all encounters between the

u nderta ken towa rds the end the

physiothera pist a n d the patient.

treatment series to reflect o n the

Assessment proced u res do not

therapeutic a n d educational

stop after the first exa mination

process, to determine the c u rrent

a t initial consultations in which

state inclu ding the effect of self

the physiothera pist comes to a

m a nagement strategies a n d to

diagnosis of the movement

make a prognosis a n d u ndertake

disorder of the patient a n d

interventions to enha nce long-term

develops collaboratively with the patient a treatment plan assessment is an ongoing

com pliance. Initial assessment - takes place in the first session(s) a n d inclu des

a nalytica l process t h roughout

su bjective and physical

all therapy sessions.

exa minations a n d first

Assessment during the application

reassessment procedu res. Scope:

of therapy - determines if

finding ca uses of and contributing

treatment objectives are being

factors to the movement d i sorder,

ach ieved and that n o u ndesired

determining a n y preca utions

side-effects occu r.

and contra i n d ications to

90

M A ITLAND'S PER IPH E R AL M A N IP U LATION

examination a n d treatment

Psychosocial assessment - an

assessment may give more insights

procedures, determining treatment

i n tegral part of the overa l l

into the world of the individ ual

o bj ective(s) and selecting

physiotherapy assessment. Th rough

illn ess experience of the patient

mea ningful interventions, actively

attentive l i stening to key words,

and may contribute to a

i n tegrating the patient in the

carefu l observation of key gestures

multidimensional a p proach to

process. Progressive assessment -

and asking deliberate qu estions it

trea tment.

is possible to ascertain w hether

Reassessment procedures - need to

retrospective a n d prospective

there a re a ny cognitive, affective

be u n dertaken regula rly in each

assessments are u n d e rtaken in

or sociocultural processes a n d

session to monitor the effects of

addition to the session - by-session

behavioural aspects ('yellow flags')

the treatm ent procedures.

assessments to determine the

that may hinder the return to full

overall effects of treatment.

function. In fact, psychosocial

INTRODUCTION As pointed out in the first chapter of this book, assess ment is one of the cornerstones of this concept of physiotherapy. Analytical assessment (evaluation) encompasses observation, judgement and reflection. It includes all procedures which are undertaken to moni tor the therapeutic process throughout all encounters between the physiotherapist and the patient. It is emphasized that assessment procedures do not stop after the first examination at initial consultation in which the physiotherapist comes to a diagnOSiS of the patient's movement disorder and develops collabora tively with the patient a treatment plan. During all ses sions the physiotherapist should explore, in cooperation with the patient, if and how the treatment goals are gradually being achieved. The selected treatment interventions - be they mobilizations, manipulations or other forms of physiotherapy practice - will be care fully monitored as to their effects and, if needed, the therapy will be adjusted to the actual situation of the patient. Assessment and treatment procedures cannot be viewed separately: assessment procedures have an automatic transition into treatment procedures and vice versa (Fig. 5.1). The therapeutic process is an expression of often complex, highly tacit clinical reasoning processes (Mattingly 1991, Higgs & Jones 1995) in which many different decisions need to be made and wherein the physiotherapist usually engages in vari ous forms of clinical reasoning at the same time (Edwards 2000). Although it will often be useful for beginners in the field to learn set procedures of assessment and planning of subsequent sessions, it is emphasized that the therapeutic process is a 'process of continuous improvisation, in which clinicians need to be able to

Physiotherapy process Session 1

Last Session

Therapeutic Relationship Figure 5.1

Assessment and treatment procedures are distinct

but inseparable components in the physiotherapy process. The whole process is carried by the development of a therapeutic relationship and communication. Reproduced by kind permission from Hengeveld

(2000).

simultaneously perceive and interpret multiple physi cal, psychological and social patient cues and adjust their treatment and responses to the evolving patient session. This form of dynamic interaction requires more than strong biomedical knowledge' Gones 1995). The sometimes delicate process in which the patient is guided from an 'individual illness experience with illness behaviours' towards an experienc€ of 'individ ual health and health-maintaining behaviours with regard to movement functions' (Hengeveld 2003), and in which the therapist integrates insights from 'evidence-based practice' (Chapter 4), is best governed by assessment procedures and continuous reflection. In contemporary descriptions of the physiotherapy profeSSion, examination and evaluation procedures are declared to be integral parts of the physiotherapy process (CSP 1990, KNGF 1998, WCPT 1999, APTA 2001 ). Regrettably in some European countries, phys iotherapists still have an auxiliary status in which they are expected to perform treatments as ordered by

Princip les of assessment

another authority in the treatment team and to leave out their profession-specific assessments as a basis for clinical decision making. Nevertheless, due to many professionalization efforts in many countries, physiotherapists increasingly assume their responsi bility as an equal partner in an interdisciplinary team. Within this professionalization process the physiotherapy-specific assessment procedures pro gressively play a unique role in interdisciplinary cooperation. However, in spite of this favourable professional development, .based on observations during supervi sions in daily clinical practice in various countries, it still cannot be emphasized enough that no physiother apeutic treatment should be carried out without

The employment of assessment procedures may be con sidered as a professional attitude of continuous critical appraisal. Herein the physiotherapist continuously assesses examination findings, evaluates treatment effects and above all reflects on the decisions and choices made. Additionally, the therapeutic relationship and the communication and educational processes are being assessed. With the use of continuous assessment procedures physiotherapists express their principal role in self-responsible 'problem solving of movement dys functions and enhancing movement' rather than solely performance of treatment measures as prescribed by another authority in the treatment team. At times it seems that some physiotherapists feel they would not be able to apply 'the Maitland Concept' if in certain clinical circumstances they would not be able to apply the art of passive mobilization techn iques or manipulations with some patients. If they nevertheless engage themselves in the process of con tinuous assessment and reflection they will always be employing one of the most essential aspects of this concept. thorough physiotherapy-specific examination.

Com munication In the process of continuous assessment communicat ion plays an essential role. Some communication strat egies are described in Chapter 3. Precise wording is essential. Furthermore, careful observation is import ant to pick up the subtleties of non-verbal commu nication as an expression of the individual illness experience or of the therapeutic relationship. In all phases of assessment, but certainly during reassess ment procedures, subtle communication may guide the patient to a different perception of the movement disorder. When the patient is guided towards self observation by gentle and precise communication strategies, it is in fact possible that the patient for the

first time experiences that beneficial changes in move ment functions occur, even if the pain seems lasting.

Balance between procedures and interactions: client centredness It has been shown that more experienced physiother apists, with their experience of pattern recognition and superior organization of their knowledge base, are more capable of interacting with the patient during treat ment procedures and develop a different kind of thera peutic relationship in which the technical procedures and social interactions with the patient are in balance (Jensen et al 1992, 1999). However, some qualitative research studies indicate that there may be a tendency for physiotherapists to let their procedures prevail in a first session, with a therapist-centred rather than a patient-centred agenda (Trede 2000). Additionally, more empathy towards the patients with their personal background appears to be shown in later sessions than in the first consultation (Thomson et a1 1997) and infor mation seeking with regard to the patients' personal experiences with their problem is more likely to happen in a second treatment session than in the first meeting (Sluys & Fennema 1989). Often this will be well received by patients; however, some patients require more 'sensitive practice' and may be 'lost' in a too pro cedural agenda if the setting has not been discussed beforehand (Schachter et al 1999) or if patients' per sonal or cultural beliefs have not been sufficiently respected (Edwards 2000). A beginner in the profession may feel overwhelmed with all the requirements to fulfil a more 'patient centred' agenda, as clinical experience seems to be an essential prerequisite to developing such an approach. There is some indication that experienced physiother apists have developed the interactive skills as a part of the intuitive, experiential knowledge base (Edwards 2000, Hengeveld 2000). While intuitive reasoning undoubtedly has its place within clinical practice under certain conditions, it has the disadvantage that it often contains the application of implicit knowledge. If not made explicit, beginners may not get sufficient sup port in clinical training to develop these implicit skills. Furthermore, it is possible that interactive skills have become so self-evident that they may not receive extra attention in the therapeutic process and are missing in the declarative knowledge of a profession. The following quote may serve as an example: 'Physiotherapists may give the impression that they do not recognize and publicly value the interpersonal and contextual aspects of their activities' (Bithell 1999). However, in order to allow a conscious development of these skills, it is important to find a healthy balance

91

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MA ITLAND'S PERIPHERAL MAN IPULATION

L during undergraduate training between the applica tion of more routine procedures and interactive rea soning skills. Recognition of some critical phases in the therapeutic process may aid in the development of a balanced approach between procedures and inter actions (see Fig. 3.3). It is important that the physio therapist not only seeks information, but also gives information to the patient at crucial moments.

• •

The World Confederation of Physical Therapists defines diagnOSiS within physiotherapy practice as follows:

Diagnosis arises from the examination and evaluation and represents the outcome of a process of clinical reasoning. This may be expressed in term of movement dysfunction or may encompass categories of impairments, functional Limitations, abiLities/ disabiLities or syndromes. wePT (1999, p. 7)

Interview style In order to gain relevant information with regard to physiotherapy diagnosis and treatment, as well as to simultaneously develop a therapeutic relationship, it is important to follow an interview style with half open questions rather than a fixed set of questions or a questionnaire. The procedures of history taking as described in Chapter 6 are in fact half-open questions in which the physiotherapist may seek clarification on information given and 'delve' further into a certain topic if it seems relevant. However, if these procedures of questioning are too rigidly applied, solely to find information on symptoms and signs with their conse quences, important information on patients' individ ual perspectives on their disorder and their capacity to cope with the disability may get lost (French 1988). Furthermore, if therapists rely solely on strict ques tions or even a questionnaire alone, many important cues such as facial expression, selection of words, into nation of voice - which are also very decisive in clinical decision making and the development of a therapeutic relationship - may be missed out. Therefore the physio therapist is encouraged to keep a certain flexibility in the application of the procedures of questioning and to integrate other forms of clinical reasoning (e.g. narra tive reasoning). This will enable the therapist to get an account of the patient's individual story rather than controlling the patient with strict assessment criteria in which the patient is allowed to talk only about those aspects that are relevant to physiotherapy diagnosis and treatment planning from the perspective of the physiotherapist (Thomson 1998). This process requires a high skill in interviewing and examination, which may be challenging for a novice in the field. It is recommended that the novice therapist initially follows an algorithm of set procedures, plan ning steps and certain communication strategies in crit ical phases of the therapeutic process (Chapter 6).

determination of treatment interventions define parameters to monitor the effects of all therapeutic interventions.

This description of physiotherapy diagnOSiS indicates that most of the diagnostics within physiotherapy fol Iow a movement paradigm; however, the findings of a physiotherapist may support pathobiological diagnos tics in the realm of medical practitioners as well. Furthermore, the description indicates that the inter ventions of physiotherapists are aimed at the enhance ment of movement functions. Passive mobilizations and manipulations frequently play a central role in this process and often may be considered as a 'kick-start' to normal active movement functions (Banks 2002).

Forms of assessment Various forms (and timings) of assessment have been described (Maitland 1987, 1991; Maitland et al 2001) and are summarized as follows: •

•

•

•

•

at initial consultation(s), including the welcoming and information phase reassessments in various phases of each treatment session assessment during the application of treatment interventions periodic retrospective assessments and prospective assessments to monitor the overall process final analytical assessment, including the parting phase in which measures are undertaken to enhance 'long-term compliance'.

These assessment forms need to be incorporated into critical phases of the therapeutic process, as described in Chapter 3.

Purposes of assessment Physiotherapy assessment serves several purposes: • •

physiotherapy diagnOSiS definition of therapy objectives

ASSESSMENT AT INITIAL EXAMINATION In the first treatment session(s) the physiotherapist has to sort out a complexity of information about the

Princi ples of assessment

patient and shape a treatment plan accordingly. This information includes the following cues: • • • •

•

•

biomedical psychological social cultural.

Often a considerable amount of improvisation is necessary to adapt the procedures to the special needs of the patient. However, and especially for novices in the field, it is essential to develop a clear, disciplined set of procedures of examination and planning. After some years of clinical experience, when these proce dures have become more natural, automatic skills, the experienced physiotherapist increasingly will be able to modify and adapt the basic procedures to the indi vidual needs of the patient.

Algorithm for first session(s}

This has been investigated with occupational therapists (Mattingly 199 1 ), but similar processes occur within physiotherapy as well (Hengeveld 1998, Edwards 2000, Jones & Rivett 2004) (Fig. 5.2).

Causes and contributing factors To achieve the above-mentioned objectives the physio therapist needs to have developed highly complex skills of clinical reasoning in which not only various forms of clinical reasoning but also various paradigms to medical practice are employed: •

When considering the causes of the patient's prob lem the physiotherapist follows a biomedical model of thinking in seeking information about pathobiolog ical processes. This is an essential element of assess ment, as it defines possible precautions and contraindications to physical examination and treat ment procedures; furthermore, it may support phys icians in biomedical diagnosis. If the physiotherapist suspects that the patient's disorder is not primarily a movement disorder, but a pathobiological process which requires further medical investigation, the patient should be referred back to the physician.

•

Another perspective which is frequently followed in the assessment of pain during movement is the employment of a neurophysiological model of pain mechanisms in which it is acknowledged that pain may exist due to processes in neuronal networks in the absence of pathobiological tissue processes. The research on pain and neurophysiological pain mech anisms provides physiotherapists with useful theoret ical frameworks for explanations of clinical practice.

•

As a most essential model for physiotherapy practice, the physiotherapist follows a biopsychosocial movement

The following algorithm of information, procedures, reflection and planning is suggested for a first session with a patient: • • •

•

•

Welcoming and information phase Subjective examination Summary and planning of the physical examination Physical examination, including first treatment and reassessment Summary of first session: - reflection/summarizing - hypotheses - planning of next session.

(These steps are described in detail in Chapter 6.)

Objectives of the first session(s) Within the first session(s) physiotherapists follow var ious objectives, searching for information regarding: • •

causes and contributing factors treatment goals and suitable interventions

active integration o f the patient i n the treatment process any precautions and contraindications as regards examination procedures or treatment interventions.

Causes

Treatment goals

Contributing factors

Selection of interventions

,

,.----.....-..,

/

CLINICAL JUDGEMENT

Contraindications? Precautions?

Active integration of the patient in the therapeutic process (Therapeutic relationship - communication)

Figure 5.2

Various objectives of

assessment in the initial phase of physiotherapy.

93

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M A I T LA N D ' S P E RI P H E RA L M A N I P U LAT I O N

paradigm i n which a physiotherapy-specific diagno sis of movement functions and disorders is defined, which serves as a basis for treatment planning. Within the different paradigms physiotherapists analyse various factors which may both cause and contribute to the patient's movement disorder. These hypotheses may include: • •

• • •

•

movement behaviour and habits impairments of various movement functions (e.g. joint movements, neurodynamics, muscle functions, soft tissues, etc.) activity levels, participation and lifestyle factors pathobiological processes cognitive, affective, sociocultural factors, earlier experience neurophysiological pain mechanisms.

The contributing factors may be one reason why the momentary nociceptive state or movement dysfunc tion developed in the first place or is maintained. In the Maitland Concept this was originally called 'the cause of the cause'; however, the term is somewhat awkward, as often a multitude of contributing factors may exist (see Reassessment below).

Treatment planning The causes and contributing factors should be taken into account when planning treatment, which opti mally takes place in a collaborative manner with the patient. However, it needs to be determined if certain interventions cannot be performed (yet), as precau tions and contraindications may be present. Treatment objectives regarding movement dysfunctions

Treatment objectives are probably best defined in terms of impairments/functions, activity and participation as described in the International Classification of Func tioning, Disability and Health (WHO 2001) (Chapter 4). Cognitive and affective goals Following the definition of the treatment objectives on the various levels of dis ablement and movement disorders, it is often relevant to define (and reassess) treatment goals on cognitive and emotional levels as well. Emotional factors, cogni tive aspects, beliefs and so on have been described as psychosocial risk factors (,yellow flags') to ongoing disability due to pain (Kendall et al 1997, Turk 1997, Linton 2000, VIae yen & Linton 2000). Physiotherapists increasingly acknowledge and follow up these factors in their therapies. . Fear - or better said, 'lack of trust' - of moving may be influenced directly by providing patients with the experience of the feared movements and activities

under the guidance of the physiotherapist (Muncey 1998). At times passive physiological movements may play an important role, which could be a first step towards active movement (Zusmann 1998). On a cognitive level, physiotherapists may pursue, for example, educational strategies with regard to the benefits of movement in spinal problems (Abenhaim et al 2000) or in degenerative osteoarthritic changes (Dieppe 1998). Furthermore, they may follow teaching strategies with regard to pain and neurophysiological pain mechanisms (Gifford 1998a, Butler & Moseley 2003), as the patient's own paradigms or belief systems may differ from those of the physiotherapist. It is pos sible that a patient believes that 'hurt equals harm' and therefore thinks that the disorder will be resolved by resting or by removing the structures at fault, whereas the physiotherapist follows the perspective of reduced activity rather than bed rest in acute nociceptive pain states with a gradual increase in the level of movement and activity as the healing process continues. If these viewpoints or individual paradigms have not been clarified, it may leave the patient confused and there fore pOSSibly impedes compliance with therapy and treatment outcomes. A recent study indicates the bene ficial effects of educational strategies on some physical examination tests (Moseley 2004). Selection of interventions

The selection of treatment procedures in the first session(s) takes place collabora tively with the patient, the physiotherapist offering var ious possibilities in which the agreed treatment goals may be achieved and reassessed. A balanced approach to the selection of treatment interventions is needed (McIndoe 1995), in which the phYSiotherapist has devel oped skills in various treatment methods. Currently the debate on the merits of 'hands-on' and 'hands-off' treat ment seems somewhat polarized, in which 'hands-on' treatment could be seen solely as a passive modality in which the patient becomes increasingly dependent on the hands of the physiotherapist. However, if passive movements are used judiciously in combination with self-management strategies, education and communi cation, manipulative physiotherapists have a lot to offer in the treatment of painful movement disorders and the secondary prevention of chronic disability due to pain.

Therapeutic relationship and active integration of the patient The therapeutic relationship has been described in Chapter 3. The first session starting with history taking follows various aims, including: •

information gathering with respect to physiotherapy diagnosis and treatment planning

Principles of assessment

•

the development of a therapeutic relationship (Casanova 2000).

Communication processes with regard to information gathering increasingly have become explicit proce dures and are well described (Maitland 1986). However, the interactions serving the therapeutic relationship and psychosocial assessment - with elements such as expectations, fears, emotions, beliefs and so on - usually take place impliCitly, often almost casually. Frequently these aspects of the therapeutic interactions do not receive much attention in under- and postgraduate physiotherapy education (Chin A Paw et al 1993, Wiegant 1993, Hayes et a11999) and seem to be taken as self-evident, not needing much further consideration. However, with regard to the definition of 'good physiotherapy practice', next to thorough professional skills, patients particularly appreciate those elements which determine a therapeutic relationship. Aspects such as empathy, friendliness, listening skills, having the impression that questions can be asked, explan ations, trust and the capacity to motivate people, etc. (de Haan et a11995, Kerssens et a11995, Sim 1996, May 2001) may in fact influence the active integration of the patient in the therapeutic process (Mattingly 1991, Klaber Moffet & Richardson 1997) and enhance com pliance to the recommendations and self-management strategies as suggested by the physiotherapist (Sluys 2000); for more details, see Chapter 3.

Precautions and contraindications In a first session in which initial decisions will be made regarding treatment goals and the selection of thera peutic interventions, it is essential to consider pre cautions and contraindications to the physiotherapy interventions. Clinicians may diagnose according to their thera peutic possibilities and blend out other causes and treatment possibilities for which different specialists in a team need to be consulted. This may be one of the major errors in the reasoning processes of clinicians, in which certain hypotheses are being favoured above less preferable hypotheses (Grant et al 1988). A sur geon, for example, may pOSitively search for a lesion to be operated upon and overlook possibilities of move ment therapy, or in a psychiatriC unit the patient may be screened for a psychiatric disorder while the pos sibility of an acute pathobiological process is ignored. Physiotherapists may have a tendency to search positively for movement dysfunctions and blend out pathobiological causes, which require the attention of a medical practitioner. Various publications repeatedly publish reports of patients seemingly presenting with movement disorders when in fact serious pathobiology

was present (Boissonnault 1995, Refshauge & Gass 1995, Wells 2004). However, the opposite has also been reported when a patient was treated for visceral problems, whereas the symptoms derived from a movement disorder (Grieve 1986). In atypical presen tations of symptoms it is important that the physio therapist is alert to serious pathobiological processes and refers the patient to the appropriate specialist if needed. Direct-contoct practitioners For many years it has been considered the specific responsibility of a physiothera pist to assess precautions and contraindications to examination and treatment procedures (Maitland 1968). However, since phYSiotherapists increaSingly assume the status of a 'direct-contact practitioner', responSibility and accountability increase with regard to possible contraindications or situations which addi tionally need the care of another specialist in the treat ment team. Physiotherapists need to develop a network of other specialists to whom a patient may be referred if this is deemed necessary.

Contraindication or precaution? In basic textbooks of physiotherapy the topic of contraindications at times seems somewhat clouded, as frequently it is stated that tumours, inflammatory processes, metabolic diseases and fresh fractures would be considered a contraindi cation to physiotherapy interventions. However, almost every physiotherapist will remember the treat ment of a patient presenting with such a biomedical diagnosis. These medical conditions may define cer tain precautions to particular physiotherapy interven tions; however, in themselves they may not necessarily be a contraindication. At times temporary contraindications to examin ation procedures and treatment exist, if specific bio medical information is missing. A patient may, for example, present with severe pain in the upper arm after a fall from a bicycle a couple of days ago. At inspection the patient shows haematoma in the upper arm and active movements of the glenohumeral joint are painful and restricted in most directions. The physi otherapist suspects a fracture and refers the patient back to the clinician. Medical examination reveals a stable fissure of the major tubercle of the humerus and 10 days later the patient is referred back to the physio therapist. The contraindication of the first session is now in fact an indication for movement therapy, while respecting the necessary precautions regarding the healing phases of the fracture. Rather than the above-mentioned pathobiological conditions, frequently it may be more helpful in the assessment of patients with low back pain to identify

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any risk factors for serious disease ('red flags')l which should aid the clinician in making decisions regarding further medical investigation or referral to other clin icians (CSAG 1994, Kendall et a11997, Waddell 2004): •

• • • • • • •

• • • • •

features of cauda equina syndrome (especially urinary retention, bilateral neurological symptoms and signs, saddle anaesthesia, loss of anal sphincter tone or faecal incontinence) significant trauma systematically unwell, weight loss history of cancer fever intravenous drug use steroid use patient <20 years or >50 years, presenting with a first episode of pain severe, unremitting nighttime pain pain that gets worse, once lying down marked morning stiffness ESR >25 X-ray: vertebral collapse or bone destruction.

When indicated, various body systems should be screened in the first physiotherapy consultation in order to identify pathological processes which require the attention and diagnosis of another specialist. The following screening is suggested: • • • • • • • • • • •

cardiovascular system pulmonary system gastrointestinal system urogenital system endocrine system nervous system pathological origins of head and facial pain musculoskeletal system disease rheumatic disease psychiatric disorders skin disorders.

For detailed reading, consult Boissonnault (1995) and Goodman & Snyder (2000). In general, information from the basic examin ation procedures of the manipulative physiotherapist (Chapter 6) may highlight situations in which patients

need referral to an appropriate medical practitioner (Refshauge & Gass 1995): • •

• • •

•

•

• •

Precautions In the absence of contraindications, cer tain precautions may need to be respected in examin ation or treatment procedures. Physical examination In the planning phases of physi cal examination and treatment precautions must be considered in order to determine the extent of physical examination that can be undertaken safely. In this regard, physical examination is not necessarily a fixed set of standard procedures. The precautions (and contraindications) are mostly determined by hypotheses with regard to pathobiolog ical processes and neurophysiological pain mechanisms. In dominant nociceptive or peripheral neurogenic mechanisms the constructs of 'severity and irritability' of pain and 'nature' factors serve in the decision making process regarding dosage (extent) of physical examination and initial treatment (see 'Planning of the physical examination', Chapter 6). Precautions in relation to physical examination pro cedures may be determined by: • •

1

Reference has been made to so-called 'orange flags', which are indicative of psychiatric disorders for which patients should also be referred to appropriate practitioners. This may be an essential distinction from biopsychosocial risk factors ('yellow flags') to long-term disability due to pain, which are not necessarily indicators of any psychosocial problem or psycho pathological process (Main 2004).

any severe unremitting pain any severe unremitting pain that stays the same or worsens despite rest, analgesia or appropriate intervention severe pain with little disturbance of movement severe night pain worsening neurolOgical deficit despite appropriate intervention non-mechanical behaviour (e.g. excellent response to anti-inflammatory medication, little movement disturbance, lack of response to analgesia, unusual pain patterns, inability to ease symptoms by positioning or postures or movement, heat or other modalities, long-lasting morning stiffness) severe pain without major trauma (or severe undiagnosed pain following major trauma) or a relatively minor incident in history leading to severe pain and disability severe muscle reactions ('spasm') marked trauma prior to the current symptoms.

•

• • •

the irritability of the disorder the severity of the disorder pathobiological processes - tissue mechanisms, stages of tissue healing, dominant neurophysiological pain mechanisms the stage and stability of the disorder (history) the patient's general health the patient's movement behaviour, perspectives and expectations.

Principles of assessment

Precautions in treatment planning During treatment plan ning and before the application of each intervention, it is essential for the physiotherapist to consider: 'Which objectives do I want to achieve with this intervention but what should not happen?' This clinical question is often answered implicitly by more experienced phys iotherapists; however, for novices in the field it is essential that they consider these questions explicitly before the application of any treatment intervention (mobilization, electrotherapeutic modality, exercises, information strategies, etc.). The consideration of precautions during the applica tion of therapeutic interventions is an important element of 'assessment during the treatment' in which the physiotherapist regularly checks whether treatment goals are being achieved and that no undesired side effects occur (see Assessment during treatment below). •

•

During treatment the therapist should be carefully monitoring inflammatory signs and nerve con duction by the regular evaluation of reflexes, sen sation and muscle strength, as well as the occurrence of pain, if the objective of treatment is to move within pain-free limits. The therapist should also monitor a fracture site if movement is already tak ing place but the fracture is not yet 100% stable. Reassessment of cognitive information to monitor if the information given to the patient was clear and did not increase any confusion. The patient may repeat in his own words how he understood the information; it is essential to give the patient time to ask questions and to refer back to the infor mation ('I gave you a lot of information last time, but I'm not sure if it was a bit too much. Do you have any questions regarding this?').

an ultimate source of information in the diagnostiC process. Therefore the process of information gathering with regard to physiotherapy diagnostics may stretch out over the first two or three treatment sessions before most hypotheses are clarified and a more definitive course of treatment is outlined (see Fig. 5.1). REASSESSMENT As pointed out at the beginning of this chapter, the effects of the various interventions are continuously monitored and the treatment is adapted to the actual situation of the patient as required. Reassessment proce dures play a fundamental role in this process. Reassess ment has always been an important aspect of the Maitland Concept of physiotherapy. As a process it was first described in 1968 (Maitland 1968) and nowadays it has become a part of the declarative knowledge of the profession (WCPT 1999). Reassessment procedures should take place during each treatment session: •

during the initial physical examination phase in the first encounter between physiotherapist and patient, after the examination of various active and passive movement tests

•

at the beginning of each subsequent treatment ses sion: pretreatment assessment, to reflect on the reac tions to the last treatment session and the time before the patient came to therapy

•

immediately after the application of the various treatment interventions - proving the value of the interventions; this includes interventions such as information and education

•

at the end of the treatment session.

Summary: purpose of initial assessment

Reassessment procedures have different purposes:

On the one hand, the first session(s) serve to gather information with regard to causes, contributing fac tors, precautions and contraindications, and treatment planning, and on the other hand to develop a thera peutic relationship. During this process the physiotherapist develops multiple competing hypotheses concerning sources of movement disorders, pathobiological processes, pre cautions and contraindications, contributing factors, individual illness experience, levels of disablement, management and prognosis. These hypotheses may be confirmed, modified or rejected depending on the results of the examinations and the reactions to the first treatment interventions. If treatment interventions are accompanied by thor ough reassessment procedures, treatment itself becomes

•

They allow the physiotherapist to compare treat ment results, hence proving the value of the selected interventions.

•

Reassessment after treatment aids differential diag nosis. Not only examination findings but also reac tions to treatment interventions (particularly with passive movements) make a contribution to differ ential diagnosis of the sources of the movement dysfunctions.

•

Reassessment enables the physiotherapist to reflect on the decisions made during the diagnostic and therapeutic processes. Through regular reassessment procedures hypotheses with regard to sources, con tributing factors and management strategies may be confirmed, modified or rejected. Via the consequent

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[ application of reassessment procedures the physio therapist learns to recognize patterns of clinical pre sentations, with more or less successful reactions to the intervention selected. For these reasons reassess ment procedures support the development of the individual, experiential knowledge base of the physiotherapist. •

•

Regular reassessment procedures additionally sup port the learning processes of the patient. From a cognitive-behavioural therapy perspective, reassess ment procedures may assist the patient in develop ing the perception that beneficial changes occur, even if the pain as a sensation seems lasting. It is during the reassessment that patients may actually experience changes in a state in which they did not expect any differences to occur. With the combination of careful communication strategies and a good awareness of the possible changes in subjective and physical examination parameters ('asterisks'), reassessment procedures may be considered as one of the crucial aspects of the therapeutic process.

Box

-

5.1

Indicators of change------"1

Subjective examination •

Pain : sensory aspects such as intensity, quality, d u ration, localization, frequency

•

Level of activity a n d participation normalizes

•

Trust t o use body again i n daily life functions

•

Decrease in the use of medication

•

I n creased u n derstanding

(WHO 200 1 )

•

Em ployment of diverse coping strategies if the pain or discomfort fla res up again

Physical examination pa rameters •

I nspection para meter (e.g. anta lgic posture)

•

Active tests: range of motion, quality of movement, sym ptom response

•

Passive tests: cha nge in the behavio u r of pain, sense of resistance and motor responses ( 'spasm')

•

Iso metric m uscle testing: changes in strength, quality of contraction and symptom response

•

Palpation fin d i ngs: quality and symptom response

•

Neurological conduction testing: cha nges i n quantity a n d q u a l i ty o f responses

Indicators of change In the application of reassessment procedures physio therapists need to have a clear picture in mind as to how the symptoms and signs may change as a result of the interventions (Box S.l). 1t is possible that the patient initially may perceive the condition as unchanged, not having learned yet which small changes may be considered as a positive development. If the reassessment in such a case is only superficial, the thera pist may react too quickly with a different approach to treatment. However, if the therapist more profoundly assesses the details of the various symptoms and signs and educates the patient to observe accordingly, both the physiotherapist and the patient may learn that the previ ous treatment in fact has made a beneficial change in the patient's movement disorder and the selected approach to therapy needs to be continued.

Treatment intensity •

For exa m ple, passive movement, active exercises, soft tissue tec h n iques, higher dosage possible without provoking d i scomfort

Behavioural parameters •

For exam ple, facial expression, non-verbal la nguage, eye contact, use of key words a n d phrases, a utomatic movements s u c h as habitual i n tegration of arm with d a i l y life functions, etc.

" I n the g u idance of a state of 'individual i l l ness experience' towards a state of individual health experience, many detailed changes may indicate a positive progression, even if the patient initia l ly may perceive the condition as unchanged.

In order to be able to perform fruitful reassessment procedures in which both patient and phYSiotherapist learn about possible favourable changes after an inter vention, the quality of communication and the choice of words are essential.

'How did it feel this morning when you got out of bed compared with how it used to feel?' The start should be in more general terms, allowing the patient to provide information that seems important. This information may be more valuable because of its spontaneous nature. After this spontaneous phase at the beginning of a session, the physiotherapist may deliberately seek to reassess the level of activity, the incidence and qual ity of pain and the integration of newly learned coping strategies.

Subjective reassessment

Convert statements offact into comparisons

At the beginning of a session it is important to seek spon taneous comments. It is not helpful to ask immediately,

It is essential in the reassessment process to convert state ments of fact into comparisons to previous statements.

Quality of communication during reassessment procedures

Principles of assessment

99

] The comparisons should be recorded in the patient's case notes. It is essential that physiotherapists recognize the statements of fact which are regularly given by patients and to convert them directly into comparisons. For example, a patient may initially answer to the question 'How have you been? ' with 'The same', suggesting that the therapy may not have helped at all yet. However, further questioning may indicate that favourable changes have indeed occurred: Q 'The same? What bothered you especialiy?' A 'Last night during the football game on television, I started to feel my leg again.' Q 'About what time was that?' A 'Towards the end of the game.' Q 'Did your leg recuperate?' A 'I got up and I did this shaking with my leg, as you showed me to do, and then it disappeared quickly.' Q 'Could you compare this with the last time you watched a football game on television? ' A 'Oh, well that was 3 weeks ago, then I could not sit at ali, I had to lie down.' Q 'How did it differ last night?' A 'Well, I could sit much longer and that exercise really helped to get the pain down again.' Another way to achieve a better comparison may be the question, 'If you compare with 3 weeks ago, when you came for therapy for the first time, do you think you would have been able to watch a football game?', to which the answer may well be, 'Oh no, 1 could not sit at all, now it is much better.' In order to develop a useful reassessment, state ments of fact have to be converted into comparisons to previous statements.

Some relevant communication techniques in reassessment procedures There are some important communication techniques to attain this form of subjective reassessment: •

Immediate-response questions - sometimes a patient's statement needs an immediate-response question in order to receive clear information with regard to comparisons. In response to the question, 'How have you been? ', the patient may say, 'I'm feeling better.' This answer demands an immediate ques tion, sometimes even before the patient has time to take breath or say anything else, for example 'Better than what? ' or, 'Better than when?' It is possible that the patient was worse immediately after treatment and has improved now to the state he was in before the last treatment, thus no further improvement may have occurred, although the

initial statement of the patient may tempt the physiotherapist to think so. •

Key words and phrases - Having asked the question, 'How have you been?', the patient may respond in a general and rather uninformative way. However, during subsequent statements the patient may include, for example, the word 'Monday'. This may mean something to the patient and therefore it is often effective to use it and ask, 'What was it about Monday?', or 'What happened on Monday? '

•

Paralleling - Often it is helpful to follow the patient's line of thought and to adapt the questions appropri ately. However, it is essential for the physiothera pist to keep clearly in mind which information is being sought and not to be so confused by the patient's line of thought that the 'information seek ing' is forgotten.

Collaborative goal setting and parameter definition In addition to defining treatment objectives in a collab orative way (Mead 2000) as suggested in Chapter 3, frequently it is also useful to decide on which param eters to use to measure progress of these objectives in a participative manner. The following communication example may underline this principle: Q 'I would like to summarize: we agreed that we would work together on your pain in your neck and shoul der, which occur especially when you are painting for a longer period and when you work at your personal computer for a longer period of time. Am I correct with this summary?' A 'Oh, well, yes.' Q 'Or did 1 miss out on something? Are there other times when you feel restricted because of this problem?' A 'I also have problems when 1 read in bed and some times 1 cannot sleep because of the pain.' Q 'Oh yes, I'm sorry that I did not mention that in the summary. Now we also need to measure the progress. We won't be able to have the situation going from 'bad today' to 'good tomorrow'. How would you be able to find out by yourself at home if things may be changing?' A 'Well, I wouldn't know.' Q 'Sometimes people report that they will be able to perform activities longer, the pain may be less intense or the area of symptoms may become smaller. Or you may recuperate quicker after the activity, especially if you try the exercise that we did just now. Which activity is it most important for you to improve the soonest, if possible?' A 'Painting and writing at the PC'

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L Q 'How long are you able t o perform these activities?' A 'Well, about an hour and then I stop because it hurts too much.' Q 'Would you like to be able to do these things for longer?' A 'Oh sure. Before I got this shoulder problem, I could paint for hours.' Q 'Would you be able to monitor until our next session how long you feel able to paint or write, and, at any time you feel less comfortable with your arm, to do the exercise and see if you feel capable of painting or writing any longer?' A 'Oh sure, I'll do that.' Q 'Then I will look from my perspective at the test movements in sitting that we performed together today. However, it would be great if you could remember how they felt today. I need your informa tion on these tests as well.'

Balance in reassessment in subjective and physical parameters It is vital to have a clear picture of the patient's main problem, including where and when the pain occurs, how daily life functions may be limited and how the patient is able to cope with the situation. In addition, the objectives of treatment should be clarified, which may on the one hand be control of pain and on the other the improvement of the limited activities and restriction of participation aspects. Too often in later treatment sessions both the patient and the physio therapist have the impression that nothing seems to change for the better only because this information has not been specified in sufficient detail in the initial ses sion. With sufficiently detailed information a better comparison of all the relevant parameters is possible, and more precise statements can be made regarding which aspects in the patient's situation are changing and which elements remain unaltered. A balanced approach to the reassessment of sub jective and physical parameters is necessary. Some physiotherapists rely solely on the observation of phys ical examination findings and only employ tests with an acceptable inter- and intra-tester reliability. How ever, it is argued that clinicians should retain a certain degree of scepticism if tests with a high reliability coefficient are directly claimed to be clinically useful as well (Keating & Matyas 1998, Bruton et al 2000) and vice versa: tests with a low correlation coefficient (e.g. some palpation tests) therefore would not be use ful clinically. Often the combination of tests of both sub jective and movement parameters, as well as pain in combination with resistance, may provide the clinician with valid reassessment parameters (MacDermid et al

1999). Leaving out subjective parameters carries the inherent danger that the therapeutic process becomes a rather mechanical process, in which not much space is left for the individual perceptions of the patient with regard to the disorder. In fact it is increasingly recommended, both in clinical work and research, that the patient's perspectives be integrated (Borkan et al 1998).

Measurable changes Before a patient subjectively feels more free both in daily life activities and pain levels, or before the physio therapist can reliably measure changes in range of motion, subtle changes in inspection or palpation find ings may be the first indicators of positive changes in the patient's condition. In certain conditions, such as acute radicular pain states where it can be expected that occurrence of clear measurable changes may take place in 10-14 days, patience both from the patient and the physiotherapist is required. In the case of possible radicular changes the physiotherapist will also need to employ regularly those tests that are indicative of pos sible negative changes with regard to precautions and contraindications (e.g. regular performance of neuro logical conductivity examination tests).

Behavioural parameters In certain conditions, frequently in the need of a more multidimensional approach to treatment, the physio therapist may not always be able to directly observe changes in, for example, mobility or pain reaction. In such cases it may be useful to use behavioural param eters as an indicator of change in the patient's condi tion, indicative of the individual illness experience. The following examples serve to highlight this point: •

In patients with complex regional pain syndromes (CRPS I) protection and guarding of the extremity may frequently be observed (Merskey & Bogduk 1994). After some sessions it may be an indicator of improvement in the patient's condition if the move ments of the arm become more and more a part of the unconscious body language and the hand is more habitually used again (e.g. in fastening a shirt).

•

The facial expression, smiles, eye contact, selection of words and even the detail in which an incident or a history of a disorder is described may also be indicative of a change in the individual illness expe rience. As an example, it is possible that a patient uses less frequently emotionally laden words such as 'It's all so terrible', answers less often with

Principles of assessment

'Yes . . . but', smiles more frequently, at times may make a joke, has more eye contact or becomes more aware of other people in the environment, and so on.

Change within the first

24

hours after treatment

There are specific times after treatment when changes in the patient's symptoms and signs can indicate the effect of treatment: •

• •

immediately after treatment and up to about 4 hours after treatment the evening of the treatment on rising the next morning.

The question can be asked, 'How did you feel when you walked out of here last time compared with when you walked in?' A patient may feel much improved immediately after treatment; however, it may not have lasted longer than an hour. This may indicate that the physiotherapist should continue with a similar treat ment and see if the improvement lasts for any longer, especially if treatment with passive mobilization is sup ported with self-management strategies. If the improve ment is only of short duration and the patient's symptoms and signs quickly fall back to the same level as in the initial assessment, it is possible that additional sources need attention (e.g. movement dysfunctions in the neck or neurodynamic system in combination with the symptoms and signs of a tennis elbow). If the patient feels exacerbation of symptoms after treatment, it is essential to find out how the patient felt on leaving the treatment room and how the symptoms developed afterwards. If symptoms were increased for about 4 hours, and during the evening the symptoms were reduced to even less than before the treatment, then the reaction may be considered as a favourable response. Rising from bed the following morning may also be indicative of favourable changes if the patient feels able to rise more quickly than usual and the stiff ness was less intense or did not last as long as usual. Having more difficulty rising from bed the morning after treatment may be indicative of a less favourable response to treatment, which may be the case in move ment dysfunctions with an inflammatory component. However, this needs clear consideration since, if a patient has been able to sleep for several hours during the night for the first time in many weeks, then it is a favourable response to treatment and in this case any morning stiffness does not need to be of too much con cern to the physiotherapist. Patients may report soreness following a previous treatment session. This must always be clarified. Is it the disorder that has become sore, or is it just soreness

from the manual handling of the treatment technique? ('Is it a surface bruised feeling from my hand, or is it 'the thing' that you have got wrong which is sore?') On those occasions when it is determined that a patient's symptoms have been aggravated by the previous treatment, it is not always that the wrong technique was used - it may be that it was performed too strongly, with too much movement, for too long, or in the wrong position. Therefore, an effort must be made to see if the patient is aware of what it was about the technique that caused the soreness. This is particularly relevant if previous uses of the technique had been producing favourable progress so far.

The 'art' of reassessment Reassessment may be considered as an 'art' in many therapeu tic interventions.

Which interventions influence which parameters? It is important that the physiotherapist develops a clear image as to which interventions have an effect on the patient's condition. It is possible that some inter ventions may influence some active movement param eters and activities of the patient, whereas other interventions influence other tests and activities.

Follow multiple parameters in reassessment procedures At times physiotherapists claim to perform regular reassessments by performing only one physical examination test at the end of a whole session with various interventions. However, if reassessment is performed in such a manner, the physiotherapist will not learn which interventions are more beneficial than others for the patient's condition. Furthermore, the physiotherapist may come to the wrong conclusion that nothing in the patient's condition has changed, only because the incorrect reassessment parameter was being used.

Profound reassessment Others claim to re-evaluate the patient's condition by giving out a questionnaire or asking at irregular times 'How are you [the patient] doing?' or they randomly measure the mobility of a joint movement. However, all these forms of so-called reassessment are too superficial to gain a clear, detailed picture of the progress of the patient's condition and how the thera peutic interventions are influencing this process.

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M A I TLA N D ' S P E R I P H E R A L M A N I P U LATI O N

L A balanced approach to reassessment and therapeutic interventions It is essential to have a balanced approach between the application of therapeutic interventions and their reassessments. It is imperative that the physiotherapist knows which interventions are more and which are less beneficial. Mostly the physiotherapist will need to reassess the general wellbeing of the patient and three to four movements after the application of a treatment intervention. However, at times of high irritability of a problem the physiotherapist may only reassess the current level of the pain ('present pain'), reassess the neurological conduction tests immediately after the intervention and test in more detail at the beginning of the next session. In the treatment of an elderly patient who has diffi culty in moving with any agility, it is possible that the physiotherapist may decide to let the patient continue to lie supine while reassessing the possible improve ments during the session and only at the beginning and towards the end of the session to test the patient's movements in sitting or standing.

Q A

Q A

Q

A

Q

Reassessment of cognitive objectives It has been stated that in physiotherapy much infor mation is given (Kok & Bouter 1990) but the quality of this information may need improvement (Van der Linden 1987, Sluys 2000) in order to enhance compli ance to the suggestions of self-management (Sluys 2000). For example, manipulative physiotherapists may use educational strategies with regard to the benefits of movement in pain states, in osteoarthritis or with disc lesions as well as to current insights on neurophy Siological pain mechanisms. The information given may be confusing or too complicated for the patient or may be in conflict with the patient's belief system. Reassessment of the cognitive interventions may be one step forward to improve the quality of information and education. •

After the physiotherapist has given some informa tion, it is worthwhile asking the patient to repeat in their own words what has been understood from the information: Q 'I have given you a lot of information - however I'm not sure if I've done a good job and that every thing is clear to you. Would you mind repeating in your own words how you've understood what I've told you?' •

In a back school, a patient may have just been given the information that it would be more useful to

A

Q

keep the back straight. However, the physiotherapist is aware that in certain circumstances the patient may not be able to comply with this due to job requirements and that other problem-solving strat egies will be required: 'I have given you a lot of information - how do you feel about this?' 'Oh well, I'll just have to do it if I want to keep my back healthy.' 'Isn't it going to be difficult to keep your back straight when you are working again as a car mechanic?' 'I've been thinking about this. As I told you, you should come and look at my job. It is hard at times. However, I will try.' 'I see. Well it's wonderful that you are so motivated. However, I know that there are situations in which it is just not possible to keep your back straight - for example if I came to you with a problem with the engine in my car, you would need to bend over the engine. Can you see any way to bend over the engine and still keep your back protected?' 'Well, I could put one leg up, or lean with both my knees against the frame.' 'These are very good strategies. What do you think you would do, if your back starts to hurt in spite of these plans?' 'Well, I could do this straightening of my back a few times as you've shown me so far.' 'Would you agree to me setting up this type of situ ation to see if we can practise these things as well as talking about them?'

After having given a lot of information, especially if it seems to be in conflict with the patient's current belief system, it is often very useful to give the patient time to reflect on the information given, and to return in, say, half an hour and give the patient time to ask any questions or to bring up any doubts. Alternatively, it may be helpful to ask the patient to think about things and write down any questions, and in the next session to discuss any situations which may have been unclear, confusing or even unacceptable. It is impor tant in such a case to truly take time for this discussion.

Cognitive-behavioural perspective to reassessment procedures Over the last decade an increasing number of publica tions have advocated that physiotherapists develop a cognitive-behavioural perspective to their work (Harding & Williams 1995, Klaber Moffet & Richardson 1997, Simmonds et al 2000). Cognitive-behavioural approaches aim to address any cognitive, emotional and behavioural responses to pain and disability.

Princi ples of assessment

Within physiotherapy practice a cognitive behavioural approach is a very subtle process in which the physiotherapist endeavours to be aware of the effects of all the interventions (including communication) on the thoughts, feelings and beliefs of the patient.

Therapy as a learning pracess Therapy may be considered as a learning process for the patient (and physiotherapist) in which the patient may go through a change with regard to ways of think ing, feeling or acting. Careful, comprehensive reassess ment procedures may be of particular value in guiding a patient in this learning process.

Guide patients in their experience In treatment it is suggested guiding patients towards their own experiences of activities rather than telling them what to do (Muncey 1998). In reassessment pro cedures a similar perspective is also necessary: guide the patient towards experiencing changes rather than telling them what the physiotherapist has observed. In this way reassessment may be considered as one of the most essential phases in the therapeutic process. It is a prerequisite that the patient is actively integrated into the process and that the physiotherapist explains the procedures and the patient's role in this process. A more superficial subjective reassessment - where the patient is only briefly asked to report on the pain, and further questions with regard to functioning and coping strategies are omitted - may contribute to feelings of hopelessness and helplessness in the patient. A patient may finish the treatment with the belief that physiother apy has not helped, although in fact some favourable changes have occurred, but neither the patient nor the physiotherapist has become aware of them.

Reassessment of physical examination tests It is crucial not only to perform test manoeuvres from the perspective of the physiotherapist but also to allow the patient to give an account of their wellbeing after the intervention and their own perspective on their capacity to move. It is essential that the patient recognizes the reassess ment procedures during the treatment session as such and does not misinterpret them as one of the many exercises to be performed; it is therefore important to announce it as another step in the programme of the treatment session. Furthermore, patients need to be educated to recog nize their own perception of all relevant parameters.

Patients need to be encouraged to observe not only their pain but also changes in range, freedom and trust to move the limb again in comparison with before the intervention. Frequently, patients are allowed only a passive role in which they can give information on changes in pain, but questions are omitted on how they themselves perceive the quality and range of the test movement. After that, often a reinforcement by the phYSiother apist is useful in order to teach the patient more about the physiotherapy-specific movement paradigms. Especially in the beginning of treatment it is essential that the phYSiotherapist gently educates the patient on those elements of a movement test that are relevant for the interpretation of reassessment.

(ET, Examiner's thoughts; Q, question; A, answer) Q 'Mr X, now that I have moved your arm for a while as a treatment, I would like to compare how you are now to how you were before. Could you please stand up again?' (patient stands up) Q 'How do you feel now in comparison with 10 min utes ago, before 1 did these mobilizations?' A 'I think just about the same, it does not hurt.' ET These remarks are more statements of facts than comparisons; however, as it is the first treatment, I would like to ensure that he does not feel worse gen erally; during the test movements 1 will compare in more detail. Q 'Is there anything that you feel may be worse than before?' A 'Oh no, certainly not.' Q '1 would like to look at some of your movements again - do you remember the ones we looked at, before 1 started treatment?' A 'I lifted my arm, didn't I?' Q 'That's right, and also you put your arm behind your back. Could you first lift your arm now and tell me what your impression is - how is it in comparison with before?' A 'It still hurts - here.' Q 'How do you feel this in comparison with before?' A 'Well, just about the same.' ET Previously he indicated much more in his whole upper arm, and now he indicates more locally around the shoulder. Although that could be an indication of improvement, I feel that Mr X does not necessarily perceive it as such, because it still hurts. Q 'Now you show me that you feel it mostly here (touches the patient in shoulder area) - do you remem ber where you felt it before?' A 'No, not really.' Q 'I remember you showed me more in your upper arm before; if that is the case, then it might be a sign

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[

ET

Q

A

Q Q

of improvement. Next time we should both look a bit more closely.' I had the impression his range of motion was also improved; I wonder if he perceives that as well. However, I do not want to be too suggestive in my questions, but I would like Mr X to learn that the parameters of range and quality of move ment are also of relevance in the interpretation of improvement. 'You've told me about the pain but I am also inter ested in how you feel about the way you move - do you have any impression of your arm moving differ ently, with more ease, or further up, or the other way round - maybe more difficult or not so high up?' (performs the movement again) 'No, I think I move a bit more freely - and don't you think I can move higher up?' 'Yes, that was my impression as well. I would like to measure this again.' (patient complies) 'What I've learned from this reassessment is that your arm seems to react well on the movements I performed on your shoulder. It tells me that your body needs to be moved, on the one hand by me, but I would like to show you a few movements which you can perform by yourself, particularly if you start to feel uncomfortable again. What do you think about that?'

Before performing reassessment procedures during the treatment session it is essential to: • •

announce it guide the patient's perceptions and divert statements of fact into comparisons

•

reinforce the effect by explanation ('What I've learned from this . . . ').

A balanced approach to reassessment of pain and function and activity - use of metaphors It has been suggested that, in reassessment proce dures, the physiotherapist should focus more on what the patient has been able to do rather than asking solely how much it had hurt (WaddeU 1998), otherwise the phYSiotherapist may inadvertently reinforce mal adaptive pain behaviour. This is an essential point. The approach must necessarily balance the reassessment of pain with an evaluation of function and coping strategies. Many phYSiotherapists seem to recognize this point from their years of clinical experience as they some times state that they rather avoid talking about pain, preferring to ask what the patient can or cannot do (Hengeveld 2000). With this aspect they shift attention

from the symptom 'pain' to the symptom 'activity and function' and to coping strategies. Metaphors Some physiotherapists may try to find an agreement with the patient not to talk about pain any more (Hengeveld 2000); however, this would deny the patient the individual experience of pain and suffering for which the help of the physiotherapist is sought. However, rather than avoid talking about pain, it is often useful to use metaphors in reassessment proce dures and still be able to acknowledge the experience of the patients with regard to pain and wellbeing. Instead of asking, 'How is your pain now in comparison with before?', it could be asked, for example, 'What does your body tell you now compared with before?' Some people give their own metaphors for their experience during the subjective examination which can be used during physical examination procedures; some may use colours or weather states. Others may find agreement with, for example:

Q 'If the pain is like a big wave on the ocean, would you only be satisfied if the ocean was fully calm without any ripple?' A 'Oh no, I can certainly accept some pain. It just should not get worse than it is now.'

In reassessment this could be used, for example: Q 'How is the wave now compared with before? Still on high storm?' A 'No, it seems a bit less.' Functional demonstrations i n physical examination If a patient seems overly focussed on the pain sensation, it is often useful to integrate more 'functional demon strations' (e.g. the tennis service) or working activity into the reassessments as these are frequently more meaningful to the patient than other physical exami nation tests such as SLR or hip flexion in supine posi tion. Furthermore, it is essential that, during the movement, the patient learns to observe parameters other than pain alone as a sensation (see ·above).

Conclusion: reassessment Reassessment procedures are an integral part of the physiotherapy process. A balanced approach to the comparison of subjective and physical parameters ('asterisks') is needed in which communication and a cognitive-behavioural approach play essential roles. Comparison of parameters will only be achieved if the starting point is clear: if it is not sufficiently clear from the first assessment which daily life functions are

Principles of assessment

limited due to pain or other reasons, no good com parison will be possible in later sessions. This may often leave the patient and physiotherapist in doubt as to whether the therapy has really served its pur pose. Furthermore, the definition of clear treatment objectives is impeded and neither patient nor physio therapist is capable of observing in sufficient detail if something is changing beneficially in the patient's situation. Although some will say this is too time consuming to be of value, successful treatment compels this degree of accuracy. It is essential if the physiotherapist is to remain in control of the treatment situation collabora tively with the patient. Given practice and experience, it is not a lengthy procedure.

•

increase of pain (particularly in cases of acute noci ceptive or peripheral neurogenic pain states)

•

neural conductivity (monitoring reflexes, muscle function and sensation regularly)

•

healing processes in soft tissues or bones (in relation to the phases of physiological healing processes)

•

autonomic reactions (e.g. during palpation of the spine)

•

general tension with increased muscle guarding and breathing patterns in those patients whose contribut ing factors to the problem may be lack of relaxation (this may be particularly relevant in the treatment of the thoracic spine or shoulder dysfunctions)

•

self-efficacy beliefs! externalization of locus of control! development of passive coping strategies (e.g. attributing the effects of treatment only to the hands of the therapist, but no application of self management strategies)

•

fear to move behaviour)

•

confusion (e.g. too much information without evaluating how the patient has understood the information).

ASSESSMENT DU R ING TREATMENT Another form of assessment is the evaluation during the application of treatment interventions. The follow ing aspects are monitored during the treatment: • •

Are the treatment objectives being achieved? Are there any undesired side-effects, as defined by the precautions in the planning phase of the session?

During the application of passive movement techniques changes in pain or resistance behaviour are evaluated. As long as these changes are favourable, the technique may be continued. When the changes cease to take place, it is often useful to perform a reassessment pro cedure to evaluate the direct effect of the technique as applied to the patient's condition. The duration of a passive movement technique will normally be decided by the reaction during the intervention.

Assessment during treatment often appears to be a more implicit process. However, it is essential to be consciousLy aware of the goals of each intervention and the current precautions. The physiotherapist needs to be alert both to possible beneficial changes as well as to certain undesired side-effects .

'Nothing at the price of If passive movement techniques are being employed, the goals of treatment may often be control or diminution of pain, or normalizing the range of motion; however, 'nothing at the price of' for example: -

•

inflammatory signs (be alert to redness, swelling, temperature)

(e.g.

increased fear avoidance

Pain responses during the application of passive movement techniques Two pain responses may occur while performing a technique: •

•

the pain may be felt in rhythm with the oscillations of the technique an ache may develop during the application of the technique.

It is difficult to distinguish between pain in rhythm with the technique and pain that may be increasing, because misunderstandings between the physiothera pist and patient occur easily. The easiest way for the physiotherapist to make this assessment is to ask the patient, while performing the technique • •

'Does-it-hurt-each-time-I-move?' or 'Is it in rhythm with what I'm doing or is it a constant feeling that is increasing as I continue?'

In cases of irritability of the pain the physiotherapist is usually mindful not to provoke any pain or discomfort during the application of a technique; however in cases where the condition is more stable and the pain

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L shows an 'on-off' behaviour more towards the end of the available range of movement, it may be beneficial that symptoms are provoked during the application of the technique. The physiotherapist will often posi tion the joint in an end-of-range position and perform oscillatory techniques towards the end of the available range of that technique. It needs to be emphasized that these symptoms should be occurring in the rhythm of the technique and once the technique is released (e.g. the technique is performed in a smaller grade or the joint is taken out of its end-of-range position), the pain should subside almost immediately. If symptoms increase independently of the rhythm of the technique, the physiotherapist needs to ascer tain that the condition of the patient is not worsening a change in the rhythm, speed, amplitude or position in range, or a complete change of technique may be needed. Notwithstanding if some symptoms increase for example in the lumbar spine while performing accessory movements in the spine - if, simultaneously, radiating symptoms in the calf or buttock decrease, then this may be interpreted as a favourable change and it is often useful to continue with the technique before any changes cease to take place. The assessments of what is happening while every technique is being performed must be recorded on the treatment record (Chapter 9).

PROG RESS IVE ANA LYTICAL ASSESSMENT: RETROSPECTIVE AND PROS PECTIVE ASSESSMENT It is essential to perform a regular review of the thera peutic process, in addition to the session by session (re)assessment procedures and forms of assessment during treatment. This is necessary to keep the right perspective of the patient's disorder. Some patients may state they feel much better when asked on a day-to-day basis. When asked after, for example, four sessions, 'How do you feel now com pared with four sessions ago?', the patient may answer after a long period of thought, 'I'm sure it's a bit better, at least it's certainly not any worse.' Such a retrospec tive answer makes the physiotherapist realize that not as much daily progress seems to have been made as originally thought. The opposite of course may also happen: the patient does not think he has made much progress, as he may still have difficulties cleaning windows. However, if asked in retrospect, for example, 'If you compare with, let's say 3 weeks ago, do you think you would have been able to clean those win dows?', then the answer may be, 'Oh no, it's certainly much better, because then I was not even able to lift my

arm long enough to wash my hair - now I am able to clean all the windows of the house. But of course, it was hurting.' This regular review of the therapeutic process is a reflective process and has several purposes: •

Reflections on all the decisions made.

•

Reflections on the generated hypotheses so far.

•

Analysis of the examination process so far.

•

Evaluation of the therapeutic interventions and their effects; determination if the therapy takes the course as originally planned, or if an adaptation of the treatment objectives needs to be made.

•

Evaluation of the educational process. (It is often worthwhile following a reflective process with the patient, similar to other educational processes [Brockbank & McGill 1998]. What has the patient learned so far and what was especially relevant in the therapy?)

•

If needed, reassessment relationship.

of

the

therapeutic

It requires communication skills to determine changes from the perspective of the patient and to (re)deter mine treatment goals. The therapeutic process may be considered as a navigation process in which it is neces sary to carefully monitor whether treatment goals have to be adjusted, which objectives have been achieved and to adapt the therapeutic interventions. At times, when spontaneous recovery or, on the contrary, no fur ther progression seems to be taking place, it may be useful to interrupt the therapy for approximately 2 weeks to assess possible changes without the addi tional interference of the physiotherapist. Retrospective assessments should take place: •

• • • •

at regular intervals (e.g. as a review of the therapeutic process in every fourth session if a patient is treated on an outpatient basis; if a patient is treated on a stationary basis of, for example, 3 weeks, then it is often useful to assess halfway through the treatment period) after a planned break from treatment if the therapeutic progress seems to stagnate to determine if treatment should be continued when spontaneous recovery seems to occur.

Retrospective assessment in review phases This should encompass information from the perspec tive of both the patient and the physiotherapist. First,

Principles of assessment

spontaneous information from the patient needs to be sought: •

•

•

Seeking spontaneous information from the patient: 'If you compare with about 3 weeks ago, how are you now in comparison with then?' It is essential not only to follow up changes in symptoms, but also to ascertain if the patient is able to perform daily life activities again, sometimes in spite of the pain. Effects of the treatment interventions: 'Of all the things we have done in therapy, is there anything that you think has been particularly helpful for you? Has there been anything that was not helpful at all or may have aggravated your problem?' What were the effects of the exercises, recommen dations and instructions given? Are there any diffi culties in the performance of certain self-management strategies? Do they reach the expected goals in all circumstances? (particularly if the objective of the interventions should be 'control over wellbeing' see AppendiX 2).

•

What have you learned so far from therapy?

•

It is essential to ascertain the level of activities and symptoms in comparison with not only the begin ning of treatment a few sessions ago but also with the worst period in the short-term history.

•

The symptoms and the level of activities have to be put in perspective to the period before the disorder had worsened. Some patients may have been con tent with a certain level of symptoms beforehand. In fact it may be even better than before, although not fully symptom free. To determine in such a case if therapy should be interrupted, the following questions could be asked:

Q '1 understand that you feel much better than before, but that it is not fully gone. How are you now in comparison with 6 months ago, before it all started?' A 'Well, I think that it's about the same again. It's back to normal.' Q 'Are you satisfied with it as it is right now, or would you expect any further improvement?' or Q 'Would you have sought help of a doctor or therapist, just as it is right now?' •

The physiotherapist should check the treatment records and determine which subjective and physical parameters ('asterisks') have changed after which interventions. It is emphasized that various interven tions may be necessary to normalize all parameters.

Prospective assessment After the review of the therapeutic process the therap ist should decide collaboratively with the patient on the treatment objectives for the next period of therapy. It may be useful to ask the patient some of the follow ing questions: •

'On which aspects should we work together now?' (The process of 'thinking from the end' as described in Chapter 4 may be useful in this stage of treatment.)

•

'Which activities need to get better?', 'Are there any activities in your work or hobbies which you do not have the confidence to do or need to be very careful in performing?', 'Which activities are still bothering you?'

•

Effects of self-management strategies: 'Do you feel the exercises I've shown you are effective enough in daily life?'

If new treatment objectives have been defined (e.g. the patient does not have enough confidence yet in bend ing down during his work as an electrician, or would like to play golf again), the activities may be used as physical parameters ('asterisks') during reassessment procedures in order to be able to guide the patient to the experience that the activities may be improving.

If therapy seems to be stagnating At times the treatment seems to stagnate or does not seem to bring the desired results. The physiotherapist needs to consider the following reflections in such a case: •

Have 1 compared the subjective and physical parameters in sufficient detail?

•

Did 1 follow up the right physical asterisks? (For example, instead of pursuing parameters which reproduce the patient's symptoms with, for example, 'combined movements', parameters are being fol lowed up which seemed to be comparable signs, but are now shown to be irrelevant - see Chapter 6.)

•

Have 1 performed a review of the therapeutic process with a retrospective assessment, collaboratively with the patient?

•

Has the right source of the symptoms been treated?

•

Have the self-management procedures been pursued profoundly enough? Did the procedure provide the patient with sufficient control over their wellbeing on all daily life situations? (Appendix 2).

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[ The following questions may be asked: •

•

•

• • •

•

•

• •

When does the patient consider that the condition stopped improving? Why does the patient consider the improvement stopped? Does the patient think that progress has occurred with earlier treatment? At what stage did the improvement take place? Was the improvement progressive? Which intervention seemed to have brought some progression? How does the patient feel now compared with before treatment began? How does the patient feel now compared with how he was before the onset of the episode? Does the patient think he is back to his normal? What treatment goals need to be achieved from this session onwards?

Once the therapist has determined the patient's opin ion in relation to all of the above-mentioned questions, it is the right stage to start a full re-examination, both subjective and physical, with the following questions: • • •

•

•

'What is your problem at this stage?' 'When does it bother you most?' 'Is there anything you can do here and now to demonstrate to me a way in which you can provoke the symptoms?' 'Are there any other aspects of your symptoms, or the ways in which they affect you, that you think might be helpful to my understanding of your problem?' 'If you have symptoms, is there anything you do by yourself - even instinctively - to ease them?'

Planned break from treatment Many patients have a disorder that may not be fully normalized in every regard. Under such circumstances the end result of treatment will be a 'compromise result'. It is not easy to know when that compromise result has been reached. A time will arrive when the patient's symptoms do not continue to improve, and in fact there is a possibility that treatment perpetuates the symptoms. In this case the patient can be given a break from treatment of approximately 2 weeks, after which an assessment of the subjective and physical parameters can be made. If the symptoms have improved, the patient should be left for another 2-3 weeks or may be discharged on the assumption that the symptoms will continue to improve without treatment. If the symptoms and signs remained the same, the patient should be given four or

five more treatments and then taken off treatment again for a further 2 weeks. At the end of this period it will be possible to determine whether the extra treat ment produced any improvements and whether a further few treatments should be administered.

Conclusion: retrospective and prospective assessment A retrospective assessment as outlined above can take as long as any session. The searching for detail is important at this point, because during retrospective assessments important decisions may need to be made with regard to the future management of the patient's disorder.

FINA L ANALYTICA L ASSESSMENT Towards the end of the therapeutic process a final ana lytical assessment may need to be performed (Box 5.2). Frequently it is useful to prepare the patient over two or three sessions for the discharge of treatment. In the final stage of analytical assessment all the information of the therapeutic process should be analysed: • • • •

first examination behaviour of the disorder throughout treatment details derived from retrospective assessments state of affairs at the end of the treatment series, taking into account the changes in subjective and physical parameters.

In collaboration with the patient the clinician needs to make an assessment in relation to: •

•

•

•

•

•

reflection on overall therapeutic process - which interventions brought which results? reflection on learning process - what was especially important for the patient and what has been learned? the effectiveness of any prophylactic measures and self-management interventions compliance-enhancement strategies - which self management interventions are especially beneficial?; in which situations would the patient anticipate any difficulties in the future?; which activities/ exercises would the patient resume in the case of recurrence of symptoms? suggestion of any medical or other measures that can be carried out prognosis on possible remaining functional deficits on impairment, activity and/ or participation levels (ICF - WHO 2001).

Principles of assessment

Box 5.2

Overview of the various forms of assessment and their objectives

Assessment at first consultation

Assessment d uring treatment

•

•

Determination of the physiothera py-specific diagnosis:

•

•

Finding causes and contributing factors to the

mobilizations, monitoring of the changes in the

movement disorder of the patient

behaviour of pain, resistance or motor responses ('spasm')

Ma nagement: determination of goa ls of treatment, selecting meaningful interventions

•

Develo pment of a therapeutic relatio nship: motivation, respecting the i n dividu a l illness experience, co l l aborative goa l setting

•

Determination of any preca utions a n d / or contra indications to physical exa m i n ation procedures or therapeutic interventions

•

•

such as: pathobiological processes, i n clud i n g

assessments (regular review of the thera peutic process in add ition to the session-by-session reassessments) •

contributing factors precautions a n d contra ind ications i n d ividual illness experience

have im proved so far; which ones have remained •

Are agreed treatment objectives being achieved ?

•

W h a t has the patient learned so fa r? W h a t was pa rticularly i m porta n t to the patient in the learning process?

•

D u ring the initial exa m i nation phase after the tests

•

•

(col laboratively with the patient) •

Final a nalytical assessment •

process: reflection on overall therapeutic process: wh ich

I m mediately after the a p p l ication of the various

interventions brought which results? reflection on learning process: what was especia l l y

interventions; includes interventions such as

i m porta nt for t h e patient - w h a t has been learned?

information a n d education

•

•

•

the effectiveness of any prophylactic measures a n d

At the end of the treatment session

self-ma nagement interventions •

Prospective view: a nticipation of possible difficulties /

Comparison of treatment results - proving the va l u e of

enha ncement strategies of lo ng-term com p l i a n ce with

the selected interventions

advice, self-ma nagement measures and exercises : com pliance enha ncement strategies: Which self

Differential d iagnosis: by reassessment of therapeutic interventions a contribution to differential d iagnosis is

m a n agement i n terventions a re especially

provided

beneficia l ? I n which situations would the patient

Enable the physiotherapist to reflect on the decisions

a n ticipate a ny difficu lties in the future? W h ich

made; enha nce the development of c l i n ical patterns in

activities / exercises would the patient resume in the case of recurrence of symptoms?

memory, hence support of the develo pment of the experiential knowledge base •

Review of the whole therapeutic process, includ ing statements of the patient on the i n d ividual lea rning

At the begi n ning of each subsequent treatment

Purposes

(Re)determination of the para meter to monitor the agreed goals of trea tments

treatment interventions - proving the value of the

•

Prospective assessment: (re)determination of treatment objectives for the next period

session •

Monitoring the effect of the various treatment i nterventions

Reassessments exa mination of various active and passive movement

Which su bjective a n d physical pa rameters ('asterisks') uncha nged?

management (objectives, interventions) prognosis (short term, long term)

Assessment of the overall wel l being of the patient in compa rison with first sessions

•

neu rophysiological pain mechanisms sources of symptoms a n d movement dysfunctions

Avoidance of u n d esired side-effects

Progressive analysis: retrospective and prospective

Procedura l c l i n ica l reason i ng: the assessment p rocess is guided by the genera tion a n d testing of hypotheses

•

Determination if the objectives of the intervention are being achieved : during the appl ication of passive

expressed i n terms of movement dysfunctions

•

Prognosis on possible rem a i ning functional deficits

Support of the learning process of the patien t : in

on i m p a i rment, activity a n d / or participation level s

reassessment procedures in combination with careful

(ICF - WHO

com m u n ication, the patient may be enab led to experience beneficial cha nges

•

1 99 1 )

Suggestion of a ny medical or other measures that ca n be carried out

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ASSESSMENT AND CLINICAL R EASONING Analytical assessment and clinical reasoning may be considered as twin elements of the therapeutic process. The description of physiotherapy by the World Confederation of Physical Therapy (1999, p. 7) reflects the basic principles of this concept regarding assess ment and clinical reasoning, as follows:

Assessment includes both the examination of individuals or groups with actual or potential impairments, junctional limitations, disabilities or other conditions of health by history taking, screening and the use of specific tests and measures and evaluation of the results of the examination through analysis and synthesis within a process of clinical reasoning. As described in Chapter 4, physiotherapists may employ various forms of clinical reasoning. Within the diagnostic process and determination of treatment, procedural reasoning with a process of hypothesis gen eration and pattern recognition frequently plays a cen tral role (Payton 1987). The other forms of clinical reasoning frequently used include (Edwards 2000, Jones & Rivett 2004): • • •

interactive clinical reasoning conditional clinical reasoning narrative reasoning.

It is considered that the various strategies of clinical reasoning are in an intrinsic relationship in clinical practice, in which the physiotherapist moves between the various forms of reasoning to shape an optimum examination and treatment process collaboratively with the patient (Edwards et al 2004). Procedural rea soning, which is principally cognitive based and involves a process of hypothesis generation and test ing, aids the diagnostic process and treatment plan ning. Forms of narrative and interactive reasoning resulting from an interpretive paradigm are frequently employed to develop a deeper understanding of the patient's individual experience regarding pain and disability, including beliefs, thoughts, feelings and sociocultural influences.

knowledge base, as experienced therapists are more likely to engage in interactive processes in contrast to novices who tend to be more mechanical and proced ural in their encounters with patients during a thera peutic process (Jensen et al 1990). It has been proposed that empathy does not necessarily increase over the years of clinical experience; however, interactive skills training is more likely to enhance this in experienced physiotherapists (Thomson et al 1997) . It is emphasized that a balance between procedural and interactive reasoning is necessary in order to shape a constructive therapeutic relationship as a basis for the physiotherapy process.

Narrative clinical reasoning Various forms of narrative reasoning may be employed in the educational and therapeutic processing of the patient. It may be employed consciously in order to allow patients to give their own account of the disabil ity and pain rather than being controlled by strict crite ria in which patients are only allowed to talk about those aspects which serve the physiotherapy diagnosis (Thomson 1998). It has been suggested that the interpretation of the individual story should be a core task in medicine; neglect of individual narratives may lead to alienation of the patient from the care giver (Kleinmann 1988). The diagnostic process may be positively influ enced if the therapist gives space to the personal story and experience of the patient, as a mutual understand ing between therapist and patient is more likely to unfold and the therapist gains insights into those aspects that are truly meaningful to the patient. Furthermore, narratives may be intrinsically thera peutic, as they aid the patient in gaining a deeper understanding of the individual experience. Addition ally, they may allow for a multidimensional approach to treatment, as the thoughts, beliefs, preferences and sociocultural context of the patient may be taken into consideration (Greenhalgh & Hurwitz 1998). The deliberate application of narrative reasoning may be an art, and may be easier to apply if mastery has been achieved in procedural reasoning and inter active reasoning, with well-developed communication skills and careful observation of key gestures or sensi tive listening to key words and phrases.

Interactive clinical reasoning Interactive clinical reasoning may be employed for various purposes, as described in Chapters 3 and 4. It takes place during the direct encounters between the physiotherapist and the patient. It seems to have become an aspect of a more implicit, experiential

Procedural clinical reasoning The basic procedures of examination, assessment and (treatment) planning as outlined in this book may be considered as an expression of procedural clinical rea soning processes. From a cognitive point of view, the

Principles of assessment

problem-solving processes of physiotherapists appear to be based on hypothesis generation and/or clinical pattern recognition. For many years it has been a prin ciple of the Maitland Concept to generate hypotheses which guide decisions regarding examination and treatment procedures; however, it is recommended that physiotherapists categorize the generated hypoth eses ( Jones 1989) and make them explicit in the various planning stages of the therapeutic process.

Hypothesis deduction and induction In many problem-solving processes it has been recog nized that most adults generate hypotheses based on a process of cue acquisition (Elstein et al 1978). Within manipulative physiotherapy assessment these cues may be derived from various sources of information: •

•

•

• •

The patient, with non-verbal and verbal expressions as well as movement behaviour. Based on this information, physiotherapists may start to generate multiple hypotheses (e.g. prognosis, level of disability, illness experience from the first moment of the encounter between patient and therapist). Referral form with the medical information and possible questions of the referring clinician. Subjective examination with information regarding the pain, activity limitations and participation restriction, history of the disorder, general health, etc. Physical examination procedures. Treatment, including the various reassessment procedures.

It has been emphasized that the process of hypothesis generation and testing is a cycl ical process in which the physiotherapist develops an initial concept of the patient's problem, with mul tiple hypotheses from the very first moment of the encounter between patient and therapist. During the process of both the subjective and the physical exami nation the process of hypothesis generation is conti nued, with a modifying, rejecting and confirming of the various hypotheses (Jones 1989). Reassessment pro cedures are essential in this process, as they may con firm certain hypotheses or may signal the need to modify the hypotheses. By consequent reassessment and reflection, the process of testing hypotheses may contribute to the development of clinical patterns in memory as part of the experiential knowledge base (Higgs 1992). However, from a client-centred perspective not only physiotherapists but also patients frequently go through a cyclical process of hypothesis generation as Cyclical

process

the therapeutic and educational processes progress (Edwards 2000), which has to be taken into conside ration during all interactions.

Categorization of hypotheses In many problem-solving processes the information is organized into meaningful clusters of data (Larkin et aI 1980). In contrast to j unior physiotherapists, more experienced therapists organize the information dur ing subjective and physical examination processes into relevant categories. This frequently enables them to find a more comprehensive overview of a patient's clinical presentation (Thomas-Edding 1987) and allows the shaping of more meaningful treatment plans. Physiotherapists are therefore encouraged to organize the information of the various steps in the therapeutic process into hypothesis categories (Jones 1989). Although the process of hypothesis categorization in principle is an individual process (Larkin et aI 1980), in manipulative physiotherapy, within a biopsycho social movement paradigm, many therapists may employ similar hypothesis categories as outlined in Box 5.3.

Reflection Within the process of hypothesis deduction and induc tion, reflection or metacognitive skills are essential. It is crucial to reflect regularly on the hypotheses gener ated in critical phases of the therapeutic process. Hypotheses need to be made explicit and reflected upon in the following phases: •

•

• • •

after completion of the subjective examination as a preparation for the physical examination after completion of the physical examination and the initial treatment as a preparation for each subsequent session during retrospective assessment at the final analytical assessment in the last treatment session(s).

Without reflection, certain hypotheses may be favoured or others may be neglected Gones 1997). A lack of reflection may lead to automatic actions without any lateral thinking (De Bono 1970) or trying something unexpected in the solving of a particular problem. By regular, disciplined reflection procedures clin icians may uncover habitual practice, follow up changes in their personal clinical development and may discover the need for a next step in professional education. Critics may debate that there is 'nothing new under the sun' with clinical reasoning. However, if the rich ness of thoughts and feelings underlying therapeutic

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[

Box

Hypothesis categories frequently used in manipulative physiotherapy prac:tlce

5.3

Pathobiological processes

Sources of movement dysfunctions and pain

This category may include various data relating to tissue

The movement components from which nociceptive

processes and neu rophysiological pain mechanisms:

and peripheral neu rogenic pain processes can be

•

Pathological processes (e.g. inflammation, instability) : serving biomedical diag nostics and the determination of certai n precautions or contraindications to examination and treatment proced ures

•

Stages of tissues healing : information regarding the clinical presentation in relation to the correspon ding stages of tissue healing ; early stages of tissue healing after trauma are indicative of precautions to examination and treatment proced u res; in ongoing pain states, tenderness or inflammatory presentations which may have been present m uch longer than wou l d be expected from normal hea l i n g stages; other factors (e.g. central nervous system mod ulation, autonomic mechanisms,

•

reproduced or movement dysfunctions such as stiffness, hypermobil ity or lack of muscular control may be detected. This category includes the following fu nctions and structures contributing to the movement disorder of the patient: •

joints (local, referred)

•

m u scles

•

neu rodynamics

•

soft tissues

•

viscera, blood vessels

Contributing factors Relate to the predisposing or maintaining factors to the patient's problem. They include physical, biomechan ical,

behavioural factors) may contribute to the p resentation

environ mental, social, emotional, cognitive and / or

Pai n mechanisms relating to the neurophysiological

behavioural factors.

mechanisms u n d erlying the patient's pain experience and d isability - see the matu re organism m odel (Gifford 1 998b) and the processing model (Shacklock 1 999a) : ' i n p u t mechanisms' to the central nervous system may relate to, for exam ple, nociceptive mechanisms or perip heral neurogenic mechanisms central nervous system mod u lation will always take place; however, the central nervous system processing (plasticity) may become a dominant, ongoing factor in

the pain experience due to pathobiological,

cognitive, affective or learning p rocesses. Ongoing pain states, tenderness and d isability may be the resu lt 'output' mechanisms relate to physiological processes (e.g. au tonomic, i m m u ne or endocrine reactions) ; output processes result in motor reactions and behavioural aspects (e.g. movement patterns, help seeking, expression, avoidance behaviour) Precautions and contraindications to examination a n d treatment procedures Mostly determi ned by pathobiolog ical processes and neu ro physiological pain mechanisms. The following factors may be included :

Level of disability Determined by terms of i m pairments, activity limitations and / or participation restriction as defined in the International Classification of Functioning, Disabilities and Health (WHO

200 1 ) .

Individual i l l ness experience Consideration of the patient's beliefs, thoughts, feelings, emotions, earlier experiences, influence on the social environ ment, influence from the social environ ment, val ues, meanings, attribution and behavioural factors as well as coping strategies. Management Determined by all other hypothesis categories. Relates to a l l decisions regarding definition of treatment objectives and selection of meaningful i n terventions to g u ide patients towards a sense of health concerning .movement fu n ctions. Goals may include: •

normalization of movement im pairments (symptoms, sig ns)

•

normal ization of the level of activities and partici pation

•

pathobiological processes

•

•

irritability of the disorder

•

prevention of new episodes

•

severity of the disorder

•

awareness of use of self, relaxation

•

self- management strategies regard ing control over

•

cog n i tive goals regarding knowledge and beliefs about

•

stage and stabi lity of the disorder

•

general health

•

patient's movement behaviour, perspectives and expectations

trust in use of body

pain or wellbeing the pain and the fun ction of movement in treatment

Principles of assessment

Prognosis: for first 3-4 sessions/overall process / a fter

•

mechan ical versus i n fla m matory presentation

completion of therapeuti c process

•

relations h i p between i m p a irments, activity l i m itations

Prognosis takes place in various phases: •

Short term : Wh ich results may be expected within the first 3-4 sessions (part of c l i n i cal pattern recognition)?

•

What may be expected after co m p letion of the thera peutic process?

•

pre-elSisting d isorders (e.g. degenerative c h a n ges and a n i njury or m isuse of the knee)

•

patient's beli efs, expectations, e a rlier experiences patient's lifestyle and movement behaviour

either short- 'or long-term prognosis:

•

contri buting factors - 'cause of the source' (e.g.

•

stage of tissue healing a n d damage

•

general health, general fitness level

Based on various studies in clinical reasoning, it has been illustrated that next to the process of hypothesis generation and testing, other processes are being employed in clinical decision making: experts, in con trast to novices, may instantly recognize a situation and may be capable of selecting meaningful treatment interventions by the recognition of clinical patterns (Norman & Patel 1987). Clinical patterns are frequently described in rela tion to a pathobiological paradigm; however, they may include many more aspects (Hengeveld 1998, 2000):

•

of the d isorder and progression of the d isorder (are attacks more freq uent or d isa b l i ng?)

•

Clinical patterns: illness scripts

•

onset of the d isord er, d u ration of the h i story, stability

N u m erous factors have to be taken i nto consideration i n

actions and interactions is not made explicit, the risk exists that the daily practice stagnates in automatic patterns of decision making and professional develop ment is restricted (Ryan 1996). Consequent reflection on the clinical reasoning processes in regular planning stages of the therapeutic process should lead to a more comprehensive and efficient clinical practice.

•

uni- or m u lticomponential move m e n t d isorder

•

Wh ich results may be expected d u ri n g the overa l l process of physiotherapy?

•

and participation restrictions •

pathobiological processes, including the consequences for physical examination and/ or treatment procedures uni- or multicomponential movement dysfunctions approach to treatment. Is a more one-dimensional approach to treatment possible (see Fig. A2.1, Appendix 2) or does a multidimensional approach seem necessary, with a conscious shaping of the communication and behavioural approach to the procedures of examination, treatment and reassessment? If a more multidimensional approach to treatment seems necessary the clinician may deliberately choose an approach of narrative

posture, muscle weakness or tightness, d iscrepancies in mobil ity of joint com p l exes such as spine or wrist, etc.)

reasoning in the initial phase to allow patients to give their own account of the problem. In research on the development of clinical patterns over the years of clinical experience, it has been sug gested by Schmidt and Boshuyzen (1993) that clin icians go through various phases in the development of expertise: 1 . Accumulation of causal knowledge about disease and its consequences. 2. Through experience with real patients this knowledge transforms into narrative structures or 'illness scripts' ('encapsulation of knowledge'). 3. Use of episodic memories of actual patients in the diagnosis of new cases. They postulate that knowledge acquired in different phases forms layers in memory which remain available for use if the recent layers in memory fail to support the process of decision making. The lived experience with actual patients seems to contribute to the develop ment of clinical patterns and the instantaneous recog nition of what to do in clinical situations. Many clinicians may not be aware of the effects of clinical experience and memories of direct encounters with patients in their decision-making processes. In order to be able to successfully make use of clinical patterns and illness scripts over the years of clinical experience and 'reflect in action' (Schon 1983), clin icians need to have developed a profound theoretical knowledge base and experience of clinical examina tion, treatment and reassessment procedures. If, within the clinical presentation of a particular patient, no patterns are recognized or actual patients remem bered, clinicians need to employ the basic procedures within a process of regular 'reflection on action' (Schon

113

1 14

M A I T LA N D ' S P E R I P H E R A L M A N I P U LAT I O N

Individual stories ('Illness scripts') Clinical pattems Procedures of examination a.!"� ��! ��i �

_ _ _

_ _ _

Theoretical knowledge base Figure 5.3

Differences between experts and novices

, """\

....I

D

Hypotheses generation and testing, including reflection In actual encounters with patients

Development of clinical pattern s and i l l n ess scri pts

Over several decades numerous reasoning studies have been undertaken to investigate how experts differ from novices and how they acquire this expertise. It has been recognized that experts distinguish themselves from novices in various ways: •

Experts may have better treatment results, with more efficient problem-solving processes.

•

Experts may employ various forms of reasoning.

•

Experts seem less procedural in their approach to the patient and seem capable of more active inter active reasoning in the shaping of a therapeutic relationship.

•

Experts seem to have a better organized and acces sible knowledge base, with theoretical and clinical aspects: more clinical patterns and the employment of 'forward reasoning' with so-called 'if . . . then . . . ' rules.

•

Experts may have more patient stories in their memory and make use of them in decision-making processes.

•

Experts allocate more time for qualitative problem analysis (illness experience).

•

Experts seem to be bothered less by distractions in the therapeutic process in the application of proce dures and in interactions with patients.

•

Experts allow non-verbal cues to play a decisive role in decision making.

•

Experts develop reflective skills.

•

Experts employ both creative and lateral thinking.

•

Experts are aware of the strengths and weaknesses in their own actions and individual clinical reason ing processes.

in memory. By actual l y going through procedures of examination, treatment and reassessment, clinicians are in a direct encou nter with patients and their ind ividual stories. This appears to contribute to the development of different layers in cl inical memory which are accessible in decision-making processes with future patients. Clinicians appear to use memories of actual patients in diagnosis: if no memories of actual patients are present, they may approach the layer of cli nical patterns in memory; if no clinical patterns can be recog nized or actual patients remembered, clinicians may need to employ basic procedures of assessment and seek advice in propositional knowledge. Adapted from Schmidt & Boshuyzen

(1 993)

with kind permission from Springer-Verlag.

1983) and integrate planning phases in the therapeutic process (Fig. 5.3). Pattern development by 'trial and error' In the process of acquiring clinical patterns in memory (making them available in future decision-making processes), clin icians need to analyse their decisions frequently (Watts 1985, 2000) in the regular planning phases of the thera peutic process. The various hypotheses regarding sources, con tributing factors and treatment interventions need to be employed and scrutinized in reassessment pro cedures. Novices, in order to gain experience, should not take any shortcuts, but make the actuaL experience collaboratively with the patient about which interven tions on which source may bring the desired results. It has been said that, within reassessment proced ures, physiotherapists go through a simple 'trial-and error ' process; however, deliberately following up hypotheses and consequently subjecting them to reassessment procedures is in a sense heuristic: based on information from the subjective examination on the localization of symptoms (the 'body chart' - see Chapter 6), the physiotherapist may for example gen erate various hypotheses on the sources of the symp toms. At the stage of information gathering concerning 'behaviour of symptoms', the physiotherapist may endeavour to 'make features fit' and to confirm or reject certain hypotheses based on the analysis of the activ ities which provoke the symptoms. Frequently this heuristic process will aid the physiotherapist in setting priorities in initial physical examination procedures.

(Adapted from: Patel & Groen 1986, Jensen et al 1990, 1992, Schmidt & Boshuyzen 1993, Mattingly & Fleming 1994, Ryan 1995, Jones 1997, King & Bithell 1998, Jensen et aI 1999.)

Conclusion: procedural clinical reasoning Based on the insights gained from clinical reasoning research, it may be concluded that a process of continu ous assessment, reflection and consequent pLanning may guide novices on their path to clinical expertise. Pre requisites to this process are well-developed clinical examination and treatment skills, communication skills and a comprehensive, accessible, updated theoretical knowledge base. For further reading see Mattingly & Fleming (1994), Higgs & Jones (2000) and Jones & Rivett (2004).

Principles of assessment

PSYC HOSOCIAL ASSESSMENT AS AN INTE G RAL PART OF T H E P H YSIOT HERA PY ASSESSMENT With the shift to a biopsychosocial paradigm, the indi vidual illness experience with the person's thoughts, feelings, sociocultural context and illness behaviour is progressively taken into account in the shaping of treatment. Furthermore, with the dramatic increase of pain related disabilities in many industrialized countries it has been recognized that psychosocial factors in par ticular are frequently relevant contributing elements in such chronic conditions (Turk 1997, Linton 2000). Therefore it is recommended that physiotherapists perform an assessment to establish those psychosocial factors that hinder full recovery of function ('yellow flags') in those patients who are at risk of developing a chronic disability due to pain (Kendall et al 1997). It has also been recommended that physiotherapists should assess psychosocial contributing factors and integrate these into the rehabilitation of patients with movement disorders (Scalzitti 1997, Wright 1999, Simmonds et a1 2000, Watson & Kendall 2000). It appears that experienced phYSiotherapists impli citly adhere to a biopsychosocial paradigm and seem to have developed a 'tacit', experiential knowledge base regarding the psychosocial aspects of their work (Hengeveld 2000), calling this 'good patient handling skills' (Watson 1999). However, it seems that they may not always be explicitly aware of their actions and inter actions in this context Gensen et al 1990, 1992) and may have insufficiently conceptuaLized the psychosocial dimen sions within the phYSiotherapy-specific paradigm of movement rehabilitation with the instruments of move ment, touch and other applications (Hengeveld 2000).

Objectives of psychosocial assessment in physiotherapy The first objective is to establish any psychosociaL risk factors ('yellow flags') that may hinder patients with pain in their recovery to full function. A person is con sidered at risk of developing long-term disability due to pain if, on clinical presentation, there are one or more very strong indicators, or several less important but cumulative factors, of risk (Kendall et al 1997). Psychosocial assessment may also give insights into the world of the individual illness experience, which may assist in the process of collaborative goaL setting. Treatment objectives on activity levels can be defined throughout the subjective examination if certain ques tions regarding the patient's personal experience and beliefs are followed up and summarized with skilled communication strategies (see also Chapter 3).

A psychosocial assessment, with attentive listening skills and careful observation, may allow for a multidi mensionaL approach to physiotherapy management in which the patient may be guided to a sense of health and health-promoting behaviour regarding movement functions. In this phenomenological perspective to physiotherapy treatment, cognitive, affective, socio cultural and behavioural factors need to be conceptu alized next to physical aspects of movement functions (see also Chapter 4 and Appendix 2).

Yellow flags The psychosocial risk factors have been described in various publications (Kendall et al 1997, Watson & Kendall 2000, Waddell 2004). They have been described in a mnemonic 'ABCDEFW' in an order of conven ience, which does not necessarily indicate a ranking in relative importance (Kendall et aI 1997). Some aspects which may be of particular interest to physiotherapy practice are described in Box 5.4.

Misconceptions regarding psychosocial assessment and the b iopsychosociaJ framework Some misconceptions with regard to psychosocial assessment may lead to misinterpretation of informa tion. This may be attributed to the lack of conceptual ization as the shift to a biopsychosocial paradigm may not have completely taken place in the medical and physiotherapeutic world.

Yellow flags It is critical to aVOiding pejorative labelling of patients with yellow flags as this will have a negative effect on management and the attitudes of the clinicians (Kendall et aI 1997). Predicted poor outcomes in acute nociceptive pain states with the presence of relevant yellow flags should lead to different approaches (e.g. cognitive-behavioural approach, interdiscipli nary approaches) to treatment rather than denying therapy or shifting patients over to psychiatrists.

Central pain Based on insights from neurophysiological pain mech anisms, clinicians may use the term 'central pain' or 'central pain patient' as a substitute for the obsolete term 'psychogenic pain'; however, using the term 'cen tral nervous system modulation' has been suggested. As soon as clinicians develop hypotheses regarding central nervous system processing contributing to the pain experience, they have to consider all possible

115

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M A I TLAN D ' S P E R I P H E R A L M A N I P U LAT I O N

L Box

I

5.4

Psychosocial risk factors to long-term disabi l ity with relevance to physiotherapy practice -

Attitudes and beliefs a b o u t pain •

avoida nce behaviour (e.g. the development of g u a rding •

Diagnostic language leading to catastrophizing

•

Dramatization of back pain by health professional

and fear

movements and fea r of movement)

prod ucing dependency on treatments, and

Belief that a l l pain m ust be a bol ished before

continuation of pa ssive treatment

attempting to retu rn to work or normal activity •

•

Belief that pain is h a rmful or disabling resulting in fear

•

Expectation of increased pain with activity or work,

Advice to withdraw from job a n d other releva nt activities

lack of a bility to predict capa bility •

Catastrophizing, thinking the worst, misinterpreting

Emotions

bodily symptoms

•

•

Bel ief that pain is u nco ntrolla b l e

•

Long-term low mood, loss of sense of enjoyment

•

Passive a ttitud e t o re h a bilitation

•

Anxiety a bout and heightened awareness of bodily

•

Feeling u nder stress and u n a ble to maintain a sense

Behaviours •

Use of extended rest, disproportionate 'downtime'

•

Reduced activity levels with significant withdrawal from activities of daily livi n g , avoid a n ce of normal activity a n d prog ressive substitution of lifestyle away from prod u ctive activity

•

Irreg ula r pa rticipation or poor co m p liance with physica l exercise

•

Excessive reliance on use of aids or a p p l i a nces

•

Increased intake of a l cohol or other su bstances since onset of pain

Fear of increased pain with activity or work

sensations of control •

Feeling useless a n d not needed

Family •

Overprotective partn er/ spouse; solicitous behaviour of spouse (e.g. ta king over tasks)

•

Extent to which family mem bers support a ny attempt to return to work or other releva nt activities

•

Lack of su pport person to talk with about problems

Compensation issues

Work

•

Lack of fi n a n cial incentive to return to work

•

•

History of cla i m (s) due to other pain problems

mai ntenance of constrained or sustained postures;

•

Previo us experience of ineffective case management

inflexible work schedule p reventing appropriate breaks

(e.g. a bsence of i nterest, perception of being treated

•

pu n itively) Diagnosis and treatment •

•

Experience of conflictin g dia g n oses a n d exp l a nations, resulting i n confusion

pathophysiological, cognitive, affective, sociocultural and behavioural contributions.

Causative agents and contributing factors Within the dualistic biomedical model a causative approach to examination and treatment exists. How ever, within a biopsychosocial model there needs to be a distinction between causative agents and contribut ing factors. For example, a person with a history of sexual abuse and long-lasting pain in the hip and back area may have developed a certain sensitivity as a contributing factor. The person will certainly not be

Belief that work is h a rmful, that it will do da mage or be d a ngerous

•

Min i m a l ava i l a bility of selected duties and g rad uated retu rn to work path ways, with u nsatisfactory

H ea l th professionals sanctioning disability, not providing interventions that will improve function

job i nvolvi ng high biomechanical demands with

imp lementation of these •

Absence of i nterest of employer

Adapted

from Kendall et a l

(1 997).

helped in finding a sense of control over their well being if the clinician treats this history as a causative factor and withdraws from treatment without guiding the patient to a sense of control and increased bodily awareness in different situations.

Psychopathology Patients with a chronic pain experience may have dif fering scores in investigations into psychiatric diag noses such as depression, anxiety disorder or personality disorder; however, it has been recognized that these psychiatric presentations seldom explain the pain fully

Princip les of assessment

(Large 1996). It is argued that all too often personality

traits are mistaken for personality disorders as cat egorized in DSM-IV (Weisberg & Keefe 1997). The psy chosocial assessment is not a psychiatric assessment for psychopathology, personality disorders or social problems. This would be indicative of so-called 'orange flags' and patients should be referred to the appropri ate psychiatrist or psychologist (Main 2004). It is essen tial not to label chronic pain patients as psychiatric patients, nor to seek after pain-prone personalities, but to recognize that most chronic pain patients show nor mal psychosocial variables of the human experience which contribute to pain and disability (Linton 2000). Psychosocial assessment may be considered as an investigation into normal cognitive, affective and socio cultural variables of the human experience which may hinder the full recovery of ftmction due to pain perception and behaviour. Psychosocial yellow flags should be integrated into management and not mis used to stigmatize patients or used as an excuse to withdraw from a patient's care.

Life problems Social or marital problems and other challenging life situations may not necessarily be yellow flags. It is essential to consider if a patient is capable of recogniz ing these factors as such and is able to cope with them actively.

Secondary gain

strategies (Sluys 2000, Moseley 2004) in influencing the beliefs of the patient. However, there may be more pain- and disability related constructs that may need further conceptualiza tion in future physiotherapy practice (Hengeveld 2000). Some of these constructs are delineated in Box 5.5.

Questionnaires or interviews as an integral part of physiotherapy assessment It is postulated that every clinician should be capable of performing a screening of yellow flags (CSAG 1994) and various physiotherapists advocate the integration of this investigation into the overall assessment of physiotherapists (Scalzitti 1997, Watson 1 999, Simmonds et aI 2000). Several questionnaires have been developed to assess psychosocial aspects, such as the Fear Avoidance Beliefs Questionnaire (Waddell et a1 1993) or the Acute Low Back Pain Screening Questionnaire (Linton & Hallden 1996), and many others. Questionnaires may have some advantages as they may provide a clinician with preliminary information, which can then be followed up in further detail during the clinical interview. However, it is emphasized that psychosocial assessment should be an integral part of the overall physiotherapy assessment and treatment process, which carmot be replaced by any question naires. The integration of a psychosocial assessment in the interview may have several advantages:

Relevant psychosocial constructs in physiotherapy practice

• Clarifications can be sought. For example: Patient 'I just carmot do anything about this pain!' Therapist 'Do I understand that you feel you have hardly any control over your wellbeing?' 'Yes, that's so - it's terrible!' Patient Therapist 'Would you agree to our trying to find measures or movements that you could perform yourself to keep some sort of control?' 'Oh yes.' Patient Therapist 'Okay, which activities do you feel are mostly out of your control?' • The information may be used in the process of collaborative goal setting to define meaningful treatment objectives. • It encourages the development of trust, mutual understanding and the shaping of the therapeutic relationship.

It appears that the explicit conceptualization of psy chosocial factors in physiotherapy practice is on its way with, for example, the awareness of cognitive behavioural approaches in physiotherapy (Harding & Williams 1995) and the relevance of educational

There is some indication that psychosocial assessment may already be part of the implicit, experiential know ledge base of physiotherapists. However, it appears that the assessment is more likely to be performed intuitively in an exclusive way. If a patient is shown to

Secondary gain is described as a social advantage attained by a person as a consequence of an illness; however, tertiary gains may also exist in which others in the direct environment benefit from the illness of the person. It is important not to focus solely on the second ary gain of a person with pain without asking about the secondary losses to the person as well (Fishbain 1994). Exaggerated pain behaviour may often be taken as malingering or secondary gain. However, it is emphasized that real malingering is rare; exaggerated pain behaviour can exist for various reasons and is judged as such from the perspective of the clinician rather than the patient (Pilowsky 1997).

1 17

1 18

M A ITLAN D ' S P E R I P H E R A L M A N I P U LAT I O N

[

Box & . 8 Differea t pIydtosodaI � possibly needing further conc:eptualttat'l on In the physiotherapy process • •

D ifferences between pain, disa bility a n d suffering Behaviour (illness beh avio u r ; health-promoting behaviours) : exp ression a n d g uarding move ment patterns avoid a n ce h e l p-seeking confronting boom-busting

•

Coping strategies: active or passive (or: conscious or a utoma tic)

•

Emotions:

involvement of psychosocial contributing factors, it appears that conceptualization of these factors is insuf ficient to distinguish the different psychosocial aspects from each other and to develop specific treatment approaches from the movement perspective of the pro fession (Hengeveld 2000). In this section it has been postulated that psycho social assessment should be an integral part of the basic physiotherapy assessment as it will aid the physiother apist to recognize those patients at risk of developing chronic disability, but above all it serves the shaping of a multidimensional approach to treatment. The fol lowing aspects are prerequisites to performing psy chosocial assessment and management successfully: •

fear, a nxiety d e pressed mood

•

helplessness, h opelessness vulnera bility a n g er

•

g u ilt •

Cognition :

•

expectations catastro ph izing beliefs, knowledge self-efficacy beliefs •

Sense of control: locus of control ( i n ternalized, externalized) - self-efficacy beliefs

•

- coping strategies •

•

Learning processes: - earlier experiences (self, significa n t others)

•

- sociocultural influe nces a n d values •

Social aspects: - job satisfaction - sense of control - influence of spouse, relatives a n d social s u p port

•

skilled interviewing, examination and reassessment procedures the possibility to integrate forms of interactive and narrative reasoning, with well-developed communication skills careful observation of body language, posture and movements attentive listening and responding to key words and phrases: it is important to pay attention not only to what people say but also to how they say it and the words they choose to describe their experience communication skills (e.g. summarizing, questioning, mirroring; see Chapter 3) understanding of tl1e various psychosocial con structs as contributing factors to a pain experience conceptualization of theses constructs within the phYSiotherapy-specific movement paradigm.

Phenomenological dimensions: sense of coherence, sense of self, sense of the world, sense of wellbein g , sense of pu rpose

Integration in the physiotherapy process During various phases of the physiotherapy process it may be decided to explicitly integrate aspects of a psy chosocial assessment and management.

individual illness experience, i n divid u a l health experience Reproduced by kind permission from Hengeveld

(2000).

have symptoms in a clear stimulus-response relation ship, seems to cope well, is confident that the problem will get better and has not diminished the level of activ ity in daily life, physiotherapists may conclude that 'this is an uncomplicated sih.\ation', with a good prog nosis. Hence within this form of psychosocial assess ment many relevant risk factors have been implicitly excluded. However, if there is some indication of

Welcoming/information phase Is the patient expecting physiotherapy to be the treat ment of choice for the problem? Does the patient understand the movement perspective of physiother apists in problem-solving processes? (Chapter 3).

During subjective assessment •

Does it seem that there is a discrepancy between the pain and perceived disability, especially in combi nation with extreme guarding of movements, non verbal expression and the use of emotive words?

Principles of assessment

•

Does the pain and disability seem to last much longer than an average healing process would be expected to take?

•

Does the patient express a loss of control over wellbeing? Does the patient show excessive rest periods or high intake of medication to influence the pain? Has the patient reduced the level of activities and restricted social participation due to the problem?

•

Does the patient expect the pain to improve before they will consider an increase in activities? In such cases it may be essential to define treatment goals on levels of activity next to objectives to control the pain.

It may be decided to incorporate a psychosocial assess ment in a first session, as it has been shown tha t within 2-4 weeks after an acute nociceptive episode, cogni tive, affective and social factors increasingly start to contribute to the patient's pain experience (Vlaeyen & Linton 2000).

Retrospective and prospective assessments These assessments are essential in the process, as it has been shown that phYSiotherapists may recognize the need for a multidimensional approach to treatment (at the latest after three or four sessions) if progress does not take place as expected in the short-term prognosis (Hengeveld 2000). This is especially so if the expected improvement in activity and participation does not seem to take place, despite the therapist's expectation that the healing and nociceptive processes would allow for this increase in activity (Appendix 2).

Main aspects for physiotherapy regarding psychosocial assessment and management from a b iopsychosocial approach Overall, it may be concluded that within a biopsycho social approach to treatment, it is important to know what patients think, know and feel about their problem, and what influence there is both on and from the social environment. Some elements may be particularly rele vant to follow up in the examination procedures.

Planning phase of physical examination It is essential to summarize the main findings of the sub jective examination and the agreed goals of treatment so far. The patient needs to be informed about the purpose of the physical examination and of the various tests (to serve as a parameter for reassessment procedures).

During physical examination procedures This aspect includes information about procedures and findings and guiding the patient in the perception of the findings (see also communication examples in Chapter 3). With some patients it is essential not only to focus on the abnormalities, but also to explain to the patient which test movements are normal.

Reassessments Announce them, guide the patients to their own percep tions of change and undertake cognitive reinforcement (see Cognitive-behavioural perspective to reassessment procedures above).

Perceived disability This question may be asked at the beginning when establishing the patient's 'main problem'. If a person expresses a high perceived disability in daily life, as shown through non-verbal behaviour and selection of words, a multidimensional approach to treatment may be necessary and the physiotherapist may decide to integrate a psychosocial assessment and a careful process of collaborative goal setting in the first subject ive examination.

Beliefs and expectations about movement and physiotherapy •

•

•

• •

Information and educational strategies These strategies need to be incorporated into the process of collaborative goal setting and reassessment. The patient needs to be given time to ask questions and seek clarification.

•

Is the patient expecting that the specific movement framework of contemporary physiotherapy practice is the treatment of choice for the problem? Which explanations does the patient have on the causes of the problem? Does the patient think the problem has been investigated profoundly enough? Does the patient expect other forms of treatment? Does the patient believe that hurt equals harm, therefore no exercise, activities or work can be performed as long as it is painful? Which associations does the patient have with regard to the biomedical diagnosis of the problem? (e.g. osteoarthritis can only be treated with a joint replacement).

1 19

1 20

M A ITLA N D ' S P E R I P H E R A L M A N I P U LAT I O N

•

Does the patient have other attributions about the causes and treatment strategies for the problem due to individual cultural values and beliefs?

Behaviour •

•

•

•

Does the patient's movement behaviour seem to be in relation to the nociceptive processes? Is there any indication of fear avoidance behaviour? On the contrary, does it seem that moments of relaxation are missing in the busy life schedule of the patient? Is the patient capable of coping with stress situations?

Trust to move, sense of control and coping strategies •

•

•

Does the patient demonstrate 'trust to move' or to perform certain activities in spite of pain? Does the patient perceive a sense of control over pain and wellbeing in daily life situations? Does the patient seem to express a sense of helplessness or even hopelessness?

Opinions of other health-care workers on the problem

Therapist

'You might consider it positively, if you would allow me to say so. Obviously the direct cure has not been found so far. But one approach of treatment may have brought you a few steps forward, one a bit better than another. If I took you on a boat from Switzerland to Africa, I may bring you over the Rhine, but it may be possible that I could not guide you fully to the point of destination. I might bring you a few steps forward in your problem; how ever, it's up to you to judge if that has been relevant.'

General level of activity/participation Not only questions regarding work are relevant, but also hobbies, social contacts and other interests. Does the patient feel capable of doing all the things in life that have to be done or the patient wishes to do?

Responses of social environment 'How are your employers/ co-workers/ family respond ing to your problem?'

Clarification of treatment objectives and interventions (process of collaborative goal setting)

This relates to Kleinmann's notion (1988) that every professional looks at the problem from a profession-specific perspective and will define the problem according to a profession-specific taxonomy. Patients may have received many different diagnoses and cures for their problem, which may not have brought the desired results. It is essential that the ther apist is aware that the explanations given may con tribute to further confusion of the patient. The following communication example may highlight the relevance of clarification before entering an examin ation procedure:

Many people develop chronic disability attributed to pain based on non-clarified expectations. It is important to set limits to what can be offered in therapy and what may not be achieved in treatment. Some patients ini tially may express a treatment objective to have less pain; however, after some clarifications it appears to be more likely that they wish control over wellbeing with self-management strategies (Chapter 3). If a patient expresses the wish to be treated with passive treatment (e.g. massage), the physiotherapist should ask what the patient expects from the massage:

'Everybody says something different, why don't they find it and do something about it?' 'Since I got this problem, you are now the twentieth doctor or therapist that I've seen over the last 2 years!' 'That means you got a lot of different expla nations from everybody?' 'Yes, sure.' 'How would it be if I were to give you another (twentieth) explanation?' ...!

Q 'What kind of treatment would you expect from us?' A 'Well, my neighbour was treated with massage and mobilizations.' Q 'What would you think your body needs from this?' A 'Well, I think I would be able to relax more and I might get a bit more flexible?' Q 'Yes, then massage and mobilizations are certainly good interventions. Would you agree that we also seek some other interventions, like simple exercises which you can perform yourself to relax and to stay flexible? Then you are not so dependent upon my hands?'

Patient

Patient

Therapist Patient Therapist Patient

Principles of assessment

Attentive listening and careful observation As stated before, attentive listening and careful obser vation may give clues to the world of the individual illness experience and may be followed up by gentle questioning during the appropriate moment of the subjective examination and other phases of the ther apeutic process, for example: •

If a patient responds to the question, 'How is your general health?' reluctantly, blushing: 'Well, the doctor has not said anything', this may be an indi cation of an 'externalized locus of control' with regard to health.

•

If a patient describes an accident of several years ago in much detail, as if happened yesterday, there may be some indication of 'posttraumatic stress disorder', especially if the patient regularly has flashbacks or dreams about the incident (Van der Kolk et al 1996).

•

If a patient's pain increases during the interview or physical examination, it may be useful to observe which movements or positions the patient performs instinctively to relieve the pain. These movement directions may be employed as passive mobiliza tion strategies and self-management interventions.

Additional questions Additional questions may be asked at various stages of the subjective examination or other phases of the therapeutic process, for example: • •

• •

•

•

Have you had time off work in the past with pain? What do you understand is the cause of your pain? (Some patients may have difficulty with this question as they expect the therapist to find this out; therefore it may be asked: Which explanations have you received about why it is hurting or have you some thoughts yourself about it?) What are you expecting will help you? What are you doing to cope with the pain? Or: Is there anything you can do yourself to keep control over the pain? Are you able to perform all the activities in your life in spite of the pain? Do you think the problem was investigated sufficiently before you were sent to me?

•

•

How is your employer responding to your back pain? Your co-workers? Your family? Do you think you will return to work (or hobbies and other social contacts/ roles) - when?

CONCLUSION Working within a biopsychosocial (movement) para digm, which integrates psychosocial assessment into the overall physiotherapy assessment, becomes a sub tle process in which physiotherapists need to consider the effects of their words and actions on the personal illness experience and behaviour of the patient. This framework of practice allows the definition of treatment objectives on cognitive and affective levels next to movement rehabilitation on impairment, activity and participation levels as delineated in the IeF (WHO 2001). For example, phYSiotherapists may include sessions with educational strategies regarding the beneficial effects of movement with degenerative osteoarthritis (Dieppe 1984, 1 998) or the current insights on neurophysiological pain mechanisms in relation to the individual pain experience and behaviour of the patient (Gifford 1998a, Shacklock 1999b, Butler & Moseley 2003). It may be concluded, therefore, that the scope of physiotherapy practice has been widened with the conceptualization of biopsychosocial issues. Symptoms and signs as described in the brick wall analogy in fact should relate to the multidimensional aspects of a pain experience. Over a short period of time after an acute nociceptive onset, cognitive and affective factors may start to play a role in the pain experience (Vlaeyen & Linton 2000) which physiotherapists may address with, for example, conscious reassessment procedures, educational strategies, communication and self-management strategies. Within this context a tendency to 'hands-off' treatment may be observed. However, the essence of (manipulative) physiotherapy as a hands-on profession and the power of therapeutic touch in the reintegrative effects on bodily awareness and sense of self should not be underestimated (Rey 1995, Ledermann 1996, Van Manen 1998). All interventions, be they passive mobilizations, exercises or educational strategies need to be monitored within a process of continuous (re)assessment and reflection, in order to determine collaboratively with the patient if all interventions lead to the desired results.

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1 23

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1 25

Chapter

6

Principles of examination

THIS CHAPTER INCLUDES: •

Key words for this chapter

•

Glossary of terms for this chapter

•

Proced ures of su bj ective

•

function related) •

•

session and plan ning of follow-up

examination

session(s).

KEY WORDS

plan ning and reflection, physical examin ation.

Irritabi lity - a con struct which determines precautions to examination and treatment proced u res. It is defined as 'a little activity causin g severe pain, discomfort, paraesthesia or n umbness, which takes relatively lon g to su bside' (M aitland et al

2001). I rritability needs t o b e consid ered from various perspectives. On the one hand it d escribes the reported pain sensation, on the other it reports the activity provokin g the symptoms, inclu ding the patient's reaction to it. If the symptoms appear to be due to dominant n ociceptive or peripheral neu rogenic input mechanisms, a direct stimulu s-response relation ship may exist. H owever, central nervous system processin g

Reflection of a first examination

Plan ning of the physical

Subjective examin ation,

GLOSSARY OF TERMS

Physical examin ation - general prin ciples and proced ures

examination (pain related,

and (neurophysiological) output

examination and treatment

mechanisms (Gifford 1998a, B utler

proced ures with active and passive

2000) may contribute to ongoing

movements. This may include

tend erness and sensitivity to touch

pathobiological processes (tissue

or movement, which may d istort

mechanisms such as pathology

the direct stimulus-response

and phases of tissue healing,

relation ship. From a behavioural

n eu rophysiological symptom

perspective the con struct of

mechanisms such as central

irritability may be considered as a

n ervous system mod u lation or

form of avoid ance behaviour, as

peripheral n eu rogenic

the person havin g the pain will

mechanisms), stage and stability of

frequ ently interrupt the activity

the disorder, personal factors such

causing the pain ( H en geveld

2002).

It n eed s to be d etermined if the behaviour is adaptive to acu te

as 'lack of tru st' to move as in cases of 'fear avoid ance behaviou r'.

Physical exa m i nation - related to the

n ociceptive or peripheral

specific manipu lative

n eurogenic processes or if the

physiotherapist's an alysis of

behaviour has become maladaptive

movement d isorders and includes

over time d ue to learn ing processes

active and passive movement

and central n ervous system

testing, mu scle testing, soft tissue

mechanisms.

examination and other tests in

Nature fa ct ors - various factors in

order to reproduce the patient's

the ' n ature' of the disorder may

symptoms and to determine which

determine precautions to

movement impairments contribute

1 26

M A I T L A N D'S P E R I P H E RA L M A N I PU LAT I O N

[ to the overall activity l imitation s

in terrupted and usually can n ot be

and participation restrictions of the

taken up again d ue to the in tensity

patient. Physical examination

of the pain. In contrast to

findings serve as parameters for

irritabil ity the pain may settl e fairly

reassessmen t proced ures to

quickly after stopping the activity.

the patien t's accou n t of the

monitor the effect of therapeutic

Similar to irritability, ' severity' may

disorder and its past history. I t

be con sid ered as a form of

includes in formation o n the kind

avoid ance behaviour. As with the

of disorder, site of symptoms,

in terventions.

Severity - a con struct which

behaviour of symptoms and

needs to be a distinction between

establishment of the level of

proced u res. The activity which

seemingly adaptive or maladaptive

d isability, special questions and

provokes the pain n eeds to be

avoid ance behaviour d ue to

history.

Diagnosis from the specific (movement) perspective of physiotherapists generally expressed in terms of -

impairments of movement components, activity limi tations and resources, and participation restriction. The diagnosis may also encompass elements from the individual illness experience and from other factors contributing to the movement disorder.

Although the categorization of hypotheses in principle may be considered an individual process (Larkin et aI1980), the following hypothesis categories may be made explicit during some critical phases of the physiotherapy process by most manipulative physiotherapists:

• • • •

•

Determination of precautions and contraindications to physiotherapy interventions - this has become even more relevant than before since in an increasing number of countries physiotherapists have assumed the role of 'direct-contact practitioner '.

Treatment plan - determination of short- and long term treatment objectives, and selection of meaning ful interventions in a collaborative process with the patient.

•

Determination of parameters to monitor the results of

•

•

•

Initial preliminary treatment, including first reassess

•

ment of effects.

•

The whole process of examination, assessment and treatment is guided by clinical reasoning processes. Physiotherapists frequently follow a process of hypo thesis generation, testing and pattern recognition while making decisions with regard to physiotherapeutic care (Grant et aI1988).

Sources of symptoms or movement impairments Pathobiological mechanisms Precautions and contraindications Contributing factors Level of disability (impairments, activities, participation - ICF (WHO 2001) Individual illness experience (thoughts, beliefs, feelings, earlier experience, values, meanings, influence on and from social environment) and behavioural factors Management (including objectives of treatment and selection of interventions) PrognOSiS (for further details see Chapter 5).

In order to be able to fulfil successful examination procedures, various elements are required:

treatment. •

the

examination and treatment

•

•

-

subjective examination relates to

con struct of 'irritability' there

W hen starting the physiotherapy process, examination procedures are essential prerequisites to successful treatment and the reassessment of results. As pOinted out in Chapter 5, the general aims of examination procedures are as follows:

•

n ervous system mechanisms.

S ubj ective exam i nation

d etermines precaution s to

INTRODUCTION

•

learn in g processes and central

•

A knowledge base (theoretical, professional craft) which is accessible and well organized (Higgs & Titchen 1995, Higgs & Jones 2000) Interviewing skills (Chapter 3) Clinical skills - observation, manual handling and palpation skills, movement skills Clinical reasoning skills - cognition, continuous critical reflection on thoughts, feelings and decisions as well as the capacity to react adequately to the reflections. This may be expressed in the planning phases of the assessment and therapeutic processes.

Principles of exami nation

Within the examination process complex clinical reasoning takes place, in which additional forms of reasoning other than the above-mentioned processes of hypothesis generation and testing are also employed and different paradigms are followed (Chapter 5). For novices in manipulative physiotherapy fre quently it is helpful to follow a more or less fixed set of procedures which allow for comprehensive data gathering in interviews and physical examination procedures. Regular, consequent planning phases allow for the development of reflective skills. In plan ning, novice physiotherapists should be encouraged to make hypotheses explicit, including the conse quences of these hypotheses for further examination procedures or treatment interventions. This process may enhance the development of clinical patterns in memory. With increasing years of clinical experience it may become easier to relate to more complex forms of clin ical reasoning such as narrative reasoning in combin ation with procedural reasoning. This approach may be needed in more chronic pain states or disabilities in which a multidimensional approach to assessment and treatment is more appropriate (Greenhalgh & Hurwitz 1998, Main & Spanswick 2000). The following algorithm of information, procedures, reflection and planning is suggested for a first session: • • •

•

•

•

Welcoming and information phase Subjective examination Planning - summarizing/reflection and planning of the physical examination Physical examination, including preliminary treatment and reassessment End of session - instructions, recommendations, warnings Reflection of first session and planning of next session(s).

Nevertheless, within the algorithm it is essential to retain a certain degree of flexibility, which should allow the patient to give an account of the individual illness experience and the physiotherapist to explore certain information further in order to enhance deeper under standing of the patient's problem. The procedures of questioning and testing should leave space for 'extra procedural' information, such as key words or non verbal language which may be indicative of the individual illness experience. It is therefore essential to follow procedures in subjective and physical exam inations which give a framework to information gath ering, but the procedures should be flexible enough to adapt the processes to the specific needs of the patient.

WELCOMING AND INFORMATION PHASE

As explained in Chapter 3, the welcoming and informa tion phase is an essential stage in the therapeutic process. On the one hand the physiotherapist may inform the patient about the scope and procedures of the physiotherapy process; on the other hand the phys iotherapist may receive information relating to the beliefs and expectations of the patient, especially if the patient is expecting physiotherapy to be the optimum treatment for the problem. At the same time, the physio therapist enhances the development of a therapeutic relationship in which the therapist may start to get a feel for certain barriers or sensitivities of the patient. This stage may encompass the following steps: • •

• •

•

Introduction and joining First explanation on physiotherapy perspective the physiotherapist will examine movement functions Clarification of expectations of patient Explanation on setting (room, therapist, number of treatment sessions, etc.) Sequence of first session - what will be done and what is involved in the patient's role.

(See also 'Critical phases of the therapeutic process' and 'Verbatim examples', Chapter 3.)

SUBJECTIVE EXAMINATION

The subjective examination relates to the patient's account of the disorder and its past history. As informa tion is sought from the patient's perspective of the prob lem, it is essential that the physiotherapist endeavours to see and record the problem in the patient's terms. It is recommended that physiotherapists follow procedures with open and half-open questions, rather than a list of questions or a questionnaire. The latter frequently are more inflexible and may destroy inde pendent thinking, prevent following up of hypotheses which are generated during the process, and can oblit erate the chance of adapting to the patient's line of thought or giving the patient space to describe his personal experience of the problem. Communication skills play a central role in this process, as there will be individual differences between patients. Some patients are excellent witnesses, whereas others appear unable to understand some questions or have difficulty in answering them simply. Skill in extracting the appropriate information requires care, patience and a critical attitude. Communication is full of pitfalls. The physiotherapist may not word the ques tion in a way that clearly expresses the purpose of the

127

MAITLAND'S PERIPH ERAL MANIPULATION

128

[ question and the patient may give different meanings to the words used by the physiotherapist. To make it easier for the patient, only one question should be asked at a time, and should be pursued, within reason, until the answer is obtained. If the patient gives what seems an incongruous answer to the question, then the fault may lie in the way the question was put. It may be kinder to rephrase or explain the question than to restate it, even if it was so simply put that it may have been the patient's error. (For further information, see Chapter 3.) The subjective examination follows several objectives: •

Determination of the problem of the patient, from the patient's perspective - this includes assessment of the

The experienced physiotherapist may adapt the proced ures to the patient's line of thought with the use of the communication technique of paralleling; however, the inexperienced physiotherapist must have a starf.ng point to encourage clarity and a systematic approach. The following sections discuss the procedures of the subjective examination. Each subsection will describe the following aspects: •

•

•

patient's pain or other symptoms as well as the assessment of (movement) functions. •

•

Defining subjective parameters which serve reassess ment procedures - these parameters include information with regard to pain sensation, activity limitations and participation restrictions, behav ioural aspects such as coping strategies, use of medication and indications of psychosocial factors which may hinder a recovery of full function. Determination of precautions and contraindications to physical examination and treatment procedures. The pain experience and the concomitant disability are indicative of specific precautions to examination pro cedures. Frequently this will be described with the constructs of irritability and severity. Furthermore, hypotheses with regard not only to pathobiological tissue processes and 'red flags', healing stage of tissue and stability and stage of the disorder, but also 'trust to move' may be other decisive factors ('nature of the disorder ') in the determination of precautions to examination and treatment procedures (see Planning of the physical examination, below).

•

Procedures which serve information gathering with regard to tl1e process of physiotherapy diagnosis Communication aspects - if appropriate to the information of the section Clinical reasoning - how the obtained information may aid in the generation and modulation of different hypotheses Summary of the main information of the section.

'Kind' of disorder - the main problem

In order to establish the kind of the disorder from the perspective of the patient the physiotherapist may start with the following question ('Question I'): Q

'As far as you are concerned . . . [pause. . . J . . . what do you feel... [pause .. J is your main problem?' .

The stage of subjective examination will be completed with a reflection and planning phase, before entering the physical examination stage of the first analytical assessment. The subjective examination can be divided into five parts:

The therapist may choose to include within the ques tion 'at this stage' or 'why are you seeking the help of a physiotherapist'. The pauses in the question allow the patient time to realize that the therapist is specif ically interested in the patient's own opinion. Frequently it is very informative to complement the information of the 'first question' with the perceived disability from the perspective of the patient. From this the physiotherapist may learn to relate the information with regard to pain to the level of disability. It may be a first indication of a psychOSOCial risk factor impeding recovery to full function ('yellow flag') if the perceived disability seems somewhat incongruous to the symp toms. However, it cannot be emphasized enough that these are only hypotheses - if they are confirmed, it is only an indication to a more multidimensional approach to physiotherapy treatment, rather than denying a patient phYSiotherapy services. Most patients will answer with pain as their main complaint in the 'first question'; however, there may be many different kinds of disorder as the main reason why the patient is seeking the help of a physiotherapist:

1.

•

•

Generation of multiple hypotheses to be tested during physical examination procedures and treatment interventions. Hypothesis categories as mentioned above are described in more detail in Chapter 5.

2. 3. 4. 5.

'Kind' of disorder - establishing the main problem and perceived disability Site of symptoms - body <;:hart Behaviour of symptoms and level of disability History SpeCial questions.

• • • • •

Pain Stiffness Giving way Sensation of instability Weakness Loss of function (local impairment, activities)

Principles of exa m i nation

•

•

After: - surgery - trauma - manipulation under anaesthesia - immobilization (e.g. plaster) following fracture - disloca tion Differential diagnosis - the physiotherapist's opinion is sought to determine if the patient has a disorder which can be treated from the specific professional perspective of the manipulative physiotherapist.

Follow-up questions

Gentle following up of the 'Ql' is needed if the patient seems to have already adopted the diagnosis of the refer ring doctor or the opinion of another physiotherapist: A

'Well, the doctor said that it may be an impinged nerve at my wrist:

Hypotheses

The information from 'Ql' and the perceived disability may support the physiotherapist in the first generation of various hypotheses: •

information about the symptoms and the way they are demonstrated by the patient will often aid in a first generation of hypotheses with regard to sources of the movement dysfunction. However, other hypotheses may also be generated in this early phase of the subjective examination: •

A

•

A

Q A

Q A

Q A

'My shoulder is in the wrong position, and my muscles don't work properly: 'Is that something you found out by yourself, or did someone tell you that?' 'Well, the physiotherapist I saw about 2 months ago told me this.' 'What made you go to the physio then?' '1 had this pain in my arm: 'Is this the same thing for which you are coming to me now?' 'Yes, it's bothering me again:

Some patients may answer to 'Ql' with the long-term history, with the attendant risk of losing much time, before the current main problem has been established. With a long-term history, it is often useful to first estab lish the current main problem and its behaviour before entering the history phase: A

Q A

Q A

'Well, it all started some 15 years ago. I have always worked very hard, ever since I was a kid: 'What was it that started then?' 'Well, this pain in my shoulder.' 'Is this the same thing for which you are coming to me now?' 'Yes. Yes, of course:

Precautions and contraindications to examination and treatment procedures.

•

'What made you go to the doctor?' 'Well, that numbness in my hand in the morning, when I wake up in bed:

If the phYSiotherapist immediately records this infor mation, or repeats it gently with some emphaSiS, the patient may learn that this is the kind of information the physiotherapist is seeking. Or:

Pathobiological processes, especially neurophysiologi cal symptom mechanisms.

The immediate-response question could be, for example:

Q

Sources of movement dysfunction and nociception -

•

Individual illness experience and behaviour - therapists may implicitly generate some hypotheses with. regard to the illness experience based on the non-verbal behaviour of the patient and the way the main problem is expressed. It is essential to distinguish between observation and interpretation. It may be interpreted by the physiotherapist that 'it may become difficult'; however, the observation may have been the 'use of more emotional words' or certain non verbal behaviours (e.g. sighing). Management - particularly treatment objectives. Improvement of the main problem as expressed by the patient may be one of the end goals of the treatment.

•

Prognosis - by linking the various hypothesis categories together, a first prognosis with regard to short- and long-term effects and possibilities of treatment is often made in this phase.

Box 6.1 summarizes the 'kind' of disorder - main problem. Box 6.1 Summary: 'kind' of disorder - the main problem Q1

'As far as you are concerned . . . what do you feel ... at this stage . . . is you r moin problem, an d why are you seeking the help of a physiotherapist?'

Complemented with in formation on the perceived disability: ' H ow does that disturb your activities in daily life?' (Do you feel strongly restricted, mildly restricted or no restriction at all?)

129

1 30

MAITLA N D ' S P E R I P H E R AL M A N I PU LAT I O N

L Figure

(Initial question) Kind of disorder

P l a n ning of the subjective

6.1

examination.

Planning of subsequent subjective examination procedures

Before proceeding to the next stage of the subjective examination, it is often useful to surrunarize the infor mation already obtained to serve the process of collab orative goal setting (Chapter 3) and to reflect on the first hypotheses generated. The physiotherapist may then quickly plan the next procedures in the subjective examination (Fig. 6.1 ). The sequence of introdUCing the history or behaviour of symptoms can be varied to suit the circumstances. As one gains experience both by the process of exam ining every patient in detail and also in communication skills, the pattern of asking the individual questions to reach a diagnosis can be varied to a very wide degree. For the beginner it is essential that variations in the sequence of asking questions should be made only as confidence in the necessary skills makes it possible. It is vital that at no stage should the physiotherapist lose the train of thought: once the train of thought is lost, essential questions can eaSily be forgotten. After establishing the kind of disorder, the pattern of questioning can be directed along one of three paths: 1. History 2. Area of symptoms 3. Behaviour of symptoms.

If the patient has an acute onset, or is in severe pain, then the history probably comes first. However, if the disorder is longer lasting then it is possible that the behaviour of the symptoms, once the therapist has a general idea of the areas of the problem, should be fol lowed next. The third possibility is that the patient has an area of referred pain into a limb, and because it is crucial to decide whether this referral is radicular or not, it will be necessary to define clearly the area of symptoms before going into either the history or the behaviour of the symptoms. Whatever area of subjective examination is chosen first, the final goal is to arrive at an informative (movement) diagnosis in which the physiotherapist aligns the clinical information with the theoretical knowledge base and biomedical diagnOSiS. Hypotheses

Theoretical knowledge Anatomy, physiology, neurophysiology,

Clinical information .....

pathology, psychology, biomechanics

Hypotheses

Figure

6.2

Hx, Sy, Si Facts and 'impressions'

1----....

Chart demonstrating relationships a nd contexts

for theoretical a n d clinica l knowledge with related hypotheses. Hx, history; Sy, symptoms; Si, signs.

are generated and tested throughout the process of examination, assessment and treatment (Fig. 6.2).

Site of symptoms - body chart

In the search for the area of symptoms, the findings should be as precise as possible because they form the foundation on which the examination is built. If all the symptoms as perceived by the patient are drawn on a 'body chart', reliability may increase (McCombe et al 1989). Above all it helps the physiotherapist in develop ing hypotheses on the sources of the symptoms or structures at fault. Furthermore, it will aid in reassess ment procedures in later sessions. Attention needs to be given to clarifying to follow ing aspects of the symptoms (Fig. 6.3): • •

•

•

•

Area of the symptoms Qualification of the symptoms: - type of pain (e.g. sharp, dull, throbbing, pulling) - intermittent or constant, or constant/variable - superficial or deep Areas free of symptoms, designated by a tick (.I) on the body chart Chronology of symptoms and relationship between symptoms If symptom distribution and qualification seems atypical, ask control questions with regard to

Princi ples of examin ation

Pulls

4

Int

Deep

Relationship

CD®@ Mostly together CD ® Mostly together, no relationship to CD-@ Figure 6.3

An example of recording examination findings on a body cha rt.

possible involvement of central nervous system or cauda equina disorders: - bladder and bowel function, including sensation - coughing, sneezing - 'pins and needles' in both hands and feet - gait disturbances - saddle anaesthesia - headache, dizziness. Variations in symptom areas

Pain presents in many ways as well as at many sites. A patient may have a dull but constant ache in a certain area as well as having a sharp stabbing pain in the same area when making certain movements. This becomes easy to accept when it is realized that a fall for example injures more than one structure associated with a joint. Each structure may respond to the injury with differ ent kinds of pain. Therefore, when questioning the patient regarding the symptoms, the possibility of

P+N/ B+B/ C+S// dizzy

different components of the disorder must always be kept uppermost in mind: •

Symptom areas in symptom areas, as described above. Precise attention needs to be given to the various types of symptoms a person may experi ence in the same area with different activities.

•

Referred symptoms: one source may refer symp toms to other areas.

•

Different sources may refer symptoms to the same area - this has to be kept in mind while establishing the 'behaviour of symptoms' as well as in planning the physical examination: several sources of move ment dysfunction need to be examined in the initial physical examination stage.

Verbal and non-verbal communication

In establishing the symptom areas the use of non verbal language may be helpful to understand where

13 1

132

M A ITLAN D ' S P E R I P H E R A L M A NIPULATI O N

[ The question may be worded differently and the physiotherapist may get the sought after answer immediately: 'Are there any moments when you do not feel this pain?'

and how the patient may feel the symptoms. Precision provides an invaluable foundation for the remainder of the examina tion: •

The examiner must watch how the patient indicates the area of pain and then, using finger or hand, take over from the patient to identify the area precisely.

•

The matching of non-verbal messages both with verbal responses and with touching the area strengthens the precision of the information.

•

One patient may be able to point to one precise spot of pain and another may only be able to indicate a large, vague area. Being able to point to a spot may indicate the exact site of the pain.

•

In determining the symptom-free regions, a short gentle touch on the area, with the question 'How is it here' may save time. In using only verbal lan guage the patient and physiotherapist may need to follow the feedback loop as indicated in Figure 3.2, which may cause many errors in interpretation and communication. (For example, if a phYSiotherapist ' wishes to know if the thoracic region is free of symptoms, gently touching the area will provide information more quickly than the question 'How is it between your shoulder blades', as the patient first may need to understand where the shoulder blades are and then needs to understand how it feels in that specific area.)

•

•

Some patients may have difficulties in describing the type of symptoms. Although spontaneous infor mation is preferred, the phYSiotherapist may then give a short listing of possible symptom types (e.g. pulling, stabbing, pinching, etc.), in which the most likely response is brought to the end of the list. If the patient responds somewhat impatiently 'No it just hurts', the physiotherapist should not pursue the matter further, but pay attention to later remarks with regard to pain experience. Attention is needed if the patient and physio therapist are to have the same understanding of 'constant' and intermittent pain. If the symptoms remain throughout the day, regardless of the activ ities of the patient, the therapist considers them as 'constant'. If these symptoms vary with certain activities they may be 'constant/variable'. However, many patients will answer a question, 'Are the symptoms constant or intermittent?' with 'They are constant, because every time I lift my arm, it hurts.' This may in fact indicate an intermittently occur ring symptom.

•

Similar difficulties may occur with the question of whether symptoms are either superficial or deep. Many patients do not understand the question. The phYSiotherapist may again get more valuable infor mation if the question is asked as follows: 'Do you feel that it is pulling directly under your skin, or do you think it's deeper within?'

•

Attention needs to be given throughout the whole process of subjective examination to the use of non verbal language and certain key words. Next to hypotheses with regard to sources of the movement dysfunction or precautions to examination and treatment, they may be indicative of the individual illness experience and behaviour (see 'Psychosocial assessment', Chapter 5).

Hypotheses

The information on the localization and qualification of the symptoms as designated on the 'body chart' may provide the physiotherapist with various new hypotheses, while other hypotheses generated after the establishment of the main problem with 'Ql' may be modified. The body chart is particularly informative with regard to the generation of hypotheses on: • • •

sources of the dysfunction tissue mechanisms with structures at fault neurophysiological symptom mechanisms.

Sources of movement i m p a i rments The possible sources of the movement impairments may be expressed in this early stage of subjective examination in the component concept, as outlined in Figure 6.4. It is essential to reflect briefly on the possible sources of the movement impairments at this stage of subject ive examination and to follow up these hypotheses in the next stages of the interview in order to be able to confirm, modulate or reject certain hypotheses already formed during the subjective examination. These hypotheses will be decisive in the procedures of physical examination later in the session. Tissue mechanisms Tissue mechanisms relate to path ology of tissue or stages of tissue healing. The example of Figure 6.3 may generate hypotheses with regard to entrapment neuropathy of the peripheral ulnar nerve around the elbow /wrist areas or a nerve root disorder of the lower cervical spine.

Princip les of exa mination

Joints •

Elbow: intra/periarticular

•

RlU or prox. RlH Cervical: C5--C7

•

Thoracic and ribs:

Neurodynamic system Ulnar nerve

T1-T4 •

Nerve root (Ca)

(shoulder)

Soft tissue, muscles • •

Flexor muscles Local soft tissues (periarticular; fascia)

Figure

6.4

Component concept of po ssible sources of

m ovement impairment (related to Fig.

6.3).

Frequently if symptoms are vague, dull and more difficult to localize, this may be indicative of referred symptoms from other, more proximal sources. If the symptoms are local, sharp and the patient is almost able to touch the area of symptoms, it is pos sible that a nociceptive process in the local structures is taking place. Nevertheless, in such cases it cannot yet be excluded that other components (e.g. spine or cen tral nervous system mechanisms) are not contributing to ongoing local tissue and movement sensitivity. Pulsating symptoms may be indicative of inflam matory processes, especially if they occur with car dinal signs such as redness, swelling or temperature changes. Neurophysiological symptom mechanisms Nociceptive and peripheral neurogenic symptom mechanisms mostly show typical, recognizable patterns of presen tation, usually with a more predictable stimulus response relationship, in which aggravating and easing factors may be quickly identified. These processes may occur with acute injuries, inflammatory processes or ischaemia in target tissues (e.g. epineural tissue, peri- and intra-articular connect ive tissue), resulting in nociceptive pain. Processes such as spinal nerve root compression or peripheral nerve entrapment may lead to peripheral neurogenic mechanisms, causing symptoms such as tingling, numbness, burning pain or deep annoying pain. If symptoms are vague, widespread, inconsistent and not behaving in a stimulus-response fashion, this may be indicative of central nervous system mechan isms which modulate the pain experience. This may be due to pathological processes in the central nervous

system as, for example, lesions in the thalamus, spinal cord or deafferentation syndromes. Furthermore, cen tral nervous system modulation may occur with psy chosocial factors contributing to pain and disability. The central nervous system is involved in all pain states. However, if central nervous system mechan isms seem to play a dominant role in the patient's pain experience, it is essential that the physiotherapist generates hypotheses in which pathophysiological, cognitive, affective, sociocultural and learning factors contribute to the pain experience, rather than solely claiming that 'the patient has a central pain', in which the term 'central pain' becomes a substitute for the dualistic perspective of 'psychogenic pain' (Hengeveld 2000). Hypotheses with regard to output mechanisms may be generated if the patient describes symptoms such as sweating, heaviness or swelling, which are indicative of dysfunction of autonomic nervous system mechanisms. It is important to note that many patients may have mixed mechanisms (Max 2000). Although an increas ing number of patients may show dominant central nervous system mechanisms, nociceptive processes may be present as well, which need to be addressed with competent manipulative physiotherapy care in combination with skilled communication processes and self-management strategies to enhance a sense of control over wellbeing. Based on the information from the body chart, the above-mentioned hypotheses may lead to the gener ation of other hypotheses. Precautions Symptoms indicative of peripheral neuro genic mechanisms frequently define precautions to physical examination tests and treatment procedures, as symptoms or neurological signs at times may easily aggravate without large effort. If symptoms are con stant or constant/variable, a non-mechanical disorder (e.g. an inflammatory process) may underlie the move ment disorder. A throbbing or pulsating quality in combination with redness or swelling may support this hypothesis. More sinister pathology (e.g. malignant disorders) may be suspected if later phases of the subjective examination reveal that the constant pain is associated with severe disturbance of night rest, involuntary weight loss and when no specific positions or move ments seem to ease the pain. To conclude, it is emphasized that physiotherapists should engage themselves in hypothesis generation in an early phase of subjective examination Gones 1992), frequently as early as the referral and welcoming phase of the therapeutic process (Hengeveld 2000).

133

134

MAITLAND'S PERIPHERAL MANIPULATION

l Box 6.2 chart

Summary: site of symptoms - body

•

Localization of symptoms

•

Areas free of symptoms - particularly those regions

Is it constant? (qualify local or referred)

Yes Does it vary in intensity?

which may refer into the symptomatic area as well

(qualify it)

as those body parts in which the symptom area itself may radiate •

Qualification of symptoms - type of symptom:

Chronology of and relationship between symptom

What brings it on? How severe is it?

7. How long can you be free?

areas Control questions with regard to symptoms indicative of central nervous system disorders.

Yes

Additional information from physical examination or

No

What makes it worse?

later sessions: •

When do you get it? Do you have it every day?

5. How long does it last? 6. What helps to ease it?

deep

•

1. 2. 3. 4.

(nuisance value or restricting)

intermittent - constant ( variable) ; superficial •

No

How long does it last? No matter what you do?

Relevant symptom areas which have occurred in the

Frequency?

past history of the patient's complaints

�

•

Protective deformities as observed during physical

•

Scars in the symptom area

F ig ure

•

New symptom areas over the course of treatment

symptoms.

•

Neurological conduction tests: area of changed

examination - including the response to correction

etc.

etc.

6.5

Gener al questions fo r estab lishi ng behaviour of

sensation.

Nevertheless, these initial hypotheses may be con firmed, modified or rejected as the process of informa tion gathering continues. Box 6.2 summarizes the site of symptoms - body chart. Behaviour of symptoms and level of disability

The symptoms which the patient feels and their changes in site and intensity need to be related to daily life activities and positions, including periods of rest. This is an essential part of the subjective examination, as many hypotheses with regard to precautions and contraindications as well as to management objectives may be generated during this stage. Figure 6.S gives an indication of the general questions that should be asked with regard to behaviour of symptoms. Questions should elicit facts against which subse quent progress can be evaluated. For example, a patient may tell of being able to walk as far as the front gate before the leg pain becomes severe. This fact is a basis for reassessment procedures in which it will be assessed if the patient reaches the stage of being able to walk further than the front gate. These subjective

assessments then become quantifiable facts. This fits well with the notion of some research groups that the patient's own perspective on the disorder should increasingly become incorporated into research and clinical practice (Borkan et aI1998). The behaviour of the patient's symptoms, together with information on the analysis of activities or pos itions which aggravate or ease symptoms, allow for the modification and generation of various hypotheses: •

•

•

Questions about various activities will indicate how the pain affects the patient's daily life and gives an idea of its severity. Symptom behaviour can also give an indication of the overall level of disability, which can be expressed in terms of impairments of functions, activity limi tations and participation restriction (WHO 2001). An impression may be gained on the coping strat egies which the patient may have developed to influence the discomfort or promote wellbeing. Appendix 2 emphasizes that it is important to know if a patient still has a sense of control over the pain and the perceived limitations of daily life and which strategies are being employed to achieve this sense of control.

Princip les of exa mi nation

Questions regarding activities or positions which aggravate and ease symptoms

The following questions may be asked in order to elicit information with regard to activities or positions which provoke symptoms: •

•

•

•

What provokes the pain? (e.g. sitting or getting a glass out of a cupboard) Quality of the movement or the position (e.g. Are you sitting in a particular position/ chair? Do you recall in which way you can lift your arm?) Quantity of the movement or position (e.g. Does it come on immediately you lift your arm or do you need to repeat the movement a few times? How long do you sit before the pain flares up?) Can you continue with the activity/ position in spite of the pain? (This is a better way of asking than 'Does it force you to stop or interrupt the activity?', as the question may be more resources oriented.)

However, information regarding activities or positions provoking symptoms will only be complete if informa tion is gained on 'easing factors' as well: • •

• • •

How does it recuperate? Are you able to do something yourself about the symptoms/have you found something to make it better again? Do you use something that the last phYSiotherapist taught you which may help it to get better? (This concerns information with regard to coping strategies.) How long does it take to recuperate? Does it recuperate 100%, once 'better'? Can you take up the activity or position again once the pain has subsided?

Irritability I severity of the disorder This phase of exam ination, in which aggravating and easing factors to activities or positions are being established, is essential to determine how easily the patient's symptoms are aggravated and how readily the symptoms subside, so that exacerbation of symptoms from excessive exam ination can be avoided. This will be referred to as 'irrit ability' and 'severity' in the planning phase of the physical examination (see below). To assess the irritability of a disorder, three aspects of the behaviour of a patient's symptoms must be related to a particular activity or function:

1. Determination of the activity that provokes the pain and the vigour of that activity - this may relate in particular to physical examination procedures and passive movements in treatment. 2. Knowledge of the degree and quality of the increased symptoms caused by that activity.

3. Knowledge about how long it takes for the increased symptoms to subside to their level prior to provok ing the performing activity. This aspect needs to include further information, such as what the patient may undertake actively to reduce discom fort (coping strategies). When pain is aggravated by movements, the patient should be asked to demonstrate the way in which the pain restricts the activity. Analysis of the movement then forms a primary part of the physical examination. Furthermore, it is useful to know if there are any pos itions or movements the patient can adopt to reLieve the symptoms. This may aid the physiotherapist in deter mining sources of the dysfunction as well as in select ing treatment techniques. At times the patient may demonstrate these move ments during this phase of the subjective examination; however, if it breaks the examiner's train of thought this analysis can be left until the beginning of the phys ical examination. General questions with regard to symptom behaviour

Some general questions with regard to symptom behav iour may complement the questions about activities and positions provoking the symptoms. Some patients may learn from these general questions what information is of particular interest to the physiotherapist. (a) Is there anything which makes it better in general? (b) Is there anything that you feel makes it generally worse? (c) Do you feel it probably needs rest or does it need movement to get better? (d) How is it in the morning compared with the evening? With regard to Question (c), many patients with move ment disorders and underlying osteoarthritic changes frequently say that a middle path between too much and too little movement is needed. For Question (d), if symptoms in the morning are worse than in the evening, especially if they are in combination with a sensation of stiffness, this may be indicative of minor inflammatory components and fluid retention in tissues. Moving around in the morn ing may improve the stiffness and pain. If the stiffness lasts unusually long (e.g. 3 hours) an inflammatory disease may be an underlying factor. Other symptoms in the morning at waking up, but before rising from bed, may be indicative of a disorder needing to build up muscle tone as in, for example, instabilities. Furthermore, disorders with an ischaemic component may need repeated movement after having been in the same end-of-range position for a long time.

13 5

MAITLAND'S PERIPHERAL MANIPULATI ON

13 6

[ Course over 24 hours or over 7 days

Further important information may be gained on 'behaviour' which elicits information on the symptoms over a course of 24 hours. It is often helpful to follow the course of the day and the behaviour of the symptoms. The physiotherapist may already have some information on the behaviour of pain and activities during daily life, and therefore may start with the evening, once the patient goes to bed: Course over 24 hours

•

How is it when you get into bed? (In this phase infor mation is sought about whether the patient can find comfortable positions right away or needs to search before some comfort is found. Disorders with some inflammatory components may take some time before they settle down.)

•

•

How is it in the morning, while waking up?

•

How is it in the morning, when getting up? This infor mation needs to be distinguished from waking up; if the patient feels stiffness, in which directions does this occur and how long does it last? The time of stiff ness may indicate precautions regarding a degree of inflammation, for example if the stiffness lasts fairly long (e.g. more than 2-3 hours). Many patients will often say that after having a shower and breakfast, most of the sensation of stiffness has improved, which is indicative of a movement disorder that can often be treated by the manipulative physiotherapist.

How is it during the day? - see above.

Some patients may state that the symptoms do not occur regularly, that they 'come and go'. In these cases it is essential to gain an idea of the frequency of the symptoms over a week or at times even over a month: Course over 7 days

Q

A

Q A

Q A

Q A

Q A

Q A

Does it wake you up during the night? (In this situation it is mandatory to know whether the resting pain is caused by some mechanical degree of stretch or compression affecting the structures or whether by an acute inflammatory process.) Care is required when assessing the effect of rest on pain. Frequently the patient will say the pain is worse when in bed, when in fact the symptoms may only be worse for the first hour or so as a result of the day's activities. On further questioning, the pain is usually found to be considerably relieved by the following morning. However, pain that is worse at night and severe enough to make the patient get out of bed requires careful investigation because of the possibility of more serious pathology than the mechanical prob lems usually referred for physiotherapy.

•

A

Q

'When do you have this pain around your shoulder?'

Q A

Q A

Q

A

Q

'I don't know - it comes and goes.' 'Do you feel it at any particular time of the day?' 'Sometimes I wake up with it and then it remains bad for the whole day.' 'How often per week do you think do you have bad days? Every day, a few times per week?' 'About three times per week.' 'Any particular days?' 'I've not noticed that yet.' 'Do you notice a difference between the weekend and during the working week?' 'I don't think I have it during the weekend.' 'When was the last time it was worse?' 'Last Tuesday.' 'What happened then?' 'I woke up in the morning, I was lying on my shoulder and it was very painful. When I got up, I felt very stiff for a long time.' 'When was the previous time it felt like it did before last Tuesday?' 'I think it was last Friday?' 'Was that the same as last Tuesday?' 'Yes.' 'Is there any pattern that you recognize? Were there any activities or sports that you performed on the days before?' 'Well, I go to volleyball training on Monday and Thursday nights.' 'Do you see any relationship between your pain and your training?'

Although a communication in such a manner seems elaborate, it provides the physiotherapist with valu able information regarding contributing factors to the pain and dysfunction. In this example the physiother apist may follow up information on the pain when lying on the shoulder, as well as information with regard to the activities during and after the sports training. In the worst scenario, the physiotherapist may find out that the symptoms increased about three times per week without learning of any pattern that may lead to this. However, the frequency of symptoms is still valu able information in later stages of assessment (e.g. dur ing retrospective assessments) in which the patient may indicate that the symptoms have not occurred for about 2 weeks.

Information on the general level of activities during the day or week

Frequently it will be useful to get an overall impres sion of the general levels of activity of the patient, as this provides the physiotherapist with import ant information regarding contributing factors, which

Principles of exa m i nation

may need to be followed up in later stages of the treat ment, once more is understood about the sources and mechanisms of the symptoms. This information may be completed in a second or third session, if time is running short in a first session of initial assessment. However, it is essential to seek this information in an early stage of therapy. Some patients may have a dominant sedentary occupation and transport to their work. Lack of fitness and aerobic condition may be important contributing factors to the development and maintenance of the current symptoms. Furthermore, some patients indicate some maladaptive avoidance behaviour (Vlaeyen & Linton 2000) by steering clear of activities and sports because of their pain. In such cases the physiotherapist needs to know the patient's sense of control and cop ing strategies to achieve control. If these are lacking, it may be necessary to provide self-management strat egies to control the pain in an early stage of treatment. In contrast, other individuals may have a very high level of activity in which insufficient relaxation or regeneration moments are incorporated into busy daily life schedules. Furthermore, others may have a high level of activities as mandated by their jobs; however, these may be too one-dimensional leading to relative ischaemic states in their tissues without sufficient com pensatory movements to influence pain or wellbeing. If the 'behaviour of symptoms and activities' is investigated thoroughly, both the physiotherapist and the patient are provided with essential parameters that can be followed up during reassessment processes in which the effects of treatment are evaluated. In clinical supervision it can be observed that if no progress seems to be taking place and nothing seems to change in the patient's symptoms and disability, fre quently this is due to insufficient detailed information on the 24-hour behaviour. Hypotheses based on the 'behaviour of symptoms and

In this phase of 'behaviour of symp toms' an important principle of the Maitland Concept may be followed - 'makefeatures fit'. Hypotheses generated in earlier stages of the sub jective examination may be tested and modulated in this phase. The physiotherapist may connect the cues gained in earlier stages of the subjective examination with information about the symptom behaviour and determine if they fit in recognizable clinical patterns of symptom behaviour deriving from specific sources of movement impairments and/or pathobiological processes. If the phYSiotherapist becomes aware of certain hypotheses during the process of interviewing, it is essen tial that the therapist guards against hastily following levels of activity'

favourable hypotheses or neglecting unfavourable possi bilities. For example, if the physiotherapist hypothesizes that the symptoms in the elbow area stem from a cervical disorder, specific information needs to be sought as to whether the symptoms are aggravated or eased by cervi cal movements; however, deliberate questions also need to be asked regarding elbow-related movements in order to maintain openness towards the possibility of less favourable hypotheses. The information from the 'behaviour of symptoms' may support the physiotherapist in the generation, testing and modulation of the following hypotheses: •

•

•

•

• •

Sources of the movement dysfunction, by analysis of the activities or positions provoking the symptoms Pathobiological mechanisms (neurophysiological symptom mechanisms; tissue processes - non mechanical behaviour of symptoms may be indica tive of, for example, inflammatory disorders) Level of disability (activity limitations and resources, as well as participation restriction) Precautions and contraindications to examination and treatment procedures with movements by the constructs of 'severity' and 'irritability' Prognosis Management (treatment objectives based on the information of activities and participation; pos sible interventions based on the information about 'easing' factors, including aspects of coping or self management strategies. It is essential that the physio therapist has an idea if the patient still perceives a sense of control over wellbeing and with which coping strategies this is achieved - see Appendix 2).

Furthermore, the information in this stage of the sub j ective examination provides the physiotherapist and the patient with important parameters ('asterisks') to monitor the effects of treatment in reassessment proced ures. Additionally the questions of the behaviour of symptoms may have an educational effect, as the patient may learn to see a relationship between the pain or discomfort and the movement behaviour. Box 6.3 summarizes the behaviour of symptoms and level of disability. History

The history of a disorder contains two aspects: 1. Present history - details with regard to the current episode 2. Past history - information with regard to previous episodes of the same or similar disorders.

13 7

138

MAITLAND'S PERIPHERAL MAN I PULATION

[ The history can be taken at any stage of the subjective examination and may be sought in segments during the remainder of the questioning, whenever this seems appropriate. When confronted with a more long lasting or chronic disorder the history is best left to the end because the area and the behaviour of symptoms will guide the questioning, enabling the examiner to exclude irrelevant information from the patient's story. To save time, the present history should be sought before any previous history, but this should not be an inflexible rule. In questioning regarding the history of a patient's symptoms it is necessary to recognize that the patient may have two disorders. A new problem may overlap with an older, longstanding one, and every effort must be made to differentiate between the contribution each is making to the patient's disability.

Box 6.3 Summary: behaviour of symptoms and level of disability •

Activities and / or positions which aggravate and ease symptoms

•

General questions with regard to symptom

•

Course of symptoms over

•

Gen eral level of activity during the day/ week.

behaviour

24 hours or 7 days

The phase of 'behaviour of symptoms' is essential, as: •

it provides the ph ysiotherapist with in formation for reassessment procedures in later stages of the therapeutic process. The information needs to be sufficiently detailed in order to be able to successfully make any comparisons to the initial state of the patie n t ('subjective asterisks')

•

Present history

it e n ables the physioth e rapist to generate and modulate various hypotheses with regard to

In a present history various phases can be distinguished in which specific information is sought (Fig. 6.6):

sources of the dysfunctions and n ociceptive processes, n europhysiological mechanisms,

(a) The length of time the patient has noticed the symptoms ('since when') (b) Details on the onset of the symptoms (c) Progression of the symptoms and disability since onset (d) Comparison of the pain and disability now compared with the initial stage of the symptoms.

precautions and contraindications, contributing factors an d management (treatme n t objectives with regard to activities an d participation, cognitive objectives an d coping strategies) •

it may have an e ducati onal aspect, as the patien t may learn t o see a relationship between the pain or discomfort and the moveme n t beh aviour.

Summary: present history

I Since when

I I

Details on onset of symptoms

�

�

I

I

I Progression since onset

�

I

Traumatic onset

Spontaneous onset

Effects of treatment (PT; medications;

- mechanism of incident

- localization of first symptoms

- when did other symptoms start?

- localization and severity of

- when were they first felt?

- course of symptoms

symptoms - immediate/next day - use of extremity still possible

I

immediately after incident?

Predisposing factors

�

other)

�

I

- progressive, regressive (stage)

New use

Factors relating to general health, movement behaviour, capability to bear stress:

Misuse

- general health, virus, influenza, fatigue, 'slow healer'

Overuse

- stress, anxiety, worries, high levels of activities/lack of relaxation

Abuse

- reduced general fitness and aerobic condition

'Disuse' and 'non-use'

- general movement behaviour, beliefs and cognitions with regards to pain and movement (e.g. avoidance when pain) - basic condition of structures (e.g. osteoarthritic changes)

Figure 6.6

I

(stable, non-stable)

J

- swelling

I

I Now: onset

Summary: present hist ory.

Principles of examination

Points (b) and (c) of the present history require much detailed questioning in order to be able grasp the pre disposing factors and the amount of injury as well as the stage and stability of the disorder. Details on the onset of the symptoms With regard to Point (b), in general patients may say that their symp toms developed either suddenly with an incident or gradually. In both situations it is essential to obtain further detailed information.

When trauma of a major degree (such as that resulting from a sports or a car accident) causes symptoms, it is necessary to know: Traumatic onset

•

•

the degree of trauma - ascertain the extent of bruising, its colour and duration, if this seems necessary; the extent of damage to the vehicle (if appropriate) whether the patient was aware the accident was going to happen, i.e. was the patient able to prepare for the blow or was it an unguarded blow? (the latter would almost certainly impose greater trauma to structures).

referring the patient t o a medical practitioner for further advice. Spontaneous onset 'Spontaneous' symptoms may have developed in various ways: • • •

It is important to clarify the 'gradual' development of symptoms: for one patient it may mean that the symp toms developed insidiously over a period of 1-4 weeks, whereas another patient may mean that the symptoms developed slowly over about one day. If the symptoms developed relatively suddenly over a period of one day it is necessary to know the following: •

•

•

•

•

•

Did you wake up with it? (This would indicate that something has happened during the day(s) before. Questions should then be posed to determine pre disposing factors such as unusual activities or forgotten trivial incidents.) Did it come on later during the day? (This would indi cate that, in the absence of any trivial incident or unusually heavy or different work, something has been developing asymptomatically, and that the day on which the symptoms began was just 'the last straw'. This may occur in situations where the patient is not aware of using the structures of the body in a one-dimensional way or that general physical fitness is reduced.)

Various aspects need to be followed up if the patient describes the origin of the symptoms of an accident: •

gradually relatively suddenly but without a clear incident minor incident causing severe problems.

Mechanism of the incident (the extent of damage to a body structure may be different if a patient broke the radius due to an object falling on the forearm or because of falling on a slippery surface, in which the arm has been pulled towards extension of the shoulder before falling on the hand. In later stages, after healing is complete but some symptoms may still be disturbing, the injuring movement may become the direction of passive mobilization tech niques).

Gradual onset With symptoms of a more gradual onset, it needs to be determined if the patient knows of any reason why it should have begun. This may be clarified with the following questions:

Localization and severity of symptoms immedi ately after the incident.

•

Swelling - immediate swelling may be indicative of haemorrhage, while gradual swelling overnight may be indicative of capsular irritation and gradual fluid ooze. Capability to use the extremity, or weight-bearing, immediately after the incident. If no weight-bearing is possible this may indicate major damage to the structures. Some injuries only start to cause discom fort over a period of 24-48 hours after the incident, once inflammatory processes are increasing. In cases where major osseous or ligamentous injuries

are suspected, the physiotherapist should consider if another intervention (e.g. surgery or immobil ization by plaster) is necessary, in which case the direct-contact practitioner may contemplate

•

•

What did you notice first? Do you remember when you felt it first? Do you think it has any relationship with what you may have done in the preceding days before you felt it first?

With every patient whose symptoms are of spontan eous origin it is essential to determine possible predis posingfactors that may have contributed to the onset or maintenance of the symptoms (Box 6.4). The informa tion on predisposing factors serves in formulating a prognosis and in determining treatment objectives with regard to prevention of new episodes. Progression of the symptoms and disabil ity since onset

Within this phase of the present history information on various aspects needs to be sought: •

The progress of the symptoms and the disability from the time of onset to the present moment. (This

139

1 40

MAITLAND'S PERI P H ERAL MANIPULATION

[

Predisposing factors •

concept from the specific physiotherapy perspective as

•

reasonable limits •

p u tting the body at a d isad vantage (e.g.

healed, or there m ay be a discrepancy between the

If the patient relates a trivial incident as bein g the

levels of activities in daily life and relaxation

cause of what seem s to be a gross disability, then

periods). (For further details, see Chapter

10.)

Fu rther questions m ay n eed to be asked to 'make

Other predisposing factors

fea tures fifo Either there is seriou s pathology present,

These relate to the capacity of the structures and the

or there m u st be other factors that predisposed the

body to bear stress:

been j u st 'the last straw which broke the camel's back'. Use categories

•

predisposing activities as the backgrou n d to the onset of their sym p toms. This m ay include: New use - sym p tom s d eveloped after having performed

some activity that the patient has not performed before or has not perform ed for a long time

Fatigu e

•

'Slow healer' - some people m ay take longer to 'get

•

An injury many years ago

over' any sickness they have had •

Fam ilial! genetic predisposition

•

Pre-existing osteoarthritic changes in structures in

•

Stress and worries (Gifford 1 998b, Main & Spanswick

combination with new u se, misuse or overuse

2000), including lack of relaxation in busy daily

Misuse - relatin g to an awkward fu nction or activity

which provoked stress on the structures; this inclu des habitual m ovement pattern s d u e to motor l earn ing over the years Overuse - relating to awkward activities or postures

being performed either too stron gly or for too long

Poor general health

•

As a distinctly separate group there are persons who have

•

-

bein g maintain ed.

sym ptoms to d evelop. The trivial incident m ay have

•

Disuse

the person is not fit or a previous inj u ry has not

acceptable.

•

Abuse - p hysically abusing the body beyond

to why the patient's sym ptoms have d eveloped or are

there has to be something else to make the incident •

•

It is essential that the physiotherapist d evelops a

schedules •

U n derstan ding, beliefs and attributions about the pain or d isability resu lting in m aladaptive movement behaviou r (e.g. avoid ance of activities or social contacts)

a period of time

provides the physiotherapist with information with regard to the stage and stability of the disorder. It should be ascertained if the patient perceives the symptoms as improving, worsening or static. Is the disorder in a more progressive stage, in which the situation seems to worsen, or is it improving or stable? It is essential to know if the disorder seems stable and if the patient is capable of performing many daily life activities. If the disorder seems W1stable, which means that severe episodes may be easily provoked, the physical examination and treatment procedures need to be performed with care in order to prevent exacerbation: hypothesis category - precautions and contraindications.) •

The effect of any treatment that may have been instituted so far. (It is essential to know which specific interventions of physiotherapy have been W1dertaken, including their effects on both a short- and a long-term basis. Some patients may say

that 'physiotherapy did not help'; however, after some probing questions, frequently the interven tions have helped for a short while, but the symp toms returned. In such a case the physiotherapist may contemplate continuing with the same proce dures as before, including the education of self management strategies - provided it is the same condition as before for which the patient is currently seeking help. Furthermore, information with regard to medical treatment, self-medication and other forms of self-management, as well as the effects of possible alternative health-care approaches, is sought in the same way. When a minor incident precipitates an onset of symptoms the following day, the severity of symptoms, the degree of the incident and the patient's ability (or inability) to continue working provide invaluable information regarding the degree of the damage to the structures at fault. Similarly, the comparison of

Pri nciples of exa m i nation

Hypotheses generation based on information from 'history'

Summary: previous history

\' " 1985

\,,. \,i ,. 4 \i ,,. \i," \,i ,. 4 \ ,,. \ 4 1990

1995 1998

2000

2002 2003 2004

•

How many times have you had trouble? Which episodes?

•

What provoked/aggravated the episodes?

•

How did the episodes ease? What treatments helped best?

•

How is the current episode in comparison to previous episodes?

•

Has the frequency of the episodes changed over the last couple of years?

•

Have you been confined to bed because of it?

•

How were the symptoms and the activity limitations between the episodes?

• •

The present and previous history may again provide the physiotherapist with various hypotheses:

Precautions and contraindications

•

Sources of dysfunctions the information of the onset

How did the pain develop over the course of years? ' How did the activity limitations develop over the course of years?

Figure

6.7

Summary: previous history.

symptoms on getting out of bed following the incident with the state of symptoms before going to bed, pro vides information relating to the underlying degree of disorder of the structure on which the minor incident has imposed its effect. Such disorders frequently may progress from local pain to include referred pain. It is then necessary to know whether the pain has spread gradually or whether the disorder involved referred pain from the outset.

•

• •

•

•

• •

•

•

How many times have you had trouble/which episodes did you have? What provoked/ aggravated the episodes? How did the episodes ease/what kind of treatments have helped you best so far? How is the current episode in comparison to previous episodes? Has the frequency of episodes changed over the last couple of years? Have you been confined to bed because of it? What were the symptoms and the activity limitations between the episodes? How did the pain develop over the course of years? How did the activity limitations develop over the course of years?

-

-

in history (localization of first symptoms, mechan ism of incident) may provide the physiotherapist with further hypotheses on the initial sources of the movement dysfunction. •

Individual illness experience and central nervous system modulation of the pain experience due to psychosocial factors when the pain and disability seem to last -

longer than would be expected due to normal physio logical recuperation and healing phases of tissue. However, it is essential not to jump to conclusions with regard to psychosocial contributing factors but to consider pathobiological processes causative of longer lasting tenderness, pain and disability.

Previous history

Delving into the past history is essential, particularly in relation to the original onset, if the progress of the disorder is to be understood. The more garrulous patient can make this process irksome for the novice, who must learn what can be discarded or ignored from, for example, a 20-year his tory. However, after sorting out the original onset, the intervening years can be covered by such questions as (Fig. 6.7):

if the disorder seems unstable, which means that exacerbations may easily be provoked, the physical examination procedures need to be performed carefully to pre vent exacerbation due to too vigorous or too many test movements. If a more trivial incident has led to severe pain and disability, which cannot be explained by the physiotherapist, the patient may first be referred to a medical practitioner as this may be indicative of serious pathology.

•

•

interventions to enhance prevention of future episodes. These hypotheses may be gener ated by the establishment of possible predisposing factors with regard to the 'use' of the structures, general fitness and habitual movement behaviour when pain episodes recurred.

Management

-

The combination of these factors may also influence further hypotheses with regard to prognosis. In order to achieve long-term effects, the phYSiotherapist should consider how far the patient may be able to change habituated movement behaviours. This may be due to a personal learning capability to any constraints from work situations ('black flags and blue flags'; Main 2004), which may prevent the patient from changing the movement behaviour in future (e.g. awkward working positions which are difficult to adapt). Special questions

Several questions must be asked so that the physio therapist is aware of any inherent dangers from manipu lative treatment or factors that may limit treatment in general (e.g. vertebrobasilar insufficiency, osteoporosis, stage of tissue healing in postoperative or post-injury situations). The questions may vary for each joint

1 41

J

1 42

MAITLAND'S PERIPHERAL MANIPULATION

l Box 6.5

I

Summary: subjective examination --�

-

The subjective examination may be con sidered 'an

not on completion of the examination as a retrospective

in terrogation with empa thy '. It in dicates the depth

exercise - this aids the therapist to be immediately aware

of questionin g and enables the therapist to get an

of relevant in formation to be followed up during later

impression of patients' personal experiences of their

stages in the therapeutic process.

disorders an d the impact on their lives. The subjective examination follows several objectives: •

•

•

•

Determination of the problem of the patient, from the

' Making fea tures fif is an important principle of the

Maitland Concept: •

the history fit with the behaviour and localization of

Subj ective parameters which serve reassessment

the symptoms. If severe disabling symptoms have been

procedures (subjective 'asterisks')

caused by a trivial incident, extreme cau tion is needed:

Determination of precautions and contrain dications to

'the features do not fit' and cannot be explained by the

physical examination and treatment procedures

movement behaviour of the patient or any structural

Gen eration of mul tiple hypotheses, to be tested during

changes (e.g. osteoarthritic changes). I n such cases the

physical examination procedures and treatment

patient may need to be referred to a medical

in terven tions. The subjective examination can be divided into five parts:

practitioner for further investigation. •

behaviour of the symptoms fits with a recognizable

'Kin d' of disorder - establishing the main problem and

syn drome or pathology. This includes the diagnosis

perceived disability

of patterns of biomedical pathology or movement

•

Site of symptoms - body chart

•

Behaviour of symptoms and level of disability

disorders. •

This information will be linked with examination

•

History (current, previous)

findings and reacti on s to therapeutic interventions

•

Special questions.

which may aid the n ovice in the development of clinical patterns, thus contributing to the experiential knowledge base.

a valuable learning experience as it helps to identify the essential elements for further examination and

With some patients, the experienced physiotherapist may

treatment. Committing the in formation and thoughts

engage in forms of narrative reasoning (see ' Forms

to paper is an in valuable aid in the development of

of assessment', Chapter

con scious clinical reasoning processes. Writing

understanding of the patient's beliefs, thoughts, feelings

5)

in order to get a deeper

in formation subsequen tly on the same parts of, for

and earlier experiences with the disorder and the various

example, the body chart may enhance self- monitoring

health-care practitioners. If the physiotherapist decides

skills for subsequen t sessions, to en able on eself to

to follow a more n arrative approach to the examination

assess if importan t in formation is missing.

procedures rather than a procedural approach, it is

Usin g asterisks in the recordin g of information is essen tial. This serves two fun ctions:

1 . It iden tifies those points which can be used in the reassessment of the patient's progress.

2. It serves as a teachin g process, to latch onto in formative and significant words. This speeds up the process and makes it more precise. I t

essen tial to keep an overview of the rest of the information that n eeds to be gained from the subjective examination, as the patient frequently may engage in a description of the previous history and all the treatment intervention s which have been un dertaken so far. However, for many patients it may be a healing experience if they are allowed first to give their own account of their experience rather than being interrupted by question s

is importan t that the asterisk b e used a t the instant of

which suit physiotherapy diagnosis (Kleinmann

recording the information ('asterisk as you go along'),

Green halgh Et Hurwitz

complex and are discussed in the relevant chapters, but may encompass the following:

•

General health Weight loss (especially excessive weight loss over a relatively short period)

•

•

Furthermore, the Concept also assesses whether the

•

Systematic recording of the in formation obtained is

•

Questions n eed to be asked to assess if the features of

patient's perspective

•

1 988;

1 998; Thomson 1 998).

Use of medication, pain medication, anti inflammatory drugs, use of steroids, anticoagulant medications and other medications Blood pressure History of illnesses

Principles of exa m i nation

143 ]

• • • • • •

•

Previous operations History of accidents and injuries History of hospitalizations Laboratory results Results from X-ray, MRI or CT Difficulties with eating, digesting, bladder and bowel functions Cardiovascular and pulmonary condition.

in order to be able to perform a comprehensive physical examination, respecting precautions and contraindications, as well as performing subjective reassessment procedures in subsequent sessions (see Reflection on the subjective examination process, below). •

It is important to complement these questions with spe cific screening questions concerning the various bodily systems and 'red flags' as referred to in Chapter 5. Psychosocial assessment

Additional questions with regard to psychosocial assessment may take place during the overall process of subjective examination, in summarizing stages of collaborative goal setting during the various phases of the subjective examination, or towards the end of the subjective examination, before planning the physi cal examination. For further information, see Chapters 3 and 5. Box 6.5 summarizes the subjective examination.

•

Reflection on the subjective examination process

This stage of planning needs to encompass the follow ing aspects:

PLANNING O F THE PHYSICA L EXAMINATION

•

Reflection on the subjective examination process the physiotherapist needs to verify that the subjective examination is sufficiently complete

Planning the procedures of examination, induding anticipation on possible findings, the kind of exam ination (dosage or extent of examination proced ures), sequence of testing and reassessment procedures (see Planning of the physical examin ation procedures, below).

•

As already stated, regular planning in critical phases of the therapeutic process is essential to comprehensive clinical practice. Regular planning may have become an automatic, implicit process for the more experi enced manipulative physiotherapist, as they will be able to 'reflect in action' more frequently (SchOn 1983). However, novices may actively enhance their path to professional expertise if they explicitly go through reflection and planning phases after having performed certain procedures of the physiotherapy process ('reflection on action'). In this learning process it is essential not only to document the results of examina tion procedures and therapeutic interventions, but also to record the reflections and the planned procedures. After completion of the subjective examination, it is often useful to summarize its main points and the goals of treatment agreed with the patient so far. It may also be necessary to explain to the patient the objectives of the next stage of the initial assessment the physical examination. Planning after the subjective examination as a prepa ration for the physical examination has three phases:

Expressing hypotheses which will influence the phys ical examination process. Hypotheses regarding pathobiological mechanisms, sources, contributing factors, precautions and contraindications and management in particular need to be made explicit (see Hypotheses, below).

•

•

Summary of the main information from the subjec tive examination and the treatment objectives agreed so far (in the patient records and verbally as a summary to the patient). Check if the subjective examination has been suffi ciently comprehensive with regard to any informa tion indicative of precautions or contraindications to examination procedures. In particular, the follow ing information should be checked: - body chart: intermittent or constant symptoms; quality of symptoms - behaviour of symptoms: are the symptoms movement and position dependent; is there any pain at night - if yes, how does it recuperate; duration of any stiffness in the morning - history: stability and stage of the disorder; can the physiotherapist generate tenable hypotheses as to why the symptoms have developed - special questions: any indication of conditions which affect general health. Confirmation that the physiotherapist has suffi cient, detailed information on parameters of the 'behaviour of symptoms' ('subjective asterisks'). This information should enable the physiotherapist to fulfil meaningful reassessment procedures in the next session, allowing for a comparison of the activ ities which are limited or causing discomfort (see 'Indicators of change', Chapter 5).

1 44

M AITLAND'S PERIPHERAL M A N I PULATION

[ Hypotheses In order to enhance conscious clinical reasoning, hypotheses need to be made explicit in critical phases of the therapeutic process (Ryan 1996). In this stage of planning the physical examination, the following hypotheses need to be expressed: • • •

•

Sources of symptoms and physical impairments Contributing factors Precautions and contraindications, including possible pathobiological mechanisms underlying the disorder Management.

Sources of symptoms and physical impairments

The hypothesis category 'sources' relates to the actual structure or target tissues from which the symptoms may derive. The following components will most fre quently be considered in this category: •

• •

•

joints, with the peri- and intra-articular structures; local j oints and joints referring into the symptomatic area muscles, including tendons and tendon sheaths neurodynamic system, with possible pathophysiological and pathomechanical changes (Shacklock 1995) soft tissue.

The manipulative physiotherapist will usually be able to detect movement impairments in the above mentioned components. Hypotheses regarding a detailed structural analysis, however, may be more challenging and in all probability will be derived from the deduc tion of all the information from the subjective and physical examinations, probationary treatments and their reassessment (Moon 1990, Refshauge & Gass 1995). A balanced approach is therefore essential in specifying structural lesions as a source of the nocicep tive processes in this phase of planning. Analysis of impairments in the movement compon ents during physical examination supports the physio therapist in making comprehensive decisions with regard to management. After the subjective examin ation, the physiotherapist may have already learned which treatment objectives need to be achieved on activity and participation levels as described in the

Sometimes different sources may contribute to the same symptom areas. Verification of the various hypotheses as to possible sources of, or factors con tributing to, the patient's problem may stretch over two or three sessions. A typical error in clinical reason ing may occur, in that the physiotherapist skips the assessment of possible additional sources of the symp toms once one source has been brought forward and continues with the treatment of the first source. However, frequently the patient may need a mixed treatment of different sources, rather than treating one source before starting with the other. Hypotheses with regard to sources of the symptoms and impairments need to be made with reference to the hypotheses of the dominant neurophysiological pain mechanisms (Jones & Rivett 2004). With a dominance of nociceptive or peripheral neurogenic mechanisms, the phYSiotherapist will usually be able to examine and interpret findings of physical examination tests as a relatively accurate reflection of the specific tissues involved, be they impairments of peri- or intra-articular, neurodynamic or soft tissue movement components. Normalization of these abnormal findings by passive movements, in combination with self-management strategies, frequently contributes to improvement of the patient's movement disorder. However, with a dominance of central nervous sys tem mechanisms attention needs to be given to the interpretation of the findings of the physical examin ation, as findings of tender tissues or painful movement impairments may be false-pOSitive clinical findings due to sensitization processes in the central nervous system. If central nervous system mechanisms seem to be a dominant feature in the patient's pain experience, the physiotherapist should not jump to the conclusion that only 'hands-off' treatment may be the choice of ther apy and therefore skip physical examination of move ment impairments. Careful manual handling skills, in combination with self-management, educational strat egies and skilled communication may guide many patients towards an increased trust to move in daily life situations. Skilful analysis of possible movement impairments is an important step in the physical examination of the patient's movement disorder. In fact it may be one of the first steps for the patient to regaining trust to move again (Zusmann 1998).

International Classification of Functioning, Disabilities and Health (rCF) (WHO 2001 ). However, the contribution

Contributing factors

of possible impairments in movement components of joints, neurodynamic system or soft tissue structures to the disability and pain can only be investigated with physical examination procedures (see Fig. 4.2).

Contributing factors are predisposing or associated factors involved in the development or maintenance of the patient's problem. These factors may be important precipitating factors of recurrences and need to be

Princip les of exa m ination

addressed in treatment, once the physiotherapist has gained a better understanding of the sources and the pathobiological process. This hypothesis category may include the following factors: •

• •

• • •

physical/ biomechanical (e.g. working postures leading to ischaemia, muscle recruitment patterns) emotional (e.g. lack of trust to move) cognitive (e.g. beliefs, knowledge about the problem) sociocultural (e.g. values) environmental behavioural, particularly movement behaviour in daily life situations and when symptoms occur.

In planning the procedures of the physical examin ation it is important to make the hypothesis category 'contributing factors' explicit. However, it needs to be decided when in the assessment process some factors will be investigated, as some elements (e.g. muscular control as a contributing factor) may be examined bet ter in later stages of the therapeutic process since they are unlikely to be decisive in treatment decisions in a first session.

to be interrupted, because of the intensity of the pain' (Maitland et aI 2001). A comparatively minor activity (e.g. ironing for half an hour) that causes pain of a severity that forces the patient to stop ironing, but subsides within 10 minutes such that another half hour of ironing can be carried out, indicates minor irritability of the disorder. This therefore frequently permits a full examination plus some treatment on the first day, without the likelihood of exacerbation. If, however, the pain did not subside until the patient had had a full night's sleep, the dis order would be considered to be highly irritable and the examinations and treatment would have to be tailored to avoid exacerbation (Maitland et aI 2001). It is argued that the word 'irritability' may have been misunderstood and misused by phYSiotherapists (Sayres 1 997). Irritability and severity need to be con sidered from various perspectives. On the one hand it describes the reported pain sensation; on the other hand it reports the activity provoking the symptoms, including the patient's reaction to it. •

Precautions and contraindications

Hypotheses with regard to precautions and con traindications to physical examination and treatment procedures serve to determine the extent of the phys ical examination that can be safely undertaken. Further more, they aid in the decision if contraindications to examination procedures or treatment interventions are present (see 'Summary: purpose of initial assessment', Chapter 5). The precautions and contraindications are mostly determined by hypotheses with regard to pathobio logical processes and neurophysiological pain mechan , isms and may include the following factors: •

• • • • •

Pathobiological processes - tissue mechanisms, stages of tissue healing, neurophysiological pain mechanisms Irritability of the disorder (see below) Severity of the disorder (see below) Stage and stability of the disorder General health Patient's movement behaviour, perspectives and expectations.

Constructs of irritabil ity and severity of the problem

Irritability has been defined as 'a little activity causing severe pain, discomfort, paraesthesia or numbness, which takes relatively long to subside' and that of severity as 'the activity that causes the symptoms has

•

•

If the symptoms appear to be due to dominant noci ceptive or peripheral neurogenic input mecha nisms, a direct stimulus-response relationship may be present and the intensity of the symptoms may be interpreted as a direct result of processes in the target tissues. In these cases the extent of the exam ination strategies will usually be taken to the point in movements when pain commences or increases ('PJ '). Frequently only a few tests need to be per formed in order to find comparable signs which may serve as parameters in subsequent reassess ment procedures. Central nervous system processing and (neuro physiological) output mechanisms (Gifford 1 998a, Butler 2000) may also contribute to ongoing tender ness and sensitivity to touch or movement, which may distort the direct stimulus-response relation ship. This may lead to misinterpretations of irri tability with regard to the extent of examination and treatment procedures as well as the education of and instructions to the patient. , From a behavioural perspective ( output mechan isms'; Gifford 1998a), the constructs of irritability and severity may be considered as a form of avoid ance behaviour, as the person having the pain will often interrupt the activity causing the pain (Hengeveld 2002). In this context, in order to make a differentiated hypothesis with regard to 'irritabil ity' or 'severity' it needs to be determined if the behaviour is adaptive to acute nociceptive or periph eral neurogenic processes or if the behaviour has

1 45

1 46

MAITLAND'S PERIPHERAL MANIPULATION

[ become maladaptive over time due to learning processes and central nervous system mechanisms. When doubting if the symptoms may be classified as severe/ irritable or not In those situations where the symptoms seem severe due to learning processes, the physiother apist may have difficulty in classifying the symptoms as such. Some patients may indicate during the subjective examination that they are not capable of, for example, carrying a bag or putting on socks because it is too painful. Based on this infor�ation t e sy pto s ?f these patients may be classifIed as severe or Irnt able'. However, on further questioning it may become clear that it was months ago that such activities were tried for the last time. In this case it may be a form of avoidance behaviour due to learning processes with affective, cognitive and sociocultural variables rather than a direct result of abnormal nociceptive or periph eral neurogenic input alone. It has been acknowledged that the clinician's behav iour during the performance of examination procedures may reinforce the illness behaviour and experienc� of the patient (Hadler 1996, Pilowsky 1997). In su�h a SItu ation it may be possible that the careful testing only until the onset of pain (,PI') and immediately away from the point of pain, in fact may reinforce the maladaptive avoidance behaviour of the patient further. As the decision on severity / irritability in this stage of the examination will determine the extent of the examination procedures, it is important to be aware of these possible reinforcing effects due to interactions and behaviour during the examination procedures. In the above-mentioned situation it is possible to plan the extent of the physical exa ation a� recom . . mended for those patients with seventy or IrntabilIty, i.e. to perform a few tests or the standard procedures without overpressure. Test movements may be taken slightly 'beyond the onset of pain', rather than only 'until the onset of pain'. A point in the movement may occur where the patient indicates that the pain increases. The therapIst then gently moves back in the movement to check if the pain subsides quickly enough, then moves on to the onset of the pain again, at the same time enquiring if the patient has the trust to move a bit further. For example, if the patient is able, at flexion of the arm, to move to 90° before the pain starts, but still has trust to move on until about 110°, the physiotherapist has found two important variables in the test movement:

�

�

•

(ET, Examiner's thoughts; Q, question; A, answer) Q

�

�

•

The following communication example may explain some of the subtleties of the examination process in these circumstances:

PI at 90° of flexion 'TrustI' at 110° of flexion, indicating the point in the movement at which the patient 'trusted to move' to in spite of the pain.

A

Q A

Q

'I would like to examine the movements of your arm - how far you may be able to move the arm, and if some movements are okay but others pro voke discomfort. However, I would not like to push you into any movements that you are not confident of doing yourself. Will you give me a sign if that happens?' 'Oh yes.' 'Could you lift your arm up, as far as you trust yourself to do?' (moves until c. 900 flexion) 'Oh no, not further than this.'

(takes off the weight of the arm and slightly back to c. 800 offlexion) 'And if I move it like this?'

A

'Now it is alright again.'

Q

(moves arm gently back to 900 of flexion) 'And now

here again?' (grimaces) 'Oh, there it hurts again.' Q (back to 800 offlexion) 'Now, okay again?' A 'Yes.' Q 'Was the pain the second time the same as the first time? Or did it get worse the second time?' A 'No, it was the same.' ET If the pain had increased the second time I would stop the testing now. However, it seems to have more of an 'on-{)ff' character than I initially thought. I want him to move the arm gently 'beyond PI'. 'Okay, could I gently take you back to that point of Q pain?' A 'Okay.' Q 'Now it hurts again?' A 'Yes.' Q 'Would you trust yourself to move a bit further in spite of the pain? Only as far as what you trust to move!' A (grimaces and moves until c. 1 1 00) 'Until here.' Q 'Okay, and back again. How are you now?' A 'It's alright again.' Q 'I would like you to remember this movement, as we will check it later in therapy again maybe your pain has changed after the treatment or maybe you will trust to lift your arm a bit higher.' A

Performance of an examination in such a manner requires an awareness of the subtleties of co�unica . tion and the effects of touch during the exammatlOn

Principles of exa m i nation

process. In fact the patient may learn various aspects from the examination procedures, for example: •

•

•

•

the pain may be more movement dependent than initially believed there may be movements which provoke more discomfort and there may be movements which are less discomforting instead of believing that everything hurts all the time in the same manner it is not dangerous to move carefully beyond the point where a pain has commenced the patient may learn to trust the physiotherapist, as the questioning and testing indicated that the patient would not be forced to move in ways which he did not trust himself.

A procedure performed in such a manner may be seen as an expression of a biopsychosocial approach to ini tial treatment of fear avoidance behaviour with regard to movements and activities. Hence, the gradual expo sure to activities may start with the first physical examination procedures.

symptom mechanisms, sources of the symptoms/ impairments and contributing factors. At times it may be useful to spread out certain examination procedures over two to three sessions in order to get a more refined picture of the patient's movement impairments and reactions to initial treat ment interventions. It may confuse the physiotherapist in the analysis of the disorder if too many tests investi gating various structures are being performed in one session. Furthermore, precautions may restrict the extent of testing to prevent exacerbation of symptoms due to too vigorous examination. It is argued that the 'manual therapy diagnosis must include a hierarchy of considerations from the activity / participation restrictions, and any associated unhelpful perspective or psychosocial aspects, to specific physical impairments and their associated structure/tissue sources' Oones & Rivett 2004, p. 1 6). Therefore it may take a few sessions of assessment and treatment, plus assessment of the results of therapy, before the therapist is capable of making a comprehen sive diagnosis from the specific professional perspec tive of the manipulative physiotherapist.

Management

Hypotheses with regard to management are based on information from the subjective examination so far and the agreed goals of treatment with regard to activ ities and participation in the first phase of collabora tive goal setting. The physical examination will provide the manipulative physiotherapist with information regarding treatment objectives of specific movement impairments. However, in this stage, before the phys ical examination, it is useful to anticipate if the treat ment of movement impairments may contribute to the patient's state of health with regard to movement functions. If treatment with passive movement is considered an option, it is essential to reflect before undertaking the examination procedures if the physio therapist expects to be treating a more pain-dominant or a more resistance-dominant problem. During exam ination the physiotherapist may deliberately search for those movements that may be useful in a pain dominant or more resistance-dominant problem, and hence make quicker decisions on the selection of treat ment, if this has been anticipated beforehand.

Planning of the physical examination procedures

It is emphasized that the physiotherapist should not perform a fixed set of examination procedures, but deliberately select test procedures based on hypotheses regarding the precautions/contraindications, dominant

Anticipation on physical examination

Before embarking on physical examination proced ures, the novice should consider the specific objective of the physical examination, be it the reproduction of symptoms and finding movement impairments or the analysis of activities and bodily awareness. In order to make a deliberate selection of test proced ures, hence saving time, the following questions should be considered before further planning of the physical examination: •

•

•

•

•

Do you think you will need to be gentle or moderately firm with your examination procedures? Do you expect a 'comparable sign' to be easy / hard to find? (If hard to find, 'functional demonstration tests' and 'if necessary tests' may be planned in advance, hence saving time.) What movements do you anticipate to be , comparable'? Might there be any positions or movements that need specific consideration during physical examination (e.g. lying in prone positions)? Will your examination in the first session mainly be concerned with determining possible sources of movement impairments, or will you examine contributing factors as well (e.g. muscle recruitment patterns)?

1 47

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MAITLAND'S PERIPHERAL MAN I P ULATION

[ Extent of testing procedures

Planning the sequence of the physical examination

The hypotheses regarding precautions and contra indications serve to determine the extent of physical examination that may be safely undertaken. The following questions need to be addressed in this planning phase:

As already stated, in multicomponential movement disorders it may be useful to spread out parts of the examination over two to three sessions. In the first ses sion the physiotherapist may examine and treat one of the expected dominant sources of the patient's dis order, while in subsequent sessions the therapist may investigate if other sources or associated factors are also contributing to the patient's problem (see Screen ing tests of possible involvement of other joints or movement system structures, below). The planning of the sequence of the physical exam ination (Box 6.6) should encompass the following aspects:

• •

•

•

•

Which symptoms would you like to reproduce? Are there any symptoms which you would not want to produce (e.g. dizziness, paraesthesia) To what extent may you provoke symptoms (list this for each relevant symptom area). A decision needs to be made as to whether the test movements of the physical examination should be either taken to the limit of the available range or taken to the point in the range when pain com mences, or begins to increase. If pain is a dominant factor in the patient's disorder, test movements are usually taken only to the point in range where the pain commences ('until the onset of P1'). In this case accessory movements should be assessed in neutral physiological positions which are fully supported, as free from discomfort as possible and avoiding compression of joint surfaces. Accessory and physi ological movements should be taken to the point in the range at which the pain is first felt (or starts to increase). When stiffness seems more dominant the test movements should be taken to the limit of available range ('until L'). This means that overpressure may be applied to all test movements to determine end of-range 'feel' and symptom response to overpres sure. Therefore, in planning the physical examination the question 'To what extent may the symptoms be reproduced with the test move ments?' should be answered: - until the onset of PI - carefully beyond PI (maybe exploring 'Trust)' see 'irritability' and possible avoidance behaviour above) - move to the limit of the test movements - explor ing the 'end-of-range feel' of resistance to the movement and examining the symptom response to overpressure. Number of tests you will be performing: - few tests (active movements short of limit) - standard tests without overpressure (active limit of movement) - standard tests with overpressure (active limit plus overpressure) - 'if necessary' tests (,when applicable' tests). Are there any positions which you would need to avoid (e.g. prone lying)?

•

•

•

•

Plan of the sequence of test procedures of the first physical examination. An indication of which elements should be exam ined in subsequent sessions. Frequently seemingly less dominant sources of the movement dysfunc tion may be examined in subsequent sessions; associated examination of contributing factors may also take place in later encounters. The planning of the sequence of the physical exam ination should describe all the test procedures that the physiotherapist plans to perform. This should include any special tests (e.g. neurological examin ation, instability tests). The moments when reassessment procedures may be integrated into the sequence of phYSical examin ation, as reassessment may be an essential aid in differential diagnosis.

PHYSICAL EXAMINATION

Physical examination by a physiotherapist may follow different lines of investigation: •

• •

analysis of painful movements, including the analy sis of the contribution of movement components such as joints, neurodynamic mechanisms, soft tis sues and muscles. This includes sources of the symptoms and contributing factors, and why the movement sensitivity as developed has been main tained or recurred (Fig. 6.8) assessment of activity limitations and resources observation of bodily perception, agility and willingness to move.

When examining movement disorders which are related to pain the primary aim is to find a 'comparable sign' at 'appropriate components'. These comparable signs will frequently serve in reassessment procedures in subsequent sessions.

Princi ples of exa mination

Box 6.6

Planning sheet as preparation of the physical examination

--------�

A) REFLECTION OF THE SUBJ ECTIVE EXAM I N ATION (Verification that the subjective exa m i nation i s complete in order to be able to start the physical exa m i nation and to perform a reassessment of subjective parameters - 'asterisks' - in subsequent sessions.) 1. Summary of the main information of the subjective exa m i nation:

2. Ag reed treatment objectives based on the findings of the subjective exa mination:

3. Which subjective parameters ('asterisks') will be used i n subsequent sessions as part of the reassessment procedures? (Describe the parameters in sufficient deta i l ) :

4 . H a s the subjective exa m ination been sufficiently comprehensive t o be able t o m a k e confident statements and t o develop hypotheses with regard to precautions and contra i nd ications to physical exa m i nation procedures? (Check information of ' 0 1 ' , body chart, behaviour o f symptoms, H x , SO) :

B) HYPOTHESES Dominant neurophysiological symptom mechanisms List the subjective information which supports the hypotheses of the various neurophysiological symptom mechanisms: - I n put mechanisms - nociceptive symptoms: - I n put mechanisms - peripheral neurogenic mechanisms: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - Processing - central nervous system mechanisms and / or cognitive/ affective / sociocultural influences: - Output mechanisms - motor and autonomic responses: • Sou rces of symptoms / i m pa i rments List all the possible sources of any part of the patient's symptoms that must be examined: - Joints underlying the symptomatic area(s): - Joints referring into the symptomatic area(s): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - Neurodynamic elements related to symptoms and dysfu nction : - Muscles underlying the symptomatic area(s): - Soft tissue structures u nderlying the symptomatic a rea(s): - Others: • Contributing factors Which associated factors may be contributi n g / causi n g / maintaining the problem and disability7: - Neuromusculoskel eta l : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (a) as reasons why the joint/ muscle or other structure has become symptomatic/ as reasons why the disorder may recur (e.g. posture, muscle imbalance, m uscle coordination, obesity, stiffness, hypermobil ity, instabil ity, deformity in neighbouring joints, etc.): . . (b) the effect of the disorder on joint stabil ity: - Medical factors:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - Cognitive factors: - Affective factors: - Behavioural factors: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . When do you expect to incorporate these factors in physical exa mination procedures (immediately/ i n later sessions?). Specify: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . • Preca utions and contra ind ications to examination procedures and treatment interventions - Are the symptoms severe / i rritable? Yes / N o (a) Specify your answer with examples from t h e subjective exa m i nation: •

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • .

.

. . . . . . • . . . . . . • . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • • . . . . . . • .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . • . . . . . . • . . . . . . . • . . . . . . •

.

. . . . . . . . . • . . . . . . • . . . . . . • . . . . . . • . . . . . • . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . • . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . .

. . . . . . . . . . . . . • . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . • . . . . . . • .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . • . . . . . . • . . . . . . . . . . . . . • . . . . . . • . . . . . . . . . .

.

. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . .

.

. . . . . . . . . • . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . . . . . . . • . . . . . . . . . . . . • . . . . . . . . . . . . . • . . . . . . • . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . • . . . . . • . . . . . . . . . . . . . . . . . . . . • . . . . . . . . . . . . . . . . . . . . .

.

-

(b) Is it possible that ongoing sensitivity takes place due to central nervous system sensitization or avoidance behaviour? Specify your answer: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Does the natu re of the problem ind icate caution? Yes / no (a) Tissue pathology: . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (b) Other pathological processes (e.g. osteoporosis) : . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

.

. .

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MAITLAND'S PERI PHERAL MANI P U LATION

[

(c) Stages of tissue healing: (d) Stage of the disorder (Hx) (progressive / regressive /static): (e) Easy to p rovoke exacerbation or acute episode (stability of disorder): (f) Confidence to move/ extreme guarding of the patient:

. .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . • . . . • . . . . . . . .. . . . . . . . • . . . . . • . . . . . • . . . . . . . . . . • . . . . • . . . . • . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . • . . . . • . . . . . . . . . • . . . .

What are the implications of this answer with regard to the extent of the physical examination?: •

. . . . . . • . . "

. . . . . • . . . . . . . . . • . . . .

Management - objectives/ if treating local movement impa i rment - P or R 1 . Which short-term or long-term goals of treatment are pursued?: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. If passive mobilization is a treatment option, do you expect to be treating pain, resistance but respecting pain, resistance or resistance to provoke 'bite'?: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. Are there any precautions or contra indications which need to be respected ('nothing at the price of ... )?: . . . . . . . • . . . • . . . . • . .

4. What advice should be included and/or measu res would you use to prevent / lessen recurrences and provide the patient with a sense of control over the symptoms?: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

.

C) PROCEDURES OF EXAMINATION Anticipation o f the results of examination procedures - Do you think you w i l l need to be gentle or moderately firm with your examination proced ures?: . . . . . . . . . . . . . . . . . . . . . . . . . - Do you expect a 'comparable sign' to be easy / hard to find? (if hard to find. 'functional demonstration tests' and 'if necessa ry tests' may be planned in advance. hence saving time). Explain why:

•

.

•

What movements do you antici pate to be 'comparable'?: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Might there be any positions or movements that need specific consideration during physical exami nation? (e.g. lying in prone positions): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Extent of examin ation proced ures - Any positions you may need to avoid in the exa m i nation? (e.g. prone lying) : - Which symptoms would you like to reproduce?: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - Are there any symptoms which you would not want to produce? (e.g. dizziness, paraesthesia): . . . . . - To what extent may you provoke symptoms? ( l ist this for each relevant symptom a rea): Until the onset of P, / ca refu lly beyond P, - maybe exploring 'Trust , ' / move to the l imit of the test movements:

.

.

. . . . . . . . . . . . . . . . . . . . • . . . . . . . . . . . . . . . . . . . • . . .

.

-

N u mber of tests you will be performing: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Few tests (active short of l i m itl / Standard tests without overpressure (active l i m it of movement) / Standard tests with overpressure (active limit plus overpressure) / ' If necessary' (or 'when applicable') tests

.

•

Which components do you examine and which tests (includ i ng reassessment procedures) will you perform in the first session? . . Which components do you expect to examine in the second session? (And with which tests?): . . . . . . . . . . . . . . . . . . . . . . . . . .

•

Which components or contributing factors do you expect to exam i ne in later sessions? (And with which tests?) :

•

Sequence o f examination procedures of the first sessio n : - Observation: - Functional demonstration test and differentiation: - Active movement tests (specify which): - Isometric tests (with which purpose?): Specify which tests: - Are any special tests indicated?: (a) neurological examination (conductivity): (b) others (e.g. instabil ity testing) : - Neurodynamic testing: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - Palpation and passive movement testi ng: (a) accessory movements (specify joint position; which acc. mvts) : (b) physiological movements: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (c) others: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

•

.

. . . . . . . . . . . •

. . . . . . . . • • . . . . . . . . . . . • . . . . . • . . . . . • . . . . . • . . . . . . . . . . . . . . • . . . . •

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . • . . . . . • . . . . . • . . . . • . . . . . • . . . . • . . . . • . . . . • . . . . . . . . . . . . . . . • . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . "

. . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . . . . . . . . . . . . . . . . . • . . . . • . . . . • . . . . • . . .

. . . . . . . . . . • . . . . . • . . . . . . • . . . . . • . . . . . . • . . . . . • . . . . • . . . . . • . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . • . . . . . • . . . . . • • . . . . . • . . . . . • . . . . . • . . . . . • . . . . • • . . . . • . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . . . . . . . • . . . . . • . . . . . . . . . . • . . . . . • . . . . • . . . . • . . . . • . . . . . . • . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . . . . . • . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . •

.

. . . . . • . . . . . • . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . • . . . . . . . . . . . • . . . . . . . . . . . . . . . . . . . . . . . . • .

.

When do you plan to perform reassessments during the P I E procedures? (Indicate this with a double line beh ind the above-mentioned test procedu res.)

.

.

Princi p l es of examination

Figure 6.8

Neurodynamic functions

Joint functions

movement impairments.

Mechanosensitivity movement dysfunction

- local - referred

t .

Soft tissues

Muscular functions - contractions - triggerpoints

,

Others

Skin, fascia,

Blood vessels

connective tissue

Viscera

A 'comparable sign' refers to a combination of pain, stiffness, motor responses or other findings which the examiner discovers on physical examination and con siders to be comparable with the patient's symptoms as described in the subjective examination. A patient's complaint may be pain felt anterior to the ankle joint; however, if stiffness and pain on pas sive flexion of the metatarsophalangeal joint of the big toe is found, then these joint signs are not considered as comparable in an 'appropriate joint'. Reproduce symptoms or produce comparable signs? During test procedures the symptoms can present as follows: •

•

Component concept: specific taxonomy

of manipulative physiotherapy evaluation of

- local - referred

The patient's pain is being reproduced with the test procedures. Frequently these tests will serve as parameters in reassessment procedures to monitor results of treatment. A degree of pain is being produced; however, it is not the kind of discomfort as described during the subjective examination. Furthermore, it is not a kind of discomfort that could be considered as normal. However, this 'degree of pain' must be found during appropriate test procedures in struc tures or components that may be related to the patient's symptoms. It is quite common to find minor joint signs at an appropriate joint which are not comparable with the patient's disability.

While test procedures which reproduce the patient's symptoms are highly significant - for example, reassessment parameters and the definition of treat ment objectives on 'impairment' levels according to reF (WHO 2001) - 'produced comparable signs' with out 'reproducing' are less definitive. Nevertheless, they are frequently just as Significant, and sometimes this is only appreciated in retrospective assessments.

On the other hand, signs which may seem compar able at the first treatments may prove to be otherwise later. This may become apparent when the patient does not improve with treatment. Under these circum stances, re-examination should be carried out, often with careful stronger test movements in an endeavour to find different signs that prove more comparable. Having found such a sign and made use of it in treat ment, the patient's symptoms and signs should improve. As improvement occurs, comparable signs may change and other comparable signs may become evident. Frequently this will require changes in treat ment techniques and adaptation of self-management strategies. Diagnosis of movement dysfunctions and detection of structural lesions The physical examination, as well as subjective exam ination findings, contributes to the clinical diagnosis, being expressed in movement dysfunctions. In more contemporary terms, a 'mechanosensitivity' to the test movements is present, if test movements provoke pain. Sometimes it is suggested that an impression may also be gained of the anatomical structures involved in the movement disorder by the stress performed on the structures during the test procedures. Although this seems possible in principle, it may also place physio therapists in a dilemma. A 'structural diagnosis' can not be made based on one or two tests. It needs to be emphaSized that physical examination tests always put more than one structure under stress, and there fore a structural analysis can only be made based on the subjective findings (especially of the body chart, behaviour of symptoms and onset of the problem), the test procedures which show abnormalities and the reactions to treatment. The structural diagnosis needs to be expressed in terms of a hypothesis, as this will

151

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MAITLAND'S PERIPHERAL MAN I PULATI ON

[ as the patient will perform the active tests within his own limits of pain and comfort. This will guide the examiner in how much handling the patient and the structures will tolerate. Other tests with impli cations for further testing (e.g. neurological exam ination - nerve conduction) are usually performed early in the physical examination.)

REPRODUCTION OF SYMPTOMS PRODUCING COMPARABLE SIGNS

Detecting abnormal movements and movement directions (impairments - movement dysfunctions)

Differentiate components of the impaired movement dysfunctions - movement diagnosis

•

be clear in their purpose to the examiner.

•

be comprehensive. (Nothing should be left out that would prevent the physiotherapist from making an initial movement diagnOSiS with respect to possible precautions and contraindications. However, some test procedures (e.g. muscle tests) may be per formed in subsequent sessions if the information from the test results would not be decisive in the management of the first session. If management would not change as a result of the test procedures, it may be decided to perform these tests in subse quent sessions.)

•

be standardized in such a way that the tests can be reproduced in a consistent manner during reassess ment procedures. If possible, it may be appropriate to perform the tests in such a way that they meet a 'gold standard' with regard to validity and reliabil ity; however, the primary goal will always be that the therapist is able to adapt the test procedures to the specific needs of the patient. Some physiothera pists only employ tests with an acceptable inter and intra-tester reliability. However, it is argued that clinicians should retain a certain degree of scepticism if tests with a high reliability coefficient are directly claimed to be clinically useful as well (Keating & Matyas 1998, Bruton et a1 2000) and vice versa: tests with a low correlation coefficient (e.g. some palpation tests) therefore would not be useful clinically. Often the combination of test parameters of both subjective and physical examination data provides the clinician with valid reassessment parameters (MacDermid et al 1999).

May analyse structures - structural diagnosis Fig u re

6.9

Algori th m of p h ys i c al exa mi nation objectives.

leave the physiotherapist open to other possibilities regarding causes and treatment options if the desired treatment results do not occur. Although the physiotherapist will diagnose more frequently in terms of movement disorders (see Fig. 6.9) than in structural diagnostics, attention needs to be given to acute symptoms due to posttraumatic situ ations, in which large structural lesions may have occurred and which may need the care of a medical practitioner. Algorithm Based on the dilemma that structural diagnosis imposes, the physiotherapist may follow the algorithm as depicted in Figure 6.9 of objectives of the physical examination. Conditions to test procedures In order to be useful in movement diagnosis and in reassessment procedures, physical examination proced ures need to meet several conditions. The test proced ures need to: •

ensure the comfort and safety of the patient. Comfort may be optimised by carrying out relevant tests in one position, before moving on to the next (e.g. perform all required tests in standing, before continuing in supine, positions).

•

be appropriate for the patient and the patient's disorder.

•

be performed systematically, to optimise efficiency. (Some tests need to be performed before the appli cation of other test procedures. Frequently it is use ful to perform active testing before passive testing,

Physiotherapists may perform physical examination procedures following the framework delineated in Box 6.7. The next sections give a general overview of the principles of some test procedures. Detailed informa tion is provided in the relevant chapters.

Observation

The main purpose of observation is to obtain general information about functional deficits with regard to posture, alignment, joint positions and local tissues.

Pri nciples of exam i n ation

General overview of physical examination procedures

BOx 6.7 Observation

General observation, local observation

Special tests (e.g. n eurological e xamin ation, instability

•

Watch for patient's willingness to move the structures

testing, vascular testin g)

PP (present pai n ) •

Correction o f protective deformities

Functional demonstration - functional tests, inclu d i n g diffe rentiation Brief appraisal Active m ovements •

Gait an alysis, other active tests in weight-bearing

•

Active physiological movements:

(sitting, stan ding)

Neu rodynamic test i n g (may be performed as part of passive testing and component an alysis) Passive movements (as component analysis, including regular reassessment) •

Movement diagram

•

Accessory moveme nts (define position in physiological range)

•

Physiological move ments (e.g. F/ Ad hip, shoulder quadrant)

•

Muscle length tests

-

overpressure

Palpation

-

'if n ecessary' testing/ 'when applicable' testing:

•

Temperature, swelling, wasting, sensation, position of

•

Soft tissue e xamination (e.g. trigger points, muscle

•

Nerve palpation

-

structures, tenderness of structures

test movements faster, repeated, sustained, changing from one e n d to the other

-

combin ed movements

-

compression, distraction

Isometric tests •

Function - strength, coordination

•

Symptom reproduction

Active tests of other components in the p l an •

Joints possibly referring into the area

•

Joints above and below - movement quality as a

in sertions)

(Palpation of temperature / swelling may be done during observation and regularly during P / E; palpation of tissue tenderness/ positions may be performed before passive testing.) Check case records an d radiographs

Highligh t main findings with asterisks

contributin g factor to move ment in the main

Plan reassessments (whe n , which in formation/ te sts)

component?

Warn i n g, instructions an d recom m e n dations

Furthermore, it may provide the physiotherapist with information regarding habitual movement patterns. Physiotherapists will explicitly observe patients for specific purposes; however, they may also implicitly observe the ways in which a patient is, for example, able to undress, stand up from a chair or move on the treatment plinth. Observation may include the following: •

Brief apprai sal

•

General observation from posterior, laterally and anterior: - general posture (although postural anomalies may contribute to the patient's symptoms, there are many deviations from the norm that have no direct relationship to the source of the symptoms) - gross changes in skin, muscle contours, body alignment

•

More localized observation of the possible compon ents involved: - skin changes, colour of skin - swelling (if this seems indicative of an inflammatory process, the physiotherapist may quickly palpate temperature and swelling in order to be able to control this, and regularly monitor that this does not increase during subsequent examination procedures) - scars in the area - bony alignment (e.g. relation of tibia to femur, patellar position; relation of scapula to thorax or upper arm to scapula) - wasting of, for example, gastrocnemius muscle

•

Willingness to move (e.g. extreme guarding or pro tection of certain movements or positions)

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MAITLAND'S PERIPHERAL MANIPULATION

L •

•

Present pain (PP) (before testing any movements, the patient's present symptoms need to be assessed. If the patient has no pain, test procedures will be performed typically until the onset of pain; if pain is present, test procedures will be performed gently until the pain slightly increases. Note: if symptoms are present, the physiotherapist should ask what the patient is able to do to relieve the symptoms. This provides valuable information regarding the movement components and the movement direc tions, which may be used in treatment procedures. Some patients may not consciously find move ments or positions to relieve the symptoms; how ever, they may instinctively employ a strategy that may prove to be invaluable in the selection of treat ment later on. ) Correction o f protective deformities (postural abnormalities are difficult to interpret, as many variations may occur without being clinically rele vant. However, it is always useful to correct the abnormalities to investigate if posture or deformity is associated with the patient's symptoms. If symp toms are reproduced, the correction may serve as a parameter for subsequent reassessment procedures.)

in small amplitudes reproducing the symptoms). - Repetition of the swing may produce an ache after two or three repetitions, and increase in intensity as the patient continues swinging. This indicates that symptoms occur 'through range' which may require treatment with techniques in a large amplitude in a smooth, slow rhythm. Once this is determined, the patient should adopt the painful position and the physiotherapist analyses the movement by differentiation tests to determine the main components of the movement affecting the patient's pain (see below). After performing a functional demonstration test, the physiotherapist should quickly reflect ('brief appraisal') on whether to continue with the physical examination as planned, or if the subsequent examin ation procedures need to be adapted, depending on the findings of the functional demonstration test. To summarize, functional demonstration tests: •

•

Functional demonstration tests

Frequently, the first movements to be sought are those which the patient can demonstrate as being associated with the disorder. The physiotherapist may ask the patient:

Q

'Is there anything you can show me, here and now, that provokes your problem?'

If the patient shows a golf swing provoking symptoms in the shoulder area, various aspects need to be analysed: •

•

The phase of the movement in which the symptom is felt (at the end of the back swing, before striking the golf ball, during the swing or at the end of follow through). The behaviour of the symptom during the activity: - Does it disappear immediately after the activity? During the swing the pain may behave in different ways: (a) the pain may remain the same with each swing (b) the pain may become stronger in intensity if the patient continues swinging (c) the pain may lessen with each swing until it becomes painless (this indicates that symptoms occur at the end of range, which may require treatment with passive movement

•

serve as parameters in reassessment procedures ('physical examination asterisks') probably reflect the perception of the patient rather than many active movement tests in supine or prone positions, hence they may be more meaningful to the patient if beneficial changes occur can often be complemented with differentiation tests to analyse the movement components contributing to the symptoms.

Additionally, functional demonstration tests may become more relevant in later stages of treatment. In some situations patients seem reluctant to take up certain activities again, although it appears that they should be capable of doing so. By regular testing of these activities the patients may experience that they can perform the activities without any harm occurring.

Differentiation tests

As part of the physical examination procedures (and treatment techniques) it is often necessary to carry out 'differentiation tests' to determine as accurately as pos sible the source of the patient's symptoms. Differen tiation tests are special tests that can be used when a test movement (active or passive) causing simultan eous movement of at least two joints or two movement system structures reproduces the patient's symptoms. Such tests differentiate which movement components contribute to the symptom-provoking test movement. Whatever movement reproduces the patient's symptoms, it is fundamental to carry out that exact

Principles of examin ation

movement for the differentiation test. The method is as follows: when the test movement is at the point in the range of reproducing the patient's pain, further move ment is produced in one of the two joints or structures which, at the same time, either reduces the movement in the joint or retains it at an unchanged degree of mechanical stress. This test, which increases the stress at one joint or structure and reduces it at another, will either increase or decrease the reproduced pain. The test is then performed in the reverse manner. The pain response (Le. increase or decrease) confirms which structure was found to be at fault with the first test. Differentiation tests are suitable in those cases where the patient's symptoms appear to have a 'stimulus-response' character. If the symptoms are severe, the differentiation tests may be performed slightly before the point of onset of pain in the test movement. If the pain allows the physiotherapist to move until the limit of the test movement, the differen tiation test may be performed at that point in the range in which the first symptoms occur. Differentiation tests can be performed in various phases of the physical examination: • • •

• •

demonstration of functional movements active movement tests passive movement tests (e.g. shoulder quadrant; hip flexion/ adduction) as essential procedures in neurodynamic tests during isometric tests (sometimes).

Conditions to successful differentiation tests •

•

•

•

Stress may be added to or subtracted from one (or a group of) movement component(s). While adding or subtracting the stress, the other components need to be kept stationary. The structures need to be slackened/stressed only a little to find comparable responses. Ideally the symptoms behave in a consistent 'on-off' character: while adding stress to a certain movement component the symptoms may increase and subtraction may decrease the symptoms.

Establish the source(s) of the movement dysfunction

oe.g. elbow complex Figure 6. 1 0

.0

Dominant movement direction? .

.

e.g. In c.60· F: pronation

A l gorith m of differentiation tests.

•

If the pain increases substantially, owing to central nervous system sensitization, or disappears during the testing, differentiation tests may be less suitable; how ever, some procedures may still serve as parameters for subsequent reassessment procedures.

Algorithm of differentiation procedures Certain differentiation procedures may only be useful once other differentiation steps have been performed. For example, in a patient with symptoms in an area on the lateral side of the elbow, it first needs to be deter mined if elbow movements are involved before the possible joints are investigated with the contribution of peri- or intra-articular components (Fig. 6.10). Note: Differentiation tests are essential procedures in this concept of manipulative physiotherapy. However, they are part of the whole differentiation process. Some dysfunctions may not be elicited by differentiation tests but by treatment of the movement components and subsequent reassessment of the results (Maitland et a1 2001).

Active movement tests

Before performing any passive tests, the physiother apist asks the patient to perform active movements. This will guide the examiner in how much handling the patient and the structures will tolerate, as most patients will perform the active tests within their own limits of pain and discomfort. Active tests include several aspects: •

Functional movements - movements in weight-bearing situations such as standing or sitting. Gait analysis may be part of these procedures. The advantage of performing active movements in weight-bearing or other functional positions may lie in the fact that these movements may be more meaningful to the patient than those in supine or side-lying positions; hence they may provide both the patient and the physiotherapist with better comparisons of change in subsequent reassessment procedures.

Establish possible involved joints

Periarticular or intra-articular components?

If possible and necessary: structural analysis

0---.;...--... . 0------... . 0----.-.;-... . e.g. RlH or prox. RlU joints

Add compression or distraction

1 55

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MAITLAND'S PERIP H ERAL MA N I P ULATIO N

[ •

Physiological movements movements along anatom -

ical axes (e.g. flexion, abduction, etc.) which can be varied in speed, can be repeated several times, may be sustained at end positions or may be performed in rapid changes. Furthermore, the test movements may be combined in order to find comparable signs. Various parameters need to be assessed during active movements: •

Willingness to move, ability to move.

•

Quality of movement including deviations and abnormal rhythms of the movement. Any abnor mality in quality of movement, deviations or abnor mal rhythms need to be countered. If the correction of the abnormality reproduces the patient's symp toms, while before countering no pain was pro voked, the alteration in quality is directly associated with the disorder (e.g. squatting with one leg mov ing laterally; shoulder flexion with a ventral devi ation of the movement from 90° flexion onwards; scapular winging during abduction).

•

•

Range of movement reference is made to standard ized ranges of motion, as expressed by the American Academy of Orthopaedic Surgeons (Heck et al 1966). However, individual variations from the norm may occur without being clinically relevant. Comparisons with the other side may be indicative of excessive range or of loss of range. It is important to note that in different positions different measure ments may be recorded. This is obvious in weight bearing joints, but the principle also applies to, for example, the shoulder where gravity assists flexion in the supine position, but resists in standing. -

any symptom reaction, in which it needs to be judged if: - the symptoms are normal (e.g. pulling at the ventral side of the hip area during extension of the leg) - the symptoms are preliminary to reproduction (e.g. strong pulling sensation, which normally does not occur) - adding slightly more stress to the movement (e.g. with overpressure) may elicit the desired symptom reproduction - the symptoms are being reproduced.

The physiotherapist should always simultaneously take the combinations of range, quality and symptom response to an active movement into account and record these accordingly. Application of further stress to active movements If symptoms have not been provoked to the desired extent with active movement testing, further stress

may be applied to the test movements. Most frequently overpressure is applied. Principle of overpressure Every joint has a passive range of motion which exceeds its active range. To this passive range, further normal movement can be gained by a stretching application of overpressure. This overpressure range has, in nearly all examples, a degree of discomfort or hurt and should be assessed before declaring a joint movement to be normal or ideal. If the active movement arrives at end of range and is painless so far, a moderate degree of oscillating pres sure is then applied at the limit of range to assess whether the movement is in fact full range and pain less. The oscillations will move gently, but increasingly, into the limit of the movement; the physiotherapist then feels some resistance and therefore the overpres sures are frequently classified as IV -, IV, IV +, IV + + . The overpressure should not be excessive, but applied with appreciation of the age, general condition of the patient and any other precautions. Of equal importance, the overpressure must not be too light. This is essential as sometimes active movement may have been considered as normal; however, only in the stretching reserve beyond the end of the active range of movement may symptoms be reproduced. This may be the case if patients first develop symptoms when they move their structures repeatedly or hold them for long periods in the same position before symptoms occur. Important: An active movement can never be classed as normal unless relatively firm overpressure can be applied painlessly. 'If necessary' tests ('when appl ica ble' tests) If active tests including overpressure do not elicit reproduction of symptoms, the test movements may be further intensified, if applicable. Variations of the active movements •

•

•

•

Speed the speed of the movement may reveal any -

abnormal rhythms in the movement and may also reproduce symptoms which otherwise would have been missed. Repeated - 10-lS X repetition of the movement before the symptoms are reproduced. Sustained - 1 0-30 seconds holding the joint at the limit of range. Moving from one extreme to another, frequently with a quick change of movement direction. This may be an indication of 'through range problems'.

Combined movements The concept of combining move ments to reproduce symptoms is well known in the spine (Edwards 1992, Maitland et al 2001 ). However,

Princi ples of examination

a similar approach is possible in peripheral joints; there are times when a patient has a relatively good range/pain response to, for example, shoulder flexion. If the patient is then asked to perform the same flexion with the arms medially rotated, then laterally rotated, the symptoms may be reproduced. The physiother apist should be sufficiently flexible to introduce combin ations of movements and changes in the sequence of movements in an endeavour to find the most com parable sign. This involves adding com pression or distraction to the movement in order to increase stress to the peri- or intra-articular movement components. The effect of compression on a weight bearing joint while in the standing position can be important and may indicate the need to introduce compression into the examination of active movements to elicit symptomatic movements. A common example is a patient with minor knee symptoms who may have a full painless range of active knee movements when tested in supine but when asked to stand and squat fully the symptoms may be reproduced. Compression and distraction

Injuring movements If a joint sign comparable with the patient's symptoms cannot be found, the patient may be able to recall the exact movement that caused the injury. Gentle repetition of this movement, simulating the condition under which the injury occurred, could be used as a test. However, not all symptoms related to joint movements have a traumatic origin and details of the trauma cannot always be recalled.

Isometric tests

Isometric tests can be performed for different purposes: •

Examination of function - to determine the strength and coordination of muscles or muscles groups in different positions of joint(s).

•

As part of a neurological examination - indicative of changes in nerve conduction. In this method of testing a maximal contraction is required if pos sible, and then a short counterforce is given, to which the muscle has to react with appropriate speed.

•

Pain reproduction - finding a pain-causing lesion in muscles, tendomuscular junctions, tendons or teno-osseous attachments (Cyriax 1978, Corrigan & Maitland 1983). In this case the isometric test is per formed slowly, avoiding any movement of joints or other structures.

The isometric tests regarding pain production do not always provide clear answers relating to structural differentiation, because an isometric test necessarily

results in compression of joint surfaces, joint shearing and stress on ligaments. Therefore positive findings should be taken with a degree of reservation, but negative findings can often be considered quite strong evidence that the tested muscles are not the source of the pain. Isometric tests which reproduce the patient's symptoms can nevertheless be used as parameters ('physical asterisks') in later reassessment procedures. Screening tests of possible involvement of other joints or movement system structures

During the initial examination or in later sessions it is often necessary to investigate the possible involvement of other components which may refer symptoms into the symptomatic areas or are contributing factors as to why a movement component has become symptomatic. The joints above and below the painful one, as well as those components which may refer symptoms, have to be investigated as part of the routine examination, be it that the tests are performed in the initial or subse quent sessions. The examination should include quick tests of the joints above and below the painful one so that they can, hopefully, be excluded from the clinical examin ation. Iffound to be limited or painful then they will have to

be examined in detail. It must be emphasized that structures or compon ents cannot be excluded from their possible involve ment based on a few symptom-free active tests alone. Generally the structures are tested with active move ments, including overpressure, if possible with some quick tests of combined active movements, as well as some relevant passive movements, with subsequent reassessment of those test movements which repro duced the symptoms in an earlier stage of examination. The relevant passive tests may include accessory movements or special physiological movements as, for example, shoulder quadrant or hip flexion/ adduction. If during these procedures no symptoms are pro voked, and the symptoms of the test movements have not changed, the component generally is excluded from further consideration. The screening procedures for the various compon ents are described in the relevant chapters. Special test procedures

Special test procedures may be performed at various stages of the physical examination as deemed appro priate by the physiotherapist: •

Neurological examination - physical examination of conduction relating to nerve roots, peripheral

1 57

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MAITLAND'S PER I PHERAL MAN I P U LATION

nerves or the central nervous system. This usually encompasses isometric muscle testing, skin sensa tion and the examination of reflexes. If indication of changes in nerve conduction is present, the test pro cedures must be performed in an early stage of the physical examination as changes in these tests may serve as relevant parameters during reassessments and, in irritable and unstable disorders, they should not be made worse with too vigorous testing. •

•

•

restricted movements (Shacldock 1995). It is essen tial therefore to reflect on possible causes of the mechanosensitivity to the movements before test ing for relatively long periods in end-of-range positions or utilize direct neurodynamic move ments as treatment procedures. The test proced ures are described in the relevant chapters. For further reading, see Butler (2000).

Instability testing may be performed if excessive

Palpation

mobility or instability seems a relevant contributing or causative factor to the patient's movement dis order. The tests are described in the relevant chapters.

Palpation procedures provide the physiotherapist with different kinds of information:

In certain circumstances, palpation of vascular pulses may be necessary. They may reveal important infor mation regarding the status of the cardiovascular system. An absent or diminished pulse may indi cate a vascular obstruction that may be related to the patient's symptoms. For further information see Boissonnault (1995) and Goodman & Snyder (2000). Using compression during active, passive physio logical or accessory movements. As already mentioned, when active, passive physiological or accessory movement tests do not reproduce any symptoms, they should be repeated while compres sion is applied. This is particularly appropriate if the disorder is thought to have an intra-articular compo nent which may be treated with compression tech niques in a later stage of treatment (see Chapters 7 and 8).

Clinical tests of the nervous system

There are three ways in which physiotherapists may perform tests to evaluate the contribution of the ner vous system to a patient's movement disorder (Butler 2000): 1. Nerve conduction tests, as described above. 2. Palpation ofnerves sites which are sensitive to touch or gentle movements may be indicative of abnormal impulse generating sites. If nerves are not directly palpable they may be compressed with specific test procedures (e.g. carpal tunnel compression test or Phalen's test). -

3. Neurodynamic testing many tests may be per formed as passive tests; however, they can also be performed as active tests and as part of a functional demonstration testing. It is important to realize not only that pathomechanical processes may limit the test procedures, but also that pathophysiological processes may be causing pain, discomfort and -

• • • • • • •

•

temperature, sweating swelling of local tissues or of joints muscle tone, including trigger points bony anomalies bony alignment soft tissue thickening, tightness, swelling tenderness in soft tissues, muscles and insertions, periosteum palpation may include nerves or, if indicated, vascular pulses.

Palpation of the structures should take place before the examination of passive movements, as some findings may change fairly quickly after the application of treatments with passive movements. However, it should be remembered that a patient may present with referred tenderness, hence the source of the dysfunc tion may be far removed from the tender or painful area. Furthermore, central nervous system sensitiza tion with autonomic 'output mechanisms' may con tribute to tenderness in tissues as well. In this case tenderness may be of a more generalized type and may increase with the continuation of the palpation (Gifford 1998a). Passive movement tests

The main scope of passive movement tests is to find movement impairments with signs (pain, resistance or motor responses - 'spasm') that are comparable with the patient's symptoms and disability. The relevant examination findings will be those which reproduce the patient's symptoms or provoke symptoms in joints which seem compatible with the patient's disorder. Passive joint movements can be broadly divided into two groups (Williams & Warwick 1980): physio logical movements and accessory movements. Physiological movements

Physiological movements are defined as movements of a joint which can be performed actively by the

Princi p l es of examination

individual and which can be examined for range, qual ity and symptom response both actively and passively. The first movements tested passively should be those physiological movements that have been tested actively. Relaxation is essential to perform the move ments passively; therefore they are frequently employed with the patient in a reclined position. During the move ment it is determined if any pain is produced. The posi tion in the range at which the pain is first experienced is ascertained by gently moving into and away from the pain. Unless the pain becomes excessive, the movement should be continued until the limit of the range. The available range - together with the site or degree of pain, including the factors which limit the movement should be recorded. This information is best recorded in a movement diagram (see Appendix 1). Component analysis with passive movements Passive movements with subsequent reassessment of relevant active comparable signs may serve in the analysis of the involvement of possible components in the patient's movement disorder. Accessory movements in various positions of the joints as well as specific passive movements of 'functional corners' (e.g. F/ Ad of the hip or E/ Ab and E/ Ad of the elbow; see Chapter 1) may be very informative regarding the possible involvement of cer tain joints if the tests are being followed by reassess ment procedures. The testing of these passive movements with subse quent reassessment allows for an important principle of this concept: differentiation by treatment. The same procedures may also be performed with other components or structures: •

•

•

If neurodynamic testing has taken a relatively long time, especially if during the test procedures changes in resistance or symptom response have occurred, it may often be useful to perform some reassessment tests prior to continuing with the examination of other components (e.g. passive movements of joints). If the physiotherapist considers certain soft tissues (e.g. muscle insertions, trigger points) to be a domin ant part of the patient's movement disorder, the therapist may examine the structure and immedi ately perform a probationary treatment, followed by reassessment of active comparable signs. However, if the improvement in the condition does not last, other mechanisms or movement disorders may be causing the local structures to be sensitive to palpation. Identical strategies may be applied to muscle length tests and probationary treatment, with subsequent reassessment.

Accessory movements Accessory movements or joint play movements cannot be performed voluntarily but will occur during physio logical movements, when a resistance is applied to active movements or when they are performed pas sively. Such accessory movements include the roll, spin and slide which accompany a joint's physio logical movements. Accessory movements should be examined passively for range and symptom response in the joint's various possible positions. The examination of a joint's accessory movements is essential if a joint is to be treated by passive move ment. If the accessory movements are limited and painful, the active movements cannot be normal. A loss of range in accessory movements of a joint can explain why a particular physiological movement is restricted. When examining accessory movements particular note should be taken of: •

•

•

the position of the bones in relation to each other (normal or abnormal) the limitations of joint movement in any direction found by accessory movement techniques the site and the degree of pain produced by each movement - is this comparable with the patient's disorder?

Special aspects of exa m i n ation with accessory movements: •

If symptoms are such that it is planned to examine structures only as 'move to pain' as in situations of severe symptoms, the accessory movements are tested with the joint positioned in its loose packed, mid-range, least painful position.

•

If the symptoms are of a quality that the test move ments can be performed as 'move to limit', they are assessed in a position slightly before the onset of symptoms, which is usually at the limit of the physio logical range or in a position short of that limit.

•

If symptoms seem to occur in a 'through range' manner (e.g. with a painful arc in shoulder abduc tion) it is often useful to position the joint in this specific range of the arc of pain and then examine the accessory movements accordingly.

Accessory movements can be examined in single joints (e.g. glenohumeral or tibiofemoral joints). In these joints the accessory movements, as produced by the thumbs or hand, can also readily be assessed for range and pain response. In multiple joint complexes (e.g. the wrist or foot) in which many joints work in harmony with various accessory movements in different direc tions (Jacob et al 1992), detailed and refined examin ation of accessory movements is often necessary before

1 59

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M A I T LA N D ' S P E R I P H E RA L M A N I P U LATI O N

joint signs are found. The physiotherapist frequently needs perseverance and a knowledge of how accessory movements can be varied in order to elicit joint signs as a basis for treatment with passive movements. Accessory movement variation •

•

•

Assessment of the accessory movements in various positions of the physiological range. (It is often useful to position the joint short of the point in the physiological range in which the symptoms occur.) Performance of the accessory movements under compression. Gliding movements of one or the other joint partner.

Many anomalies occur clinically which do not entirely agree with what is thought to be known anatomically and physiologically. A useful example is a patient with pain in the wrist during various functional move ments. Accurate examination of the intercarpal area may indicate, for example, that the pain is arising from the joint between the capitate and hamate bones as movements occurring at the joint reproduce the patient's pain. The physiotherapist can hold both bones between the fingers and thumb of each hand and slide both bones back and forth against each other to produce and feel movement at the joint. The normal relationship of the hamate--capitate joint is represented diagrammatically in Figure 6.11. For example, pain may be reproduced during movement of the hamate while the capitate is stabil ized. In theory pain should also be reproduced if the capitate is moved in the opposite direction while the hamate is stabilized (Fig. 6.12). Clinically this is not always the case although theoretically the same move ment is being produced. Importantly, the movement that reproduces the patient's symptoms should be the movement used in treatment. Movements on both partners or on the j oint l i n e Based on the above information it may be concluded that fre quently it is useful to examine a joint by producing movements on both partners of the joint, and then on the joint line between the bones (Fig. 6.13) . Each o f these three movements produces a different movement in the joint and any one of them may reproduce the patient's symptoms, or one may be more dominant than the others.

Fi gu re 6.11

Diagrammatic representation of the neutra l

position of the h a m a te-capitate joint.

Incl i n ations of the accessory movements Joint move ments produced by, for example, anteroposterior pres sures can be varied further by inclining them medially or laterally as well as cephalad or caudad. All combin ations of inclinations are possible and often necessary to reproduce symptoms or to normalize the impair ment during treatment (Fig. 6.14). When testing these fine movements with thumb movements, the angles of the pressures should be explored extenSively because there may be as little as one or two degrees of variation in the different inclin ations without getting off centre of the movement. With all test variations of accessory movements, it is essential that the pain elicited with the test movement is comparable with the information of the subjective examination and the comparable physiological move ments found so far in the physical examination.

A

B

�: :· · · · · Painless · G ... .

.

H

.. . .

.

Figure 6. 1 2

Painful a n d p a i n l ess. (a) Capitate stabilized,

ha mate moved ; (b) ha mate stabilized, capitate moved in opposite d i rection. Theoretica l ly it is reasonable to expect that both ways of performing the movement should be painful. C l i n ical ly, however, one movement ca n be pain less and the other one can be p a i nfu l.

Figure 6. 1 3

Posteroa nterior movements on both joint partners

and joint li ne. Each may el icit a different symptom response to the movement a pplied.

Figure 6. 1 4

Accessory movements appl ied to a joint, with

inclin ations i n various d i rections.

Principles of examination

With each test movement the range of movement relative to the symptoms is assessed in each direction. From this information comparisons can be made between each direction of the joint's movements. However, range and pain alone do not give suHicient information to guide the treatment. Adequate detail is required to appreciate the relative position in the range of the onset of pain and the onset of resistance, the type of resistance, the rate of increase in strength of each of these factors (Le. their behaviour during the move ment) and the relationship all of these elements bear to each other. Mostly, but not imperatively, the findings can be recorded with a movement diagram (see Chapter 7, Appendix 1). Some people may consider the extent of this detail unnecessary; however, it should be realized that all skilled manipulators have this appreciation of joint signs consciously or subconsciously and modify their handling of a joint according to small changes in the signs that occur during treatment. The finer the ther apist's appreciation of the details, the better will be the handling of the joint. In fact, these details make up

'the art of passive movement'.

Reassessment after test procedures Once comparable movements or signs have been fOWld,

they may serve as parameters in reassessment proced ures, which may have already been performed during some phases of the physical examination, as well as after treatment procedures. •

During the physical examination, if swelling around a joint is present with a slight rise in temperature it may be regularly monitored if these changes do not increase during the procedures of the physical examination.

•

The same may apply if the patient has a 'present pain' which should not increase due to too intensive test procedures.

•

In some circumstances where the patient appears to have little control over pain/wellbeing, an increase of the 'present pain' may be an appropriate moment to teach the patient a simple self-management strat egy in which direct experiencing of changes may be possible (see Appendix 2).

•

As stated above, after the application of passive movement tests, it is often useful to reassess the main comparable signs of the active tests before continuing with the passive testing of other compon ents (e.g. after the examination of the shoulder quadrant, the active tests which reproduced symp toms are first reassessed before the physiotherapist continues with the examination of, for example, accessory movements of the cervical spine or acromioclavicular joints).

Box 6.8 summarizes examination with passive movements.

Passive movement tests ca n be performed in various ways a n d with differen t pu rposes: •

Movement diagram

•

Accessory movements

•

Physiological movements (e.g. specific 'fun ction al

EVALUATION AND RE FLECTION OF TH E IN ITIAL ASSESSMENT IN THE FIRST SESSION

corners' or some periphera l joints) I n formation from the passive movement findings will guide the physiotherapist in the decision of wh ether passive mobilizations may be used in treatment a n d also which techniques t o select. T h e fin dings will give in formation in relation to position, range of

After completion of all the steps of a first session with subjective examination, planning, physical examin ation and initial treatment it is essential to reflect on the first session, to make all hypotheses explicit and to plan the following session(s).

movement a n d pain with movement (for further details see Chapters

7 and 8).

Passive movemen t procedures may also inclu de: •

neu rodyna mic tests

•

muscle length tests.

It is often useful to perform reassessment procedu res after having performed passive movements before continuing with other passive test procedures of other movement components.

Reflection on the information of the first session

In this stage it is essential to make a comprehensive summary of the main findings of the subjective and physical examinations, including tl1e reactions to initial treatment. The summary should be expressed mainly in terms of movement dysfunctions, as this constitutes the physiotherapy diagnosis: •

Main findings of the subjective examination (including main problem, aspects from body

1 61

J

1 62

MA I TLAND'S PERIPHERAL MANIPULATION

[

•

•

chart, behaviour, history and personal illness experience) Main findings of the physical examination (including observation and all relevant test findings) Initial treatment and the results as reassessed.

Making all hypotheses explicit

As many physiotherapists have been trained princi pally in biomedical diagnosis and not explicitly in physiotherapy diagnosis, they will frequently respond to the question, 'What have you found in the examin ation', with information from pathobiological processes for example, 'I think this patient has a cox-arthrosis'. In fact the novice may learn to answer, 'I have found the following movement dysfunctions and resources . . . (summary of the examination findings) . . . and consider the following hypotheses in the background of the patient's movement disorder . . . '. The phase between the first and second sessions is one of the most important phases in clinical reasoning processes. The physiotherapist certainly knows more about the patient and the problem than before the session; however, many uncertainties exist: •

•

•

Have all the sources and contributing factors been investigated sufficiently? Even if a certain course of treatment seems adequate to follow, will the patient react accordingly? Can the patient sufficiently be actively integrated into the process of movement rehabilitation?

It is therefore essential to regularly make all hypotheses explicit in the initial phase of treatment in order to guide the planning of the procedures in the next session(s): •

•

Have the following hypotheses changed or been confirmed?: - pathobiological mechanisms (pain mechanisms and tissue mechanisms) - precautions and contraindications to physical examination and treatment - sources of the movement dysfunction and symptoms - contributing factors (e.g. cognitive factors, affective factors, posture, muscular balance, behavioural factors) - management (initial impressions regarding treating pain or resistance due to movement impairments). Make all other hypotheses explicit: - level of disability (impairments, activities and participation) - individual illness experience (what does the patient seem to know, think and feel regarding the

problem; influence on and from the environment; behaviour, including avoidance, help-seeking and coping strategies) - management (short- and long-term objectives, taking into account the level of disability, cognitive and affective factors and other contributing factors; selection of treatment interventions to achieve these goals) - prognosis (what may be achievable on a short term basis, what seems to be achievable longer term; what pOSSibly cannot be achieved). This stage of planning is completed with the following question, 'Can a certain clinicaL pattern be recognized?' (e.g. pathobiological patterns, including the consequences for examination and treatment; multicomponent or one-component movement disorder; is a multidimen sional approach to treatment necessary?)

Planning the next session

The following questions need to be answered in order to perform a comprehensive assessment in the follow up session, in which it is decided which additional fac tors should be examined and how the treatment may be continued. (a) Which asterisks of the subjective examination need to be reassessed? (List them in detail.) (b) Does the subjective examination need to be com pleted (e.g. with information of body chart, behaviour, history or special questions)? (c) Which asterisks of the physical examination do you want to reassess? (List them in detail.) (d) In which way do you want to complete the physical examination? (Think of elements of observation, active testing, neurological examination, muscular testing.) (e) Do you want to screen the possible involvement of other components? (List the tests; when you want to perform a reassessment and with which tests.) (f) Which treatment interventions would you consider applying in the second session? How do you want to reassess the results? (You may use a flow chart or a 'decision tree' with points (e) and (f); Watts 1985). However, what will you do if: - the patient is better after the first session (con sider subjective and phYSical asterisks) - the patient's disorder has not changed - the patient's disorder has worsened (consider subjective and physical asterisks).

Princi ples of examination

(g) Consider the third session - which elements/ components would you like to examine or treat in the third session? After completion of the second session, similar plan ning steps can be made in order to plan the subsequent sessions. Reflection and planning of the third (fourth) session •

Have the hypotheses changed? Which hypotheses seem to be confirmed and which rejected? (Compare your notes after the first session.)

•

Is a clinical pattern recognizable/has your initial impression of the clinical pattern changed?

•

Planning of the next session - this includes the same questions as the planning of the second session. It is important now that the physiotherapist deliberately states which treatment objectives are being followed up and with which interventions (passive move ment, including self-management strategies; educa tional strategies) and what it is thought can be achieved.

In general it is recommended that (at the latest) in the third session all possible contributing components have been investigated and a more definitive course of treatment has been initialized. In the fourth session, a retrospective assessment can be performed to analyse collaboratively with the patient if the chosen course of treatment brings the patient forward in the way(s) expected. (All other forms of assessment are described in Chapter 5.)

CONCLUSION

The complexity of the aspects of examination as described in this chapter may be challenging for a novice in the field to learn. However, the procedures of examination and regular explicit planning phases are essential prerequisites to the delivery of skilled and successful physiotherapy treatment. If junior physiotherapists take the time to learn these skills in depth and apply them with a wide variety of patients, they may become a first step on the path to clinical expertise.

References Boissonnault, W. 1995. Examination in Physical Therapy

Practice - Screening for Medical Disease. New York: Churchill Livingstone Borkan, J. M., Koes, B., Reis, S. & Cherkin, D. C. 1998. A report from the second international forum for primary care research on low back pain. Spine, 23, 1992-1996 Bruton, A., Conway, J. H. & Holgate, S. T. 2000. Reliability: what is it, and how is it measured? Physiotherapy, 86, 94-99 Butler, D. 2000. The Sensitive Nervous System. Adelaide: NOI Group Corrigan, B. & Maitland, G. D. 1983. Practical Orthopaedic

Medicine. London: Butterworth-Heinemann Cyriax, J. 1978. Textbook of Orthopaedic Medicine. London: Bailliere Tindall Edwards, B. 1992. Manual of Combined Movements. Edinburgh: Churchill Livingtone Gifford, 1. 1998a. Pain, the tissues and the nervous system: a conceptual model. Physiotherapy, 84, 27-36 Gifford, 1., ed. 1998b. The mature organism model. In Topical

Issues in Pain - Whiplash: Science and Management. Fear Avoidance Beliefs and Behaviour. Adelaide: NOr Group Goodman, C. C. & Snyder, T. E. K. 2000. Differential Diagnosis in Physical Therapy. Philadelphia: W. B. Saunders Grant, R, Jones, M. & Maitland, G. 1988. Clinical decision making in upper quadrant dysfunction. In Physical Therapy of the Cervical and Thoracic Spine, ed. R Grant. New York: Churchill Livingstone

Greenhalgh, T. & Hurwitz, B., eds. 1998. Narrative Based

Medicine. London: BMJ Books Hadler, N. M. 1996. If you have to prove you are ill, you can't get well. Spine, 20, 2397-2400 Heck, c., Hendryson, 1., Carter, R et aI., eds. 1966. Joint

Motion - Method ofMeasuring and Recording. Chicago: American Academy of Orthopaedic Surgeons Hengeveld, E. 2000. Psychosocial Issues in Physiotherapy:

Manual Therapists' Perspectives and Observations. MSc Thesis. London: Department of Health Sciences, University of East London Hengeveld, E. 2002. A behavioural perspective on severity and irritability. IMTA Newsletter, 7, 5-6 Higgs, J. & Jones, M., eds. 2000. Clinical Reasoning in the Health

Professions, 2nd edn. Oxford: Butterworth-Heinemann J. & Titchen, A. 1995. The nature, generation and verification of knowledge. Physiotherapy, 81, 521-530 Jacob, H., Kunz, C. & Sennwald, G. 1992. Zur Biomechanik Higgs,

des Carpus - FunktioneUe Anatomie und Bewegungsanalyse. Orthopiide, 21, 81-87 Jones, M. 1992. Clinical reasoning in manual therapy.

Physical Therapy, 72, 875-883 Jones, M. & Rivett, D., eds. 2004. Clinical Reasoningfor

Manual Therapists. Edinburgh: Butterworth-Heinemann Keating, J. 1. & Matyas, T. A. 1998. Unreliable inferences from reliable measurements. A ustralian Journal of

Physiotherapy, 44, 5-10

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Kleirunarm, A. 1988. The Illness Narratives - S uffering, Healing

and the Human Condition. New York: Basic Books Larkin, J., McDermott, J., Simon, D. & Simon, H. 1980.

Ryan, S. 1996. Developing reasoning skills. In Making the

Most of Fieldwork Education, ed. A. Alsop & S. Ryan. London: Chapman and Hall

Expert and novice performance in solving physics

Sayres, 1. R. 1997. Defining irritability: the measure of easily

problems. Science, 208, 1135-1142

aggravated symptoms. British Journal of Therapy and Rehabilitation, 4, 18--20, 37 Schon, D. A. 1983. The Reflective Practitioner. How Professionals Think in Action. Aldershot: Arena Shacklock, M. 1995. Neurodynamics. Physiotherapy, 81, 9-16

MacDermid, J. c., Chesworth, B. M., Paterson, S. D. et al. 1999. Validity of pain and motion indicators recorded on a movement diagram of shoulder rotation. Australian

Journal of Physiotherapy, 45, 269-277 Main, C. J. 2004. Communicating about Pain to Patients. Schmerzen, alles klar? Zurzach, Switzerland

Main, C. J. & Spanswick, C. C. 2000. Pain Management - An

Interdisciplinanj Approach. Edinburgh: Churchill Livingstone Maitland, G., Hengeveld, E., Banks, K. & English, K., eds. 2001. Maitland's Vertebral Manipulation, 6th edn. Oxford: Max, M. B. 2000. Is mechanism-based pain treatment attainable? Clinical trial issues. Journal of Pain, 1, 2-9

J., Cockersole, B.

C. & Pynsent, P. B.

1989. Reproducibility of physical signs in low-back pain.

Spine, 14, 908-91 8 Moon, M. 1990. Rehabilitation and chronic musculoskeletal pain: a bio-psychosocial approach. New Zealand Journal of

Physiotherapy, 4, 23-27 Pilowsky, I. 1997. Abnormal Illness Behaviour. Chichester: John Wiley Refshauge, K. & Gass, E. 1995. Musculoskeletal Physiotherapy. Oxford: Butterworth Heinemann

meaning of practice. British Journal of Therapy and Rehabilitation, 5, 88--94 Vlaeyen, J. & Linton, S. 2000. Fear avoidance and its consequences in chronic pain states: a state of the art.

Pain, 8 5, 31 7-332

Butterworth-Heinemarm

McCombe, P., Fairbank,

Thomson, D. 1998. Counselling and clinical reasoning: the

Watts, N. 1985. Decision analysis: a tool for improving physical therapy practice and education. In Clinical

Decision Making in Physical Therapy, ed. S. Wolf, pp. 7-23. Philadelphia: F. A. Davis WHO. 2001. ICF - International Classification of Functioning,

Disabilihj and Health. Geneva: World Health Organization Williams, P. 1. & Warwick, R. 1980. Gray's Anatomy, 36th edn. Edinburgh: Churchill Livingstone Zusmann, M. 1998. Structure-oriented beliefs and disability due to back pain. Australian Journal of Physiotherapy, 44, 13-20

165

Chapter 7

Principles and method of mobilization I manipulation techniques

THIS CHAPTER INCLUDES: •

Key words for this chapter

•

Glossary of terms for this chapter

•

An outline of the method of mobilization/ manipulation techniques

•

The technique as the 'brainchild of ingenuity'

•

•

Application of forces (grade,

Features of the method of

speed, rhythm, duration)

mobilization/ manipulation

patient The starting position of the therapist

directions, starting positions, localization of forces, application

GLOSSARY OF TERMS

CD, P2' R2,

A - any starting position of a treatment or examination technique. a passive movement direction

(physiological accessory, combined). AC

-

the quantity, quality, nature

and intensity of the factors being assessed (pain, resistance, spasm). Activity limitations

-

the difficulty

an individual may have in the performance of an activity. B

-

the end of an average normal

range (the line is thickened to account for the natural variability in establishing

the patient and therapist.

The starting position of the

KEY WORDS

-

Adaptation of techniques to suit

•

techniques including:

Method, technique ingenuity,

AB

Localization of forces

Directions of mobilization/ manipulation - possibilities

B).

of forces, grades, speed, rhythm.

52 - the maximum quality

performing a mobilization/

or quantity of pain, resistance or

manipulation technique. Within

spasm which acts to limit the

the Maitland Concept the grades

range of movement.

are refined in terms of their

Core stability - primarily the ability

position in range, relationship to

of an individual, through neuro muscular control, to maintain an ideal position and alignment of the pelvis and spine in relation to the limbs during static postures and

-

-

the average normal end of a

hypermobile (not unstable) range. Inclination/angul ation - the subtle alteration in the direction

functional activities. End-of-range pain

resistance and their amplitude. H

pain produced

during examination or treatment

of a treatment technique in order to ach ieve the reproduction

which is only felt at the end of the

of the patient's symptoms more

available range.

readily. For example, if an

Grades of mobilization - a classification system

(I, II , III, IV, V)

anteroposterior mobilization on the acromioclavicular joint is

giving the clinician the ability to

inclined or angled medial it

think and act in finer detail when

may be just what is needed to

166

MAITLAND'S PERIPHERAL MANIPULATION

[ reproduce the exact pain of which

person in terms of cultural, family

the patient is complaining.

and genetic considerations;

Irritability - a clinical classification

nature of the disorder in terms of its pathological stage or natural

stretching a stiff joint by holding

history;

the stretch stationary until limiting

(4) the nature of the

and the length of time the pain

patient's symptoms in terms of

pain subsides and before a further

takes to settle. If a little activity

their functional limitations and

stretch can be applied.

causes a lot of pain which takes

their physical, psychological and

Through-range pain - pain

a proportionately long time to

social effects.

produced during examination or

settle (in relation to the amount

P', R', 5' ( ' = prime) - the quality,

treatment which can be felt by

of activity causing it), this would

quantity, nature or intensity

the patient through the range

be classed as highly irritable.

of pain, resistance and spasm

of movement, not just at the

Such an assessment would then

at the limit of range where

indicate care in examination

another factor is actually limiting

and treatment in order not to

the range. The extent of such

joint created when the joint is

reinforce the irritability.

factors beyond the limit line is

stretched at its available limit for a

unknown.

period of time. Treatment soreness

Nature - within the context of the Maitland Concept, 'nature' refers to:

(1) the nature of the person

and how they respond to or accept pain within the health-care environment;

(2)

the nature of the

P" R" S, - the therapist's assessment

beginning or end. Treatment soreness - soreness in a

can easily be 'eased off using a

of the onset of pain, resistance

grade 11+ or III technique in the

and spasm when testing a passive

same direction as the stretching

movement.

movement which created the

Staccato rhythm - a rhythm of

soreness. The 'easing off'

mobilization which is irregular

technique should be continued

and broken and often used when

until the soreness subsides.

AN OUTLINE OF THE METHOD OF MOBILIZATION / MANIPULATION TECHNIQUES

Appropriate selection of mobilization/manipulation techniques for treatment can only take place after a thorough examination and assessment of the patient's movement-related disorder. When it has been decided that passive movement treatment techniques are indi cated, the manipulative physiotherapist needs to decide on:

•

•

relieve pain, or stretch structures that are stiff)

the starting position of the pqtient (a variety of starting positions to achieve the desired effect of the tech nique are possible)

the method of localization of forces involved in the tech nique (this involves the positioning of the hands and arms so that the point of contact of the therapist with the patient is directed appropriately to the movement signs)

•

the method of application of forces involved in the technique (this involves the use of the therapist's body, arms and hands to deliver the technique in the desired style, i.e. including the position in range, the amplitude, the speed, the rhythm and the duration of the technique; such elements can be changed as necessary during the performance of the technique)

•

the expected response to treatment by passive mobi

the direction(s) of the passive movement technique

the desired effect of the technique (often based on the body's capacity to inform; the desired effect may be to

the starting position of the physiotherapist (adopted to achieve the best possible localization and applica tion of the technique)

(based on the movement signs, examples being elbow extension/adduction, tibiofemoral postero anterior movement, glenohumeral longitudinal cau dad movement in 90° of shoulder abduction)

•

painful stiff range of movement. Stationary holding - the process of

to an amount of pain produced

limit of the range of movement.

•

trying to increase, by stretching, a

relating an amount of activity

L - the pathological or disordered

•

(3) the

lization/ manipulation (should the technique result in an increase in pain-free range?; should the patient expect a degree of 'treatment soreness' before being able to stretch further?)

Principles and method of mobilization/manipulation techniques

167

] •

how the technique might be progressed to enhance recov ery from the movement-related disorder (alteration to any of the features of the method can be made to enhance the desired effects of treatment).

THE TECHNIQUE AS THE 'BRAINCHILD OF INGENUITY'

There are hundreds upon hundreds of techniques. Preferences vary from therapist to therapist, but the important thing to remember is that the position in range, amplitude, speed, rhythm, duration, pain response during performance, pathology and diag nosis all have an influence on how the technique is performed. Essentially manipulative phYSiotherapists must endeavour to be guided by what is happening during the performance of the chosen technique and also what the patient feels as a response. The technique chosen should be as individual as the patient. The main requirement is that it achieves its desired effect (Chapter 2 ). Consequently, the physio therapist should endeavour to consider all possible permutations, i.e. all the available physiological and accessory movements in every joint and all possible combinations including the use of compression and distraction, all the influences on ranges of movement of pathoneurodynamics and muscle length (and other soft tissues), all the possible starting positions of the patient and therapist, all the variations, inclin ations and points of contact involved with the localiza tion of forces, all the means of applying the forces and all the variations and adjustments of position in range, amplitude, speed, rhythm and duration of the technique.

DIRECTIONS OF MOBILIZATION - POSSIBILITIES

Analysis of movement directions and techniques which aim to return movement-impaired directions to their ideal state are fundamental requirements of the Maitland Concept. In examination, range, symptom response and quality of movement are inextricably linked together, whether this be during active functional test ing or during the search for movement related 'joint signs' by passive movement testing (Maitland 1970). Interestingly, over the last decade, there has been a paradigm shift away from the diagnostic management of most neuromusculoskeletal disorders towards the management of movement impairment (pain, stiff ness, weakness, etc.) and the associated activity limita tions or disabilities. There is more concern about

getting people moving again after an injury or painful neuromusculoskeletal episode than there is about the reductionist desire to identify the exact pathology and mechanism of symptom production (WHO 2001). The analogy with the 'permeable brick wall' mode of thinking is striking. Sahrmann (2001) in her book

Diagnosis and Treatment of Movement Impairment Syn dromes has worked tirelessly to validate her research findings and seek recognition for her primary classi fications of movement impairment into movement dir ections. For example, in the lumbar spine, flexion, extension, flexion/rotation, and extension/ rotation are the classifications used. This approach is also applica ble to upper and lower limb disorders. Other additional components which may be added to the movement direction being treated are distraction and compression. There is a time in treatment when joint surfaces should be kept apart (to avoid contact) while still being able to treat by passive movement yet avoiding the aggravating element. Equally, and more commonly, there is a time in treatment for mov ing a joint while compressing the adjacent joint sur faces together. When the patient has a lot of pain, or if the disorder is very irritable, the joint surfaces may need to be kept apart. This distraction is only a very small movement (less than 1 mm) and does not resemble traction forces. Compression is another matter. The circumstances under which this is used apply to chronic disorders chronic in terms of symptoms, not necessarily 'long term'. Two common examples are hip pain and shoul der pain. These are examples of pain being provoked by lying on the affected j oint. The longer the person is able to lie on the offending joint before pain begins, the stronger the compression needs to be during treatment and the longer the treatment technique needs to be applied. Lowther (1983, 1985) refers to these move ments as 'stirring movements' and 'cyclical loading'. In the context of the Maitland Concept, the movement direction(s) chosen for passive mobilization treatment techniques are determined from the movement-related 'joint signs' and the starting position adopted. The movement direction used in treatment (or examination) is denoted by a symbol or abbreviation for recording purposes (Table 7.1). The best format for recording the starting position of the patient and direction of the technique is the IN DID method. This could relate to a single direction treatment technique such as IN supine lying DID knee E (extension). Or it may relate to a more complex treatment technique such as IN LSS (long sitting slump), talocrural PF (plantarflexion), Inv. (inversion) DID inferior tibiofibular AP (anteroposter ior) inclined Lat. (lateral).

168

MAITLAND'S PERIPHERAL MANIPULATION

Table 7.1 F E Ab Ad

� c:

HF HE

BB Inv. Ev. OF PF Sup. Pron. EI De Protr Retr Med. Lat. OP PPIVM PAIVM ULNT LLNT

Symbols used in examination tables Flexion Extension Abduction Adduction Medial rotation Lateral rotation HorizontaI flexion Horizonta I extension Hand behind back Inversion Eversion Dorsiflexion Plantarflexion Supination Pronation Elevation Depression Protraction Retraction Medial Lateral Overpressure Passive physiological intervertebral movements Passive accessory intervertebral movements Upper limb neural tests Lower limb neural tests

Q Lock FlAb F/Ad E/Ab E/Ad Distr. Compr.

Quadrant Locking position Flexion abduction Flexion adduction Extension abduction Extension adduction Distraction Compression

;

Posteroanterior movement Anteroposterior movement Longitudinal movement (al ceph {Cephalad} (b) caud {Caudad} Longitudinal movement is the direction of movement of a joint in line with the longitudinal axis of the body in its anatomical position. When that same movement is performed in any other position than the anatomical position, that movement of the joint is still called longitudinal movement even though it is not now in line with the longitudinal axis of the body.

t ......

Transverse movement in the direction indicated Gliding adjacent joint surfaces

-++

t

From Maitland (1992).

THE METHOD OF MOBILIZATION! MANIPULATION TECHNIQUES

•

The starting position of the patient Generally speaking, the patient should be completely relaxed if treatment is to be effective without placing unwarranted strain on the structures supporting the joint. Even treatment of the thumb should be per formed with the patient lying supine. The patient should be positioned (or position him self) with the intention of achieving the desired effects of the technique. This may be: •

•

•

supine lying so that the joint to be treated is in its neutral pain-free position side lying because this is the position in which the patient's very painful joint is most comfortable prone lying because this is the best way of stretching the stiff joint

sitting or standing because this affords the only means of reproducing the functional or weight-bearing positions in which the technique can be effective.

When joints are very painful the physiotherapist should make every effort to find the most comfortable position in which to carry out treatment. This may mean spend ing time supporting the limb, or positioning the patient with towels and pillows until this optimum position is achieved. When the joint needs to be stretched to the limit to regain maximum range the patient should be pos itioned so that sufficient forces can be applied to achieve this.

The starting position of the physiotherapist •

The operator's position must afford complete con trol of the movement.

Principles and method of mobilization! manipulation techniques

•

The operator should be positioned so that forces can be applied in the exact direction required.

•

The operator's base of support and trunk core sta bility should be optimised so that the movement of the operator's body, arms and hands are the medium through which the passive movements are generated.

•

The operator's position must be comfortable, easy to maintain and the most economical in which to carry out the treatment with minimal effort.

•

The operator's position should make full use of the mechanical' advantage of levers.

•

The patient must feel confident that the joint will not be hurt by being moved further than expected, and therefore the operator must be positioned to prevent the movement going beyond an established point. The operator may need to use an arm, a leg or the trunk to block the movement at an established point in cases where large range physiological movements of major joints are being used.

Localization of forces •

The patient must have complete confidence in the operator's grasp.

•

The grip should not be tighter than that required to perform the movement and the position should make full use of the mechanical advantage of levers.

•

Wherever pOSSible, the operator should embrace the parts to be moved or stabilized. In accompani ment with this the operator should hold around the joint so as to feel the joint movement as the tech nique is being performed.

•

The tips of the thumb pads are usually the best medium through which the movement can be per ceived (remind yourself of the figurine representa tive of the cortical sensory homunculus), along with soft contact of the palms and fingers surrounding the part to be moved.

•

Careful positioning of the thumb pads around the joint will ensure that the point of contact influences the movement signs in the best possible way.

•

On occasions the heel of the hand may be used as a point of contact where more force is required. The rest of the hand and fingers still need to embrace the joint to add to the feel of the movement.

•

During treatment, minor changes in the point of contact or grip may be necessary. This will help to give the patient confidence in the physiotherapist's control of the painful area.

•

Remember during treatment the desired effect is enhanced by including the patient in the decision making (the patient at the centre). Therefore the com fort of the grip and the localization of forces may well be dictated by the patient's feelings and directions.

Application of forces The method of the passive mobilization treatment technique is completed by a detailed consideration of the dynamic elements of the passive movement. The arms and body of the operator should be the prime movers which deliver the passive movement to the part of the patient's body as required. The hands, once in place, should be the medium for sensing and feeling the movement rather than directly producing it. Of course adjustment in thumb, finger and hand contact positions can be made during the treatment but only in response to the patient's directions or the feel of the movement.

Grades of movement •

Any part of a range of movement can be used in treatment and widely varying amplitudes and speeds may also be chosen.

•

Grades of passive movement can be used to denote the position in the available range and the amplitude at which the technique of passive movement is being performed (the seeds for grades of movement were proposed by Miss Jeanne-Marie Ganne in 1965).

•

Classifying passive movements into grades forms an essential method of abbreviation and recording: - they make the clinician think in finer detail about the technique being used they give the clinician the opportunity to deal with all manner of movement-related signs with which the patient presents they form a good, if not always reliable, method of calibrating passive movements for teaching and intertherapist communication purposes they test research questions about the efficacy of passive movement (Clinch 1987).

•

Grades I-V are used in this concept to describe the treatment movements but, like all similar grad ings (e.g. rating 1-5 for muscle power) the values overlap, i.e. there is also a place for plus and minus values.

•

The grades of movement can be depicted in relation to a straight line representing a full average range

1 69

Principles and method of mobilization/manipulation techniques

Grades of mobilization/ manipulation •

•

Grade ill a large amplitude movement performed into resistance or up to the limit of the available range. Grade IV a small amplitude movement performed into resistance or up to the limit of the available range.

•

Grade I a small amplitude movement performed at the beginning of the available range. Grade I I a large amplitude movement performed within a resistance-free part of the available range.

-

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Figure 7.4 Grades of mobilization: a stiff hypermobile range (e.g. a shoulder flexion range which is naturally 200" but which has become stiff and limited at 180").

171

[

1 72

MAITLAND'S PER IPH ERAL MAN IPULATION

•

Grade V - a small amplitude high velocity general movement performed usually, but not always, at the end of the available range.

•

Grade loc V - a small amplitude high velocity thrust localized to a single joint movement usually, but not always, at the end of the available range.

•

Grade I is usually performed as a slow smooth oscillatory movement. The key feature of a grade I is that movement takes place within the joint rather than just within the soft tissues underneath the operator's hands. Because grade I mobilization techniques are not used in clinical practice as much as the other grades it becomes very difficult for the clinician to achieve effective consistency in the delivery of such a perceptibly small movement. However, grade I techniques, if applied with care, can have a measurable influence on movement related joint pain.

•

•

Grade II, if performed near the beginning of the available range, will be classified as a grade II-, and if taken deep into the range, yet still not reaching resistance, will be classified as a grade II+. Grade III can also be expressed with plus and minus values. If the movement is carried firmly towards the limit of the available range it is expressed as a grade III + but if it nudges gently into the resistance yet short of the limit of the avail able range, it is expressed as a grade III-.

•

Grade IV can be expressed as IV+ or IV- in the same way as grade III.

•

Grade V movements are really the same as grade IV or IV + with the exception that the grade V manipu lation is performed at such a speed that it renders the patient unable to prevent it.

c

I

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B

Figure 7.5 B: the end of the normal average range of passive movement with B represented as a thickened line. R2 (IV+++)

c

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The plus and minus values for grades III and IV are a representation of how far into resistance the physiotherapist is prepared to move. They are also somewhat subjective and dependent on the confidence and experience of the clinician in determining the end of the normal average range of passive movement (point B) (Fig. 7.5) or the limit (L) of the disordered range of movement (Fig. 7.6). Therefore B is thickened to take account of the variability in the individual clin ician's perception of the end of range. In the same sense, it could be argued that L and Rl (the point where the clinician first perceives an obvious detectable resistance to movement) should also be thickened to take account of this intertherapist vari ability (Fig. 7.7).

.�

> Q) CfJ

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Figure 7.7 A suggestion that the lines L and Rl to R2 could be thickened like B to represent intertherapist variability.

Therefore grade IV -, III - is a movement which moves into the early part of resistance, grade IV, III is a movement which carries well into resistance and grade IV +, III + moves even further into resistance. Grade IV +++, III +++ is a movement which moves into very strong resistance probably to the end of the range (Fig. 7.8).

Principles and method of mobilization/manipulation techniques

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Further refinement of grades of mobilization + and - soft end feel.

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+ and - values adjusted accordingly to a stiff

range.

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If the normal range of joint movement is limited by stiffness for example, grades I, II, ill and IV are restricted to the available range and the + and - values are adjusted accordingly (Fig. 7.9). Similarly pain may arise from a hypermobile joint that is slightly stiffened. Such a situation alters the position of grade ill and IV movements as shown in Figure 7.10. A common error in interpretation of grades is that grade IV is performed more strongly than a grade ill and therefore further in the range - but this is not the case. Grade IV movements should reach the same point in the range as grade ill movements, the only difference between them is their amplitude (Fig. 7.11). It is also worth remembering that when performing grades of oscillatory passive movement there are two directions to consider. The operator needs to control not only the movement into the range but also the return move ment, thus the use of double-headed arrows to depict the amplitude of the grade. As a corollary to this there is often confusion about the relationship of grades ill

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173

174

MAITLAND'S PERIPHERAL MANIPULATION

and IV to resistance in respect of the return oscillatory movement. It should be made clear that the return movement may or may not travel out of resistance depending on the required amplitude and the available range (Fig. 7.12). Within this concept grades of mobilization/manipulation are classified in terms of their amplitude and their relationship to resistance (which includes stiffness and muscle spasm) rather than pain. Several studies have tried to calibrate grades to force or amount of movement using machines such as force platforms or pressure-sensitive motion detectors (Evans et al 1988, Simmonds et al 1995). Others have tried to determine the intra- and intertherapist reliability of the detection of the onset of resistance to movement (R1) before and after training (Latimer et al1996). In most cases there are no reliable data, although the resistance curve produced by artificially lengthening ligaments corresponds very closely to the resistance curve that clinicians detect when passively moving a joint (Maitland et al 2001). However, it is still the authors' opinion that, because of its perceptible onset and it being the factor which naturaily limits joint movement, resistance to passive movement is still the most consistent and least subjective means of defining grades of passive movement. Grades of movement will remain somewhat subjective and debatable phenomena.

Rhythms of mobilization/ manipulation

Joints can be moved in many different ways from a stationary holding through slow smooth movements, to a staccato type rhythm and manipulation performed at speed. For example, a joint that is very painful will be best treated with grades performed slowly and evenly. A stiff small joint, however, would be better treated with sharp, staccato movements. When an oscillatory movement is used in treatment, the treatment direction of that movement is most commonly performed at a speed that is faster than the retreating movement. For example, if a general wrist extension is the movement to be made painless, and it is extended from the fully flexed position, the following application should be considered: •

It would be quite pointless to perform a flexionextension oscillation at the limit of flexion.

•

It would be equally pointless if the speed of the flexion part of the oscillation equalled that of the extension

•

The requirement of the technique was determined by the examination; extension from full flexion reproduced the patient's symptoms most clearly,

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Figure 7.1 2 Grade III: (a) oscillating in and out of resistance; (b) oscillating within resistance. Grade IV: (c) oscillating in and out of resistance; (d) oscillating within resistance.

Principles and method of mobilization/manipulation techniques

1 75

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Figure 7.13 Slow steps of stretching. P, pain; i, increase of pain; t, decrease of pain (e.g. shoulder flexion).

and the technique was planned to provoke a degree of pain. The treatment movement is performed thus: the patient's wrist is slowly taken to the limit of its range of flexion, from which it is then immediately extended through the range, and at a quicker speed, so that the symptoms are reproduced. The slower flexion is then repeated, and so on (Chapter 13). This can be thought of as a release technique and it has a place in mobilization that most practitioners do not appreciate. Some patients have difficulty in relaxing com pletely, even when pain is minimal. They periodically tense their muscles without realizing they do so. If large amplitude treatment movements are hindered by this tensing, treatment movements of broken rhythm and changing amplitude should be employed in an attempt to trick the muscles. Sometimes these move ments need to be performed almost as a flick. When attempting to increase the range of movement by stretching a stiff joint which is painful at the limit, the movement should be applied slowly within the avail able range up to the point when pain becomes a limiting factor (Fig. 7.13). This new position should be held stationary (stationary holding) until the pain subsides, after which a further slow stretch is added (perhaps only one or two degrees) until the pain increases again. When the tolerable limit is reached, the movement is again held until the pain decreases. The procedure is continued in these small steps until the pain does not decrease (Fig. 7.14). Small slow oscillatory movements are then performed just short of this limit. When performing slow smooth oscillatory move ments, the change in direction of the movement should be imperceptible (Fig. 7.15). This particular rhythm is best suited to disorders which cause a lot of pain (usu ally grades I and IT). When performing quicker, sharper, staccato movements the speed into the range should

'i4

A Figure

% Range

:y"

B

7.14 Slow steps of 'holding:

Forward movement Backward movement Timing of movement Figure

7.15 Slow smooth oscillatory movement.

Forward movement Backward movement Timing of movement Figure

7.16

Quicker, sharper, staccato movement.

be quicker than the return movement and varied (Fig. 7.16). Staccato rhythm is best suited to stiff joints and grades III and N. A good way of learning the art of speed and rhythm of mobilization is to practise techniques to different styles, tempos and beats of music and apply the tech nique to the rhythm of music at hand. For instance, con trast the speed and rhythm of technique needed to go along with Vivaldi's Four Seasons or Barbara Streisand singing Memories. Duration of technique

There are no set rules for how long or how many times a technique should be performed. This should be dic tated by the effects that the technique is having on the patient's symptoms and movement signs both during and after its performance. Generally speaking, tech niques which are designed to reduce movement-related pain will be performed for shorter duration (up to 2 minutes, once or twice). Techniques for joint stiffness

176

MAITLAND'S PERIPHERAL MANIPULATION

[ may need to be performed several times for several minutes, with additional time being spent using gentler techniques to help treatment soreness to subside.

value as maintenance treatment for joints with osteoarthritic changes.

Chronic aching •

Under this heading the patients do not have severe pain but have an ache which they feel is greater than they class as acceptable. The range of move ment may not be markedly restricted, but if move ment is stretched the pain will increase. This is an end-oj-range pain without a through-range pain component.

•

In such circumstances end-of-range treatment tech niques are required, i.e. grade IV accessory and physiological stretching movements at the limit of the range.

•

If, using these techniques, there is a satisfactory gain in range but the end-of-range pain has increased or occupies a larger part of the range, an easing-off technique is needed to reduce this treat ment soreness. This technique is a larger amplitude movement in the same direction as the grade IV but performed as a grade ill-, slowly and smoothly, gradually progressing to a painless grade ill. If this can be achieved, there will be no soreness resulting from the treatment.

•

If the patient's circumstances are such that restric tion of range is far more important than pain, the techniques of greatest value are the same small amplitude, end-of-range techniques but the rhythm would be staccato.

Clinical application

There are many factors that influence the choice of technique such as: •

• •

• •

• • •

accessory and physiological movements or combinations of these minimal distraction or compression sagittal, coronal, horizontal planes or longitudinal direction (in any of the planes just mentioned) combining techniques in varying sequences pathology and other factors such as recent injury or chronicity the therapist's experience and skill the nature and frame of reference of the patient the desired effect.

There are also influences on the manner in which the technique is performed such as pain and irritability, chronic aching and muscle spasm.

Pain and irritability •

If the patient has a very irritable disorder and the degree of pain is both constant and severe, the tech nique must obviously be gentle. The aim is to afford the patient relief but at the same time to avoid pain during treatment and avoid any latent reaction or exacerbation.

•

The grade to be used would need to be painless, with as large an amplitude as painless range will permit (grades I and II).

•

•

•

The rhythm would be very smooth oscillations per formed slowly. The speed would be as fast as the disorder will permit while still maintaining pain less oscillations (one or two per second) In the first stages of treatment of very painful joints, the prudent choice is to use accessory movements rather than physiological movements, as it is easier to produce a larger amplitude painlessly and more smoothly. As the symptoms decrease, so the ampli tude and the combination of different accessory movements can be used. If a disorder presents with through-range pain it should be treated with a through-range/large amplitude technique. Intra-articular disorders often present with through-range pain for which large amplitude techniques are often of most value. Likewise large amplitude techniques may be of

Table 7.2 summarizes the grades of movement in various conditions.

Muscle spasm When strong spasm is present to pro tect the area from painful movements or positions, there is only one technique to use: •

•

Move the structure to the point in range when the spasm comes into play (at this point the stretch is sustained without movement). When the pain level lowers, as it will, the stretch can be increased and held again (the range will

Table 7.2

Grades of movement in various conditions

Condition

Grades used

Through-range pain Intra-articular pathology End-of-range pain Treatment soreness

11- to 111+ 11- to III or 111IV to IV+ or IV++ II or 111- to III or 111+ painless

Principles and method of mobilization/manipulation techniques

177

]

•

gradually increase until a certain stage is reached when the spasm will not let go). At this point the stretch should be sustained but interspersed with tiny slow, smooth oscillatory movements. It is at this stage, and only at this stage,

when the technique is truly influencing the disorder. Proprioceptive neuromuscular facilitation (PNF) tech niques such as 'slow reversals', 'reciprocal relaxation' and 'contract-relax' can be used to achieve the same initial results as the stepped passive stretch. However, passive oscillatory stretching is the only technique which can achieve that small extra range that the dis order will allow. When a technique is initially used in treatment, it is commonly employed in an exploratory manner to determine the response of the joint. Hence the treat ment movement is continually modified to meet the demands of the condition. The movements used may vary in depth, gradually moving in deeper and reced ing according to what is felt at different depths. This exploratory technique is an extension of passive move ment examination.

The art and commitment of the technique

Maitland (1991) has very strong views about what he considers to be ' . . . probably the most important part of applying any manual technique'. He considers this to be 'a very personal thing and sometimes it cannot be achieved'. Maitland goes on to explain: 'Question: Have you been to an orchestral concert for piano or flute (and I suppose this applies to other solo artists playing with an orchestra)? If you have, you have seen the extent to which the soloist involves himself with the meaning of the work - with the com poser's emotions when he wrote the music? You may feel that what I am trying to say is non sense and has no place in this book. However, it is absolutely essential to involve ourselves with our patients and their problems in the same sort of man ner. I suppose what I am trying to do is reply to a state ment often made, you can't learn manipulation from books, that is quite false. But you can't learn from books unless you commit your whole self, your whole being, to try to feel what is going on with the technique while you are performing it. Please bear with me as I quote from the conductor Andre Previn. A musical concept of learning from writing and doing

As a conductor your responsibility first and last is to those notes (techniques) as written, wiping from your memory all preconceived notions. What I mean

is that you must forget the day to day circumstances of a composer 's life [author 's life] and how such circumstances might or might not have found expression in the music [text]. A lot of the time it's difficult, but that is what you must at least try to do. More importantly, how accurate are those written notes, those dots and dashes ? Music notation [manipulative texts] can at times be hopelessly vague even when dealing with absolutely fundamental ingredients of music [treatment]. Let's look at those four notes [grades and rhythms] as thelJ appear in the score [text]. The fourth note is marked with a pause over it. Well, how long should that pause be? Is it like this ? . . or is it like this ? .. And it's marked with two F's (jf) - Fortissimo - very loud. Well wait a minute. How loud is loud? How soft is soft? And when a composer like 5travinskrJ [Therapist A] specifies loud, is it the same degree of loudness - or even more important the same qualihJ of attack - as when you play Mozart [Therapist B]? Of course not. 50 how do you as a composer or instrumentalist [physiotherapist] decide that your interpretation of the notes is the only possible correct one? After all no two conductors are alike; no two performers are identical and much more to the point -every time you play a piece you discover new details you haven't noticed before. The truth is that there's never any single or definitive interpretation. Indeed I would go so far as to say that the greater the composer, the more your understanding of it is likely to develop over the years. Think about it for a moment. You can write a letter putting words to paper and while you're writing those letters you understand those words mentally without having to hear them out loud. It's the same with composers who have to learn to put musical notes on a manuscript paper as easily as words of a letter, but everybody works differently and while Beethoven's habit was to jot down his ideas in sketchbooks, Mozart, apparently, resolved every detail in his head before he committed the entire works onto paper, he hardly ever changed so much as a note. What I am trying to say is that when you are trying to improve the quality of a sick joint's movements by a passive movement technique it is necessary to put your self or your mind inside the person or, more accurately, inside the joint area, and to involve yourself emotion ally with what the joint is trying to tell you about how it wants to be moved. I believe that this commitment is the difference between the good physiotherapist and the bad phYSiotherapist.'

17 8

MAI TLAND'S PERIPHERAL MAN IPULATION

[ ADAPTATION OF T ECHNIQU ES TO SUIT THE PATI ENT AND THE TH ERAPIST

Most techniques are performed in positions similar to those used for examination, others have different pos itions for the operator. During examination many move ments are tested a few times each; during treatment one movement is performed at a time in one position and repeated many times. The position in the range may alter, however. Gentler grades of movement sometimes need different starting positions from the stronger grades. As the skill of techniques is learned and the feel of joint movement becomes instinctive, each physiother apist should modify their starting position and that of the patient to suit their own needs and circumstances.

(The size and shape of the patient and the size and shape of the physiotherapist will require these modifications.) Each physiotherapist should modify their point of contact with the patient and method of each technique according to the size and shape of their hands and the size and shape of the part to be embraced. Not all ther apists can use their thumbs, hands and arms and bodies in the same way. Modifications of the technique should be encouraged to account for this and allow the physio therapist to deliver the passive movement techniques in a way that is effective but also suits their circum stances. In this way the technique becomes the brainchild

of ingenuity. Many adaptations of techniques for the areas of the body concerned are highlighted in the Chapters 11-17.

References Clinch, R. 1987. The Effects of Grade II Mobilisation on Range of

Movement in Acutely Sprained Ankles. MTAA Proceedings, Melbourne Evans, D., Trott, P., Pugatschen, A. & Baghurst, P. 1988.

Manual Palpation of Resistance, Parts 1 and 2. IFOMT Proceedings, Cambridge, UK

Latimer, J., Lee, M . & Adams, R. 1996 The effects of training with feedback on physiotherapy students' ability to judge lumbar stiffness. Manual Therapy, 1, 266-270 Lowther, D. A. 1983. The effects of stress on the behaviour of connective tissue. Australian Journal of Physiotherapy, 29, 181 Lowther, D. A. 1985. The effects of compression and tension on the behaviour of connective tissue. In Aspects of

Manipulative Therapy, 2nd edn, ed. E. F. Glasgow et ai, pp 16-22. Melbourne: Churchill Livingstone. Maitland, G. D. 1970. Peripheral Manipulation, 2nd edn. London: Butterworths

Maitland, G. D. 1991. Peripheral Manipulation, 3rd edn. London: Butterworth-Heinemann Maitland, G. D. 1992. Neuro/musculoskeletal Examination

and Recording Guide, 5th edn. Adelaide: Lauderdale Press Maitland, G. D., Hengeveld, E., Banks, K. & English, K., eds. 200 1 . Maitland's Vertebral Manipulation, 6th edn. Oxford: Butterworth-Heinemann Sahrmann, S. A. 200 1 . Diagnosis and Treatment of Movement

Impairment Syndromes. St Louis: Mosby Simmonds, M.

J., Kumar, S. & Lechelt, E.

1995. Use of a

spinal model to quantify the forces and motion that occur during therapists' tests of spinal motion. Physical Therapy, 75, 212-222 WHO. 2001. ICF - International Classification of Functioning,

Disability and Health. Geneva: World Health Organization

1 79

Chapter

8

Principles of selection and progression of mobilization I manipulation techniques

THIS CHAPTER INCLUDES: • •

•

•

•

Key words for th is cha pter Glossary of terms for this chapter An introduction to the selection and progression of techniques The basis for selection and progression Options for selection and progression

KEY WORDS Selection, progression, movement-related disorders,

GLOSSARY OF TERMS Adaptive deformity - fau lts in posture which develop over time in response to pain, loss of range of movement, muscle imbalance or other impairment (e.g. overpronating feet as a result of ankle dorsiflexion stiffness following i njury). Algorithm - a logica l process or wel l-reasoned steps which lead to the best possible solution to a problem. Alignment faults - faults in the line of the centre of gravity from the base of support through the body. Ideally the line of the centre of gravity

•

Factors infl uencing the selection and progression process includ i n g : - classification o f joi nt signs cli nical groups 1,2, 3ab, 4 and associated signs the sou rce of the symptoms i ntra-articu lar disorders (including the im portance of adding compression i n exami nation a n d treatment) and periarticu l a r d isorders

- onset and natura l history of the d isorder - pathobiological mecha n isms (diagnosis) - dysfunction and movement i m pairments - preca utions and contra i ndications - contributing factors and barriers to recovery - prognosis.

clinical g roupings, source, history, diagnosis, dysfu nction, precautions,

contraindications, barriers, p rognosis.

should pass in such a way that the body's segments are balanced. Asterisks - the d isci pline of highl ighting the main findings in exami nation and d u ring the cou rse of an episode of care (***) Such fi ndings a re usually the su bjective and physical i m pa irments and activity l i mitations. The asterisks can be assessed and reassessed in order to measure the effectiveness of treatment. Clinical g roups - the classification of patients' symptoms and signs i nto recognizable g roups. Such g roups should respond to a ppropriate

mobilization I manipu lation techniques i n a particular way. Complex regional pain syndromes - a com plex pain dysfunction syndrome of u nknown cause that typica lly affects a single extremity. Often associated with reflex sympathetic dystrophy and the causalgia resulting from nerve injury. Components - the individu a l or i nterrelated movement system i m pa i rments which are i nvolved i n a d isorder. For exa mple, if a patient has a stiff, painfu l shoulder, treatment may need to address components in the shoulder, neck,

.

1 80

MA ITLAND'S PERIP HERAL MANIPULATION

L

thoracic spine and neurodyna mics in order for recovery to be maxim ized. Contrib u ting factors - factors such as age, genetic anomal ies, medical conditions, psychosocial i nfl uences, previous i nj u ry and ergonomics which may affect the course of the disorder's natural history. Such factors may a Iso act as ba rriers to recovery or i nfluence the expected response to treatment using mobil ization / m a n i pu lation. Disorder soreness - an i ncrease i n the patient's symptoms after treatment with mobilization/ m a n i pu lation. Such soreness may last a few moments, hours or a few days. If the patient feels better once the disorder soreness has settled this may be considered a desired effect. This effect is often requ i red to 'kick start' recovery when a disorder is getting no better. Pain inhibition - a 'weakness' in movement due to inhibition of

m uscles ca used by pain. Frequently the weakness resolves in proportion to the resolution of the pain. Protective deform i ty - an abnormal position adopted so as to protect an injured or painful body part from further damage or pain (e.g. hip flexion deformity in response to a very painful hip joint). Quality of movement - good qual ity movement takes place when, for example, a limb moves through its fu l l range, idea l ly alig ned with its neighbou ring body part, and without any sign of weakness, protective or adaptive deform ity. Poor qua lity movement occurs when a limb moves through its ra nge with a l ignment fau lts, weakness, or protective/ adaptive deformity. Stage of the disorder - each disorder has a natural history from its onset to its resol ution or its pathway to chronicity. During this natural history the disorder may go through a variety of

INTRODUCTION

et al

stages, including acute severe, recoveri ng, recurrent and chron ic non-resolving. Weak l ink - a contributing factor to recurrences of disorders. If a patient sustains recurrent injury and it always man ifests as pain or dysfu nction in the sa me place, it may be considered that there is a weak l i n k which is most susceptible to the injuring forces. An exam ple of th is is recurrent shou Ider dislocation in baseball pitchers. Wise action - the use of a l l available contem porary evidence a nd cli nical expertise i n dea l ing with neuro m usculoskeletal disorders and the common sense application of such evidence and experience to the individual patient's disorder. Yel l ow flags - psychosocial risk factors for chron icity (in low back pain) such as attitudes a nd beliefs, behaviours, compensation issues, diag nosis, emotions, fami ly, work.

2001), i.e. conditions which one would expect

to respond well to mobilization/manipulation and The selection and progression of mobilization and

conditions which may be difficult to help and the

manipulation techniques from initial contact with the

reasons why this may be so

patient to the last contact should be: •

•

inclusive, patient driven and based primarily on

wise action

(Butler

2000) drawn from all the clinical

ation, all aspects of treatment techniques and how to progress them should be considered including

based on sound, reliable and detailed assessment

starting positions, directions of passive movement,

and reassessment of the effects of treatment on the

combinations available, grades, speeds, rhythms,

patient's movement-related signs and symptoms •

considered in light of the nature of the condition and the stage in its natural history at which it presents

•

durations and styles •

to performing mobilization techniques should be an

precautions and potential barriers to the natural

option. Specific, functionally demonstrated move ment restrictions or unique sequences of movement injury may demand that the technique performed is

integrated into what are quite often multicompo

ingenious and performed in a manner that is unique

nent, multidimensional movement-related disorders •

realistic in view of factors which may suggest a favourable or unfavourable prognosis (Maitland

considered according to the individual patient's circumstances, i.e. flexible, inventive approaches

influenced by all the potential contributing factors, recovery of the disorder

•

7. In view of

the information available through careful examin

information available and acquired •

based on the principles of mobilization/manipula tion techniques as detailed in Chapter

•

striving above all to achieve their desired effects. If the techniques performed achieve their desired effects

Principles of selection and progression of mobil ization/ manipu lation techniques

(Chapter

2), and as long as the general principles

of selection and progression are considered, there can be no wrong way of performing mobilization/

THE BASIS FOR SELECTION AND PROGRESSION OF MOBILIZATION/MANIPULATION TREATMENT TECHNIQUES

manipulation techniques and the possibilities for selection and progression will be limitless.

Consider the following algorithm: •

Selection and progression

Does the patient have a neuromusculoskeletal disorder?

Selection and progression of mobilization/manipulation techniques for movement-related neuromusculoskeletal

•

Is the disorder movement related?

•

Will mobilization/manipulation fulfil the aims and desired effects of treatment - wholly, partially or

disorders should be placed within the context of the overall management of such disorders of the peripheral regions. In many cases mobilization/manipulation will con stitute the primary intervention, such as for a patient with a stiff, painful knee following several weeks of rel

probably not at all? • •

the overall management of a patient's condition or at

•

arc of shoulder movement may need gentle accessory, pain-modulating, passive movements of the shoulder to complement the functional recovery of the rotator

rant or locking position in order to remove any pain

decide upon the most

If the answer is

yes, what is the source and the cause

contributing factors involved in their production? •

How many components of the disorder need to be treated with mobilization/manipulation techniques and in which order?

•

What options are available in the choice of the technique and the method of performing it?

•

What options are available when deciding how to progress treatment based on careful assessment of

cuff and associated muscles. Later on in recovery, mobilization may be needed using the shoulder quad

no,

of the source of the symptoms and what are the

particular stages in recovery. For instance a patient with acute supraspinatus tendonitis and a very painful

If the answer is

appropriate course of action.

ative immobility after a femoral fracture. In other cases mobilization/manipulation may be needed as part of

Is mobilization/manipulation indicated? Yes or No?

the effects of the previous treatment? •

What factors will influence the selection and progression of treatment?

inhibition of the supraspinatus which may be holding back the return of normal quality and balance of shoul der movements.

Does the patient have a neuromusculoskeletal disorder?

Passive movement is not a panacea for all neuromusculoskeletal disorders

patterns of presentation of neuromusculoskeletal dis

The use of mobilization/manipulation should be con

orders and the ways in which they may respond to

sidered in conjunction with other forms of physiother apy and vice versa. Having said this, passive movement in the assessment, examination and treatment of neuro musculoskeletal disorders has a much more valuable and important role to play than is still generally under stood by many therapists. The assessment component is most important no matter what treatment is used, but in this chapter the main emphasis will be placed on the treatment by

Chapter

treatment by mobilization/manipulation. The follow ing questions, therefore, should be asked as part of the selection and progression of treatment: •

Is there a definite, partial or as yet unclassified diagnosis?

•

Is there a recognizable pathology?

•

Is there a reCOgnizable syndrome?

•

Are there any contraindications or precautions to treatment?

passive movement, as applied to the structures and disorders referred to in Chapter

10 outlines the clinical profiles and common

10.

This chapter has been formulated into the context of the actual 'decision-tree' process which most physio therapists use daily when deciding what to do with their patients. Therefore a suitable algorithm has been included as a guide to the likely branches of decision

Is the disorder movement related? What clues from the C/O and P/E (Chapter 6) suggest this? A check list may include the following: •

Does the patient's main problem suggest that the

•

Are the areas of symptoms on the body chart

symptoms are causing activity

making which are needed to, first of all, select the appro priate mobilization/manipulation treatment techniques and then to progress them logically and effectively.

limitations?

related to structures of the movement system: are

1 81

1 82

M A I T LA N D'S P E R I PH E RAL M A N I PU LATI O N

[ •

they intermittent, deep and described with •

Are the symptoms made worse or made easier by

•

contracted, fibrosed or shortened muscle?

influenced by rest and activity? Is the present and past history of the patient's

•

Are there any

movement impairments to be found on

•

•

Are there any alignment faults, protective visible on observation?

•

Will the technique complement the healing

•

Will the technique kick start the healing process by

process?

Can the patient functionally demonstrate a movement or activity which is restricted because

helping to remove physical or cognitive/emotional

of symptoms? •

barriers to recovery?

Is there a relationship between the patient's ranges of movement, symptom response and quality of

•

Does palpation reveal any relevant changes in the

movement potential? •

tissues of the movement system? •

Are there any abnormal physical findings when

enhance active rehabilitation programmes? •

spasm)?

Will the technique complement proprioceptive rehabilitation after injury and give input to

the limbs are moved passively (i.e. pain, resistance, •

Will the technique help to retain an optimal functional environment to attain maximization of

movement? •

Will the technique create an ideal environment for healing?

deformities, adaptive deformities or asymmetries •

Has the technique a role to play in the management of sports injuries and trauma?

physical examination? •

Should a technique be used which has the effect of relieving pain?

symptoms related to injury or unfamiliar use? •

Is a stretching technique required to retain range, make a normal range more mobile or lengthen

certain movements or positions; are the symptoms •

Does the technique need to stretch a stiff joint to restore range?

movement in mind (pulling, stretching, etc.)?

Can the patient's symptoms be reproduced by

Will the technique help in the process of reconditioning movement after chronic disuse?

passive movement testing?

Is mobilization/manipulation indicated? Aims of mobilization/manipulation techniques Will mobilization/manipulation treatment techniques fulfil the aims and desired effects of treatment wholly,

If the answer is •

partially or probably not at all? A checklist for such

patient's condition needs treatment which falls outside of the scope of physiotherapy practice the

•

Should the technique provoke or avoid provoking

•

Will the patient tolerate some exacerbation of the

patient should be referred on to the appropriate practitioner.

the patient's symptoms? symptoms if this is required to promote recovery? Will the technique change the pain, resistance and/or spasm and therefore the nature of the patient's complaint? •

structures normal again or contribute to this process?

•

A check list for the desired effects of mobilization/

2) may

include: Is a technique needed which will restore structures

What is the source of the symptoms and signs (which joint or vertebral segmental level)?

•

What is the cause of the source of the symptoms and signs (joints above and below, vertebral segments above and below)?

•

What are the contributing factors involved with

How many components of the disorder need to be treated with mobilization /manipulation techniques and in which order? •

Will one technique or several techniques be

•

Will accessory movements be needed before

required? physiological movements or vice-versa?

(within a joint) to their normal position or pain free status so as to recover a full-range painless movement?

yes decide:

the disorder?

Desired effects of mobilization/manipulation treatment techniques

•

If the answer is

Will the technique eventually make the abnormal

manipulation treatment techniques (Chapter

which other physiotherapeutic approaches will achieve the desired effects of treatment. If the

aims may include:

•

no decide:

•

Will the spinal component need treating before the peripheral component or vice-versa?

Principles of selection and progression of mobilizationj manipu lation tech niques

•

Will the joint signs need dealing with before or after the neurodynamic signs or the muscle length/strength changes?

What options are available in the choice of technique and the method of performing it? •

•

•

•

•

•

Physiological or accessory movement (shaft rotation). Combined physiological, combined accessory, combined physiological with accessory. Any passive movement with compression or distraction. The starting position of the patient in order to achieve the desired effects of treatment. The starting position of the physiotherapist in order to achieve the best localization and application of forces. The grade (small amplitude, large amplitude, early in range, within range, late in range, short of resistance, into resistance and 'bite'), speed, rhythm (smooth, staccato, sustained), the desired effects (short of discomfort, into discomfort, into pain, respecting pain, into 'bite') and duration of the technique.

physiological movement, passive shaft rotation of a joint is a direction of movement category that fits neatly into the same treatment category as accessory movements of the grade I and II types (Fig. 8.3). Spin or rotation within joints such as the hip and shoulder, however, is accompanied by flexion and extension of the long bones rather than rotation of the shaft. A fuller description of such movement relationships is extremely well described in the arthrology section of Gray's Anatomy (Williams & Warwick 1980). Therefore roll, spine and slide if produced separately are accessory movements. They are not the only acces sory movements, however, others being distraction, compression and gliding or translation. The gliding movements (or translations) may be coronal (medial or lateral) or sagittal (anteroposterior or posteroanterior).

Rotation arm (shaft rotation) Sli de =

Figure 8.2

Passive movements at the glenohumera l joint.

Passive movements The two basic movements available for treatment are physiologicaL movements (which are movements actively used in the many functions of the neuromusculoskel etal system) and accessory movements (which are those roll, spin, slide and gliding or translation movements which a person cannot - usually - perform actively in isolation). Distraction and compression can also be considered as accessory movements (Figs 8.1-8.4). Rotation about long or short bones can often be consid ered as shaft rotation, especially when thinking about the hip or shoulder. This will produce roll and slide between the synovial joint surfaces and often has simi lar effects to other gliding and translatory movements in the treatment of very painful, movement-related joint disorders. Consequently, although technically a

Passive movements

AND

Figure 8.3 Modification of basic movements for passive movement treatment.

I Passive movements

I

I Physiological movements

I

I

Com bined physiolo gical movements

Figure 8.1 treatment.

Basic movements available for passive movement

Figure 8.4 treatment.

I

I I

I Accessory movements (including shaft rotation)

I

Com bined physiological with accessory movements

I

I

I 4.5 Com bined accessory movements

Movements available for passive movement

1 83

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M A I TLAN D'S P E R I P H E RAL M A N I P U LAT I O N

Obviously they may be angulated, including angulations in the cephalad and caudad directions. The physiological functional movements of flexion, extension, abduction, adduction, horizontal adduction (flexion), horizontal extension, medial and lateral rota tion incorporate varying degrees of accessory move ments to allow the physiological movements to occur. They also incorporate varying degrees of other direc tions of physiological movement. For example, a man rarely raises his arm overhead in a pure sagittal plane in daily activities. Combined movements, therefore, inevitably occur in functional activity (Fig. 8.4). The relevance of this lies both in examination and consequently in passive movement treatment. In examination, when active movements are assessed, a patient may be asked to perform different movements in unusual combin ations so as to determine any abnormalities in these movements, including the reproduction of pain. As an example, a patient may be asked to abduct or flex the arms, but to do so, not as a normal free functional movement, but with the arms in medial rotation: the symptomatic arm is compared with the normal or non symptomatic arm. These same combinations of movement can be used as passive movements in treatment. In addition to these, a physiological and an accessory movement can be combined. The combinations can be in the biomech anical direction or even in the reverse direction if this will achieve the desired effect of the teclmique. For example, using as a treatment, knee extension com bined with an anteroposterior movement applied to the knee to improve knee extension:

Figure 8.5

Extension overpressu re a pplied to the femur.

Figure 8.6

Extension overpressure applied to the tibia.

Starting positions

•

biomechanically the anteroposterior movement would be applied to the femur at the knee accord ing to the concave-convex theory (Williams & Warwick 1980) (Fig. 8.5).

The starting positions for both patient and therapist, in order to achieve the aims and desired effects of treat ment, have been described and discussed in Chapter 7 and should be considered in relation to:

•

non-biomechanically, the anteroposterior movement would be applied to the tibia at the knee. These reverse or non-biomechanical accessory movements should be considered as a routine part of examin ation and as potential treatment techniques, espe cially if these directions improve the knee extension when the biomechanical directions do not (Fig. 8.6).

1. the clinical features of the patient's disorder (pain, spasm, pain and stiffness, stiffness) 2. the functional requirements achieved with the technique 3. the age and build of the patient 4. other relevant physical, psychosocial or medical conditions 5. the space and environment available 6. the specific requirements of the physiotherapist.

The accessory movements themselves can be com bined and used in examination and treatment. As a typical example, anteroposterior movement in a lat erally directed inclination can be applied to the superior margin of the medial border of the tibia. This produces a combination of anteroposterior movement with lat eral movement and medial shaft rotation of the tibia under the femur (the knee may be being supported in any physiological position) (see Fig. 8.4).

In this way the maximization of the localization of forces and application of forces can be achieved.

Grades The available grades with which any of the listed move ments can be performed have already been defined and

Principles of selection and progression of mobil ization! manipulation techn iques

discussed (Chapter 7, see also Appendix 1). Neverthe less it should be realized that these grades can be varied widely. A large amplitude movement can be used in absolutely any part of the full exertion of the range according to the definition of large amplitude grades. For example, if a person with a normal shoulder were to lie supine on a treatment couch, with the shoulder free over the side of the couch, a large amplitude of flexion of the whole shoulder girdle could start from a position of the arm hanging towards the floor and could finish as far beyond the median coronal plane of the patient's head and thorax as is physically available (Fig. 8.7). This would be recorded as a maximum range of grade III movement, assuming that the movement carried into resistance. This movement could be depicted by the symbol III. The same applies, in terms of large amplitudes, to combined movements and accessory movements. On a similar basis, small amplitude movements can be performed anywhere in the same full exertion of range. The only point is that if it is performed at or near the beginning of the range it would be a grade I and if it were performed into resistance or near the end of the range it would be a grade IV. If the amplitude was still small but performed in the middle of the resistance-free range (such as might be the case when treating a painful arc of movement), the grade can be classified as small grade II or small grade II- if it is in the first part of the resistance-free range or small grade II + if performed in the latter part of the resistance-free range (Fig. 8.8).

Figure 8.7

Maximum grade III Maxim u m grade III.

II

IV or IV+

1--

Figure 8.8 Shoulder F , grades 1--, 11-, 11+, II, III, IV or IV+: III and II depict large amplitude; I, II, (III) and IV depict the most com mon am plitude; g rade III and II would be the way to depict smaller a mplitudes, as would I and IV, whilst I and IV would also depict large amplitudes but smaller than g rades III(IV) or 11(1).

Rhythms of mobilization Many different rhythms are used in passive movement treatment: •

•

Movements can be performed at a very low speed, so smoothly that there is no one single point when the direction can be perceived as changing from one to another. A movement may be held (sustained) at one point for as long as 5 seconds waiting for pain or muscle spasm to subside before reversing the direction minimally.

•

At the other extreme are staccato rhythms which are sharp, more abrupt movements.

•

Available rhythms can be changed from one to another during the performance of a single tech nique, as can grades. For example, a slow smooth rhythm of grade III may be interspersed with one or two staccato movements still in the same grade III range. Conversely, a sustained grade IV stretching

Fig u re 8.9

Rhythms of treatment movement.

movement may be interspersed with smooth grade III- movements to ease off the soreness resulting from the stretching. This grade III- movement could then be progressed in a very controlled and assessed way to a grade III movement (Fig. 8.9).

Options for progressing treatment In conSidering what options are available when decid ing how to progress treatment on the basis of careful assessment of the effects of the previous treatment, the steps to be taken in progressing a treatment technique

1 85

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M A I TLA N D 'S P E R I P H E RA L M A N I P U LATI O N

are driven primarily b y the symptomatic response felt by the patient during the performance of the technique and the effects of the treatment over the following day or so. Detailed and repeated

assessment,

therefore, is

the demand of this concept (Chapter 5). During the ini tial examination it is important to establish how the patient is affected by the disorder or how the disorder is perceived to be affecting daily life. Accurate, consis tent C/O and

P /E asterisks must be established so that

assessment and reassessment can be meaningful. Examples of measurable asterisks may include: •

(C/O) - a geographical area of symptoms on the

Once all the factors have been considered the physio therapist should have enough information in order to: •

•

• •

•

•

(Appendix 1).

multicomponent approach to the management of

The hypothesis categories are classified as: •

the clinical evidence (signs and symptoms) includ ing the classification of disorders or components of disorders into clinical groupings to form a basis for technique selection

•

repeat the technique

•

alter a component(s) of the technique

•

add in new techniques (same source)

•

impairments,

disabilities

(dysfunction),

activity

limitations •

•

change the technique (same source)

•

choose a technique for a different source or the cause of the source manipulate rather than mobilize

•

add in automobilizations to maintain progress

the structures being treated (the source/ cause of the source)

•

•

the onset, injuring movement and stage in the natu ral history of the disorder

with treatment

•

the diagnosis and pathobiological mechanisms involved with the disorder including the pathology,

have a planned break from treatment followed by a retrospective assessment (Chapter

integrate the use of mobilization/manipulation

movement-related disorders and dysfunction.

should include:

•

confirm the prognosis through progressive,

techniques into a multidimensional,

Options for the progression of the treatment technique

•

have strategies available to deal with barriers to

retrospective and final analytical assessment •

ticular functional movement, a mechanosensitive a limb, an isometric test, a movement diagram

plan stages of progression based on influencing

progression of treatment

(P /E) - a protective deformity, a limitation in a par neurodynamic test, an area of reduced sensation in

record the procedure in a logical, methodical way factors

ring regularly at a particular time of day •

assess whether those desired effects are being achieved

body chart or its quality, depth or consistency; an activity limited by symptoms or symptoms occur

select the technique and method best suited to achieving the desired effects of treatment

the mechanisms of symptom production, the nature

5)

of the disorder and the person and the recognizable

stop treatment.

clinical syndromes •

Selection and progression of treatment using passive movement techniques

and serve as physical or non-physical barriers to recovery

In considering which factors influence the selection of and the progression of treatment using passive

the contributing factors and precautions to treatment which may influence the expectations for recovery

•

the prognosis - the expected rate of recovery and

(2000) have

the classification of neuromusculoskeletal disorders

established comprehensive and flexible hypothesis

into those which are likely to be easy to help and

categories which underpin the clinical reasoning

those which may be difficult to help.

movement techniques, Higgs and Jones

processes necessary for effective phYSiotherapeutic management of neuromusculoskeletal disorders. These hypothesis categories form part of the 'brick wall' mode of thinking as discussed in Chapter 1. When selecting and progressing mobilization techniques, each hypoth esis category should be con�idered for each patient and, within each hypothesis category, the potential role to be played by mobilization or manipulation should be considered.

The primacy of clinical evidence (signs and symptoms, clinical groupings) Irrespective of the diagnosis, the clinical information and evidence

(symptoms and signs)

should be the over

riding factor within this concept which influences: 1.

the choice of mobilization/manipulation as a treatment option

Princi ples of selection and progression of mobil ization /manipulation techn iques

2. the kind of technique used (i.e. direction, starting positions, localization of forces) 3. the style of the technique (Le. grade, speed, rhythm).

The fundamental requirement of the technique there after is that it achieves its desired effects. End-of-range symptoms are treated by different techniques (EaR techniques) than through-range-symptoms (through range techniques) or constant pain (accessory move ments in neutral physiological positions). Mild aching symptoms felt when lying on an aching joint require special techniques (under compression) as do stiff peri articular structures preventing normal function because of pain as well as stiffness (stretching techniques into stiffness to the point of provoking the pain, i.e. into 'bite'). Therefore treatment can be directed towards relief of pain, improvement of stiff functional range or reduction of protective involuntary muscle spasm. Attempts to relate treatment to pathology, there fore, can lead to considerable misunderstanding.

Instead it is better to try to formulate the different combin ations of symptoms into groups and classiJtJ treatment selec tion and progression according to each group. Although the pathology may influence the rate of progression and the prognosis, it rarely influences the type of pas sive movement technique chosen as treatment. Under these circumstances the technique used will be guided by the abnormalities of the joint movement. The three primary physical or movement-related joint signs found on examination of an impaired syn ovial joint and its supporting structures consist of pain, at rest or with movement, stiffness due to contracted structures or adhesions and muscle spasm which is invol untary and protective. Other clinical features such as voluntary holding, pain inhibition and crepitus should also be considered as joint signs. These joint signs can occur separately or in a number of combinations. This classification of movement-related joint disorders into clinical rather than diagnostic groupings enables the physiotherapist to: •

• •

•

•

•

address the patient's main concerns, i.e. address primarily the clinical features of the patient's disorder address the joint signs separately or in combination classify the clinical features in terms of their relationship to each other with movement select techniques related to clinical features rather than diagnostic labels progress treatment in relation to the effects on the clinical features or joint signs recognize patterns of combinations of joint signs and predict their response to mobilization/ manipulation

•

•

assess and reassess the effects of treatment on these clinical features with the help of clinical tools such as movement diagrams (Appendix 1) make a judgement of the predicted response to treatment based on how easy or how difficult it will be to help certain clinical features.

CLASSIFICATION OF JOINT SIGNS (CLINICAL GROUPINGS) Patients with different and often readily recognizable combinations of signs and symptoms can be divided into four main clinical groupings for the purpose of selection and progression of mobilization/manipulation techniques (Figs 8.10, 8.11). These groupings are defined, on the one hand, in terms of the movement-related signs which limit a par ticular range of movement and on the other hand by the relationship within a range of movement between these signs. Each grouping and associated groups can be defined, described, and classified in terms of move ment diagrams. Furthermore, guidelines for selection, progression and final expectation for outcome can be described based on each grouping.

Groups

Figure 8. 1 0

Subdivision of patient groupi ngs.

Groups

Figure 8.11 Grouping of patients with intermittent pain associated with particular movements.

1 87

1 88 c::

M A ITLA N D ' S P E R I P H E R A L M A N I P U LATI O N

Definitions

Group 3 (a and b)

Group 1

•

Where pain and joint stiffness are concurrent, the intensity of the pain increasing proportionally as the strength of the resistance increases: 3a, pain domi nant/limiting; 3b, stiffness dominant/limiting.

•

Pain is related to stiffness but these patients vary widely in their presentation. Although the pain and stiffness are related, the pain may be severe and limiting or it may be moderate and non-limiting, each requiring different treatments. Where pain is dominant, initial treatments must be related to pain as in group 1 and not treated with many directions of movement; when stiffness is dominant, initial treatment can correspond to that of group 2.

•

Movement-related joint signs usually occur together

•

• •

•

Where pain is the main consideration, the existing limitation of movement is due entirely to movement-related pain. Pain at rest/early onset/early limiting. The severity, irritability and nature of the pain indicates extreme care is needed in examination and delivery of the treatment technique. Figure 8.12 represents a typical movement diagram for group 1.

Group 2 •

•

•

Where loss of movement is the main impairment and pain is of little consequence. Those patients who have only a minimal intermittent ache if at all (no pain) but who are unable to move the joint because of stiffness. Movement-related joint signs occurring at the end

of the available range. •

Figure 8.13 represents a typical movement diagram for group 2. P2 (severe)

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through the available range of movement. •

Figures 8.14 and 8.15 represent typical movement diagrams for group 3a and 3b.

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P, 1.14 R, L Y2 Range (local severe) headof radius

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Cl in ica l group 3a : pain a nd stiffn ess (pa in

Cl inical group 1 : pa in.

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A Figure 8.13

hip

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Cl ini cal group 2: stiffn ess.

B Figure 8.15 domina nt).

Principles of selection and progression of mobil ization / manipu l ation tech n iques

not a voluntary, conscious process and the patient is often unable to release it voluntarily (groups 1, 3a).

Group 4 Where pain is intermittent and momentary. Patients with no obvious loss of joint range but who have momentary pain (intermittent, associated with particular movements, certain positions or certain activities). The 'bite' or jab of momentary pain is usually found with examination in combined or sustained combined movements or in functional corners. Figure 8.16 represents a movement diagram for group 4.

• •

•

•

•

there are two other kinds of muscle spasm which need to be men tioned. The first is a neurological muscle spasm caused by an upper motor neurone disorder (i.e. tonal changes/clonus) and the other is the muscle contraction produced and released voluntarily by the patient to prevent movement - voluntary hold ing (groups 2, 3b especially).

Neurological and voLuntary spasms

-

Pain inhibition Associated signs The following categories of signs may also occur, alone or in combinations with the other movement-related joint signs. Some will be associated more closely with certain groupings than others.

Spasm

Crepitus

Painless spasm a joint can be painless during move

•

-

ment because of protection afforded by muscle spasm. The protective mechanisms are, in the main, both complex and a wonder of nature. It is possible for

the degree of muscle spasm to be such that it comes into play before movement becomes painful (groups 1, 3a) (Fig. 8.17).

Pain before spasm - spasm can also come into play as

•

a more obvious protection for the joint because the movement becomes quite painful before the spasm appears (groups 1, 3a, 4) (Fig. 8.18). muscles may contract in a way that differs from the typical protective muscle spasm. It is a 'holding' rather than an obvious contraction and it affects more of the muscles around the joint. It is

•

'Pain inhibition' is a factor that may be present. It con fuses the presentation of the disorder and so confuses treatment decisions. It can be responsible for apparent (not 'actual') muscle weakness, instability or limitation of range of movement. Painful arcs of shoulder move ment are prime examples of this.

Holding spasm

-

R2 (IV+++) D

C

Crepitus is another subjective element which is evident as a 'through-range' phenomenon. It may be accompan ied by discomfort, and may, or may not, be apparent to the therapist (joint crepitus or tenosynovitis).

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Fi gure 8.17

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V.

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Figure 8.16

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(local) Figure 8.18

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I %

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1 89

1 90

M A I T LA N D'S P E R I P H E RA L M A N I P U LAT I O N

[ GUIDELINES FOR SELECTION AND PROGRESSION O F TREATMENT

Group 1 : description, initial treatment, desired effects, progression, example of movement diagram (Fig. 8. 1 9, also see Fig. 8. 1 2) Description: clinical situations which fall in to group 1 Pain is severe, irritable and can be at rest, early onset and early limiting (in such cases the importance of attention to detail in establishing the exact onset of PI or the point of increase in pain at rest can not be over emphasized) (Figs 8.20, 8.21). Patients may have severe pain at rest but with care ful positioning the pain can be abolished. This type of pain may be due to inflammation linked to a mechan ical or movement-related cause and should respond well to appropriately performed mobilization (patients who have pain at rest and no amount of positioning of the joint will change the pain are likely to have a non-mechanical/non-movement-related inflammation or some other source of pain-producing mechanism). A joint may be very painful on movement (early onset, early limiting) and when the movement is stopped the pain may continue as an ache of variable intensity lasting varying lengths of time (5 minutes to 1 hour). A joint may be painful at rest but if it is moved by the therapist the pain increases rapidly in intensity to the extent where the therapist is not prepared to move the joint further. The amount of limitation of movement due to pain may be very great and this prevents the therapist from knowing whether there is physical

resistance present, perhaps beyond the limit. The ther apist also cannot know whether there would be any muscle spasm if the joint were moved further. In other words it is not possible, because of the intensity of the pain with movement, to know what phYSical factors may be present in the joint movement into the range. The pain always has a high degree of irritability (i.e. the vigour of activity causing the pain, severity of pain so caused and the length of time taken for the increase to return to its usual level). Such factors should be established during the subjective examination (Chapter 6). When asked what activities aggravate the severe shoulder pain of a patient, and by how much and what then relieves the pain and how long it takes to be relieved, the patient may reply, 'If I put my hand too far up my back my shoulder pain is unbearable, I have to then hold my arm still across my chest for 20 minutes or so before I feel better.' Patients in group 1 also frequently experience a painful reaction following a comparatively painless activity. Consider this phenomenon in relation to the movement diagram: the joint can be moved back and forth in that part of the range before PI quite pain lessly, but if too much movement is performed the

P2 (severe)

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Figure 8.20

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PAIN

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Groups

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Figure 8.19

Group 1 .

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41

A Point of increase

Figure 8.21

L V.

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Range

Point of increase in pa in at rest.

%

B

Principles of selection and progression of mobil ization / ma n i pu lation techniques

patient will experience an exacerbation later. The more irritable the joint, the smaller is the amount of move ment required to cause this. The fact that oscillatory movements in the painless part of the range can cause an exacerbation at all shows that the point PI in Figure 8.22 is incomplete when considering pain, and indicates how carefully the patient's pain needs to be assessed and the possibility of reaction appreciated. If pain starts much later in the range (particularly if the pain is not severe), there is little likelihood of reaction from pain less treatment movement. The point of emphasis is that even though care is exercised to determine where pain begins in the range, movement in the painless part of the range may cause a painful reaction; therefore care in both assessment and treatment is essential. Irritability is first assessed by questioning the patient: this guides the amount and type of treatment performed initially. When the patient is seen for the sec ond time a clear assessment of the joint irritability can be made based on any exacerbation that has occurred directly related to a known amount of joint movement. However, it is necessary to bear in mind that at the patient's first visit the joint has been moved during examination as well as treatment. An accurate assessment

2. How early in the range the pain begins. 3. The intensity of the pain in the early part of the range (the earlier the pain appears and the more rapidly it increases, the further back from PI the treat ment movement should start and it should also be slower and smoother). If the increase in pain early in the range is moderate and the severe pain occurs later in the range, the treatment movement can be brought closer to the point where pain begins (Figs 8.22, 8.23).

Amplitude of the treatment movement The more irrit able the joint or the earlier in the range the pain starts or the more rapidly the pain increases, the smaller the amplitude the treatment movement should be. Ampl itude and position in range of the treatment move ment A smaller amplitude movement should be used as the treatment movement is brought closer to PI (early onset). If the treatment movement is performed back from PI a larger amplitude can be used (Fig. 8.24).

c

D

P2 (intense)

ofjoint irritabilihj may therefore not be possible untiL the third visit though it may prove to have been accurately assessed at the outset. The point is that it may be neces sary to repeat a chosen treatment movement up to and including the second visit. Changing a chosen treatment too quickly may not be the best thing for the patient.

Selection and progression of initial treatmen t for group 1 •

Gentle techniques are guided almost solely by pain.

•

The therapist must watch the patient's eyes and body movements at all times for signs of a painful response to the treatment movement.

•

Passive movement carried out in the painless part of the range where pain is early onset/early limiting must be preceded by very careful positioning of the joint to be treated. The amplitude, rhythm, speed and number of oscillations of the treatment move ment must also be considered very carefully.

Fi g u re 8.22 Intense pain, early o n se tlearly limiting; sma l l amplitude movement, slow smooth.

c

P2 (intense)

Position in range of the treatment movement The depth of the treatment movement (i.e. how close the move ment approaches the onset of pain) depends on three factors: 1.

The joint irritability established during the subject ive and phYSical examinations (the more irritable the pain the further back from the point of onset of pain the movement should start).

B

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A

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(local) Figure 8.23 Moderate pain, early part of range; larger amplitude movement, slow smooth.

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1 92

M A I T LA N D'S P E R I P H E R A L M A N I P U LAT I O N

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A Figure 8.24

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Choice of a mplitude.

In practice the larger the amplitude that can be per formed when treating movement-related joint pain the more effective it will be. However, in very painful, irrit able joints judgement must be exercised because if the amplitude is too large (both in assessment and treatment) it may cause an exacerbation.

Oscillation of the treatment movement When a joint is irritable a small amount of movement will cause less reaction than a large amount. A highly irritable joint should be moved less rather than more and the treat ment time should vary from 30 seconds to 2 minutes. The oscillations should be slow and smooth (Chapter 7). It is better to undertreat initially until irritability is well established. Direction of the treatment movement One of the least painful movements of the joint should be used as the treatment movement. Where findings indicate that treatment movements must be kept away from the early onset and early limit ing pain it is wiser to treat by using an accessonj movement in a pain-free position rather than a physiological move ment. For example, a patient may have painful limita tion of active shoulder flexion in standing to below the horizontal. It is much wiser to use the least painful shoulder accessory movement as treatment with the patient lying down and the arm carefully supported in a pain-free position by the patient's side. This would be preferable to the use of a physiological movement. Passive movements performed in this way can produce pain-free movement with less likelihood of exacerbation (Fig. 8.25). Such treatment should be performed for 30 seconds to 2 minutes followed by detailed reassess ment of the range of shoulder movement in standing to compare with its 'before treatment' status. Given that the patient has been examined, treated and reassessed, short-duration treatment initially should be sufficient, especially if there is a likelihood of exacerbation.

Fig u re 8.25 Pai n-free accessory movement: i GH in neutra l pain-free position.

Desired effects of treatmen t For patients in group 1, treatment in the initial stages aims to lessen pain and to allow a greater range of active movement. When pain is severe it is often diffi cult for patients to appreciate small improvements, and greater care is therefore needed on the examiner's part to discern the changes taking place. Pain may improve in three ways: 1.

It may not start until later in the range (Fig. 8.26).

2. It may start at the same point but not reach maximum intensity until later in the range (Fig. 8.27). 3. The rate of increase in pain in the early part of the range may not be as great (Fig. 8.28). Other desired effects of treatment at this stage may be to: • •

create an ideal environment for healing introduce movement early in cases where active movement is more painful than passive movement.

Progression of treatment movements If the initial treatment movement selected produces improvement or no change, the initial treatment should be repeated because, on the one hand it has produced changes in the pain with movement or the active range, and on the other hand, where no change has occurred, repeating the technique is necessary to fully establish the irritability as discussed earlier. If the initial treatment causes more pain the same treatment should be performed but with a smaller amplitude and further back in the range from Pl'

Pri nciples of selection and progression of mobil ization / ma n i pulation tech n iques

1 93

] P2 (severe)

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( b)

Figure 8.2 8 Change in rate of increase of pain, (a) before, and (b) after treatment.

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On day two (second visit), treatment should be based on reassessment of the effects of the initial treatment movement. There should be some improvement in the pain or active range of movement to indicate further repe tition of exactly the same treatment. As the joint does not require examination on the second visit, treatment can be increased if the irritability of the pain has been firmly established. The amount of treatment should be guided by any reaction that might have resulted from the first treatment session. If there is no further improvement using the initial treatment movement, a different move ment should be used and assessed. As the active range of movement becomes greater than 60% of normal, physiological movements can be introduced without fear of too much exacerbation. In

the previous exampLe of limited shouLder flexion, flexion or the quadrant direction may be used. However, until active movement has reached about 75% of normal the treat ment movement should be kept short of the point in the range where pain begins. Further progression can take place as the range of movement nears normal. The flexion or quadrant direc tion can be performed as III- to III + (as in group 3b) until the last parts of the range are recovered with both accessory and physiological grade N (as in group 2).

1 94

M A ITLA N D ' S P E R I P H E R A L M A N I P U LATI O N

[ Examination may also reveal that i t i s movement related pain alone that is preventing an otherwise full range. This pain can be treated using the following movements: •

Accessory movements or shaft rotation while the joint is supported in its neutral pain-free position. These movements should be performed short of producing any discomfort or pain initially and even avoiding an awareness of movement felt in the joint by the patient.

•

Accessory movements in the neutral pain-free posi tion are chosen initially for those patients whose antigravity, often pain-inhibited, movements are limited by pain or discomfort in the first 60% of the joint's normal range.

•

As the condition improves the treatment movement can be used into a controlled amount of pain or dis comfort (movement into 10-20% of pain or discom fort's maximum intensity is probably advisable initially).

•

Large amplitude physiological movements in the later stages of recovery are then used, i.e. when the joint's range of pain-free movement has improved so that pain and discomfort are felt only in the last 40% of the total range.

Assuming that the special passive movement tech niques produce the desired improvement in range, progressive stages of the techniques can be applied. For example, a hip joint has approximately 15-20° of active flexion before limiting discomfort is felt, after which the following steps may be taken. 1.

The hip is placed (if necessary by using pillows etc.) in its pain-free position in approximately the middle of all the joint's ranges. It may be necessary to ask the patient to adopt this position and then for the therapist to carefully adjust the joint position to obtain the most pain-free position. For the hip joint this may well be in side lying with the affected (uppermost) leg supported with pillows. The tech nique used will be the hip accessory movement or shaft rotation which can be performed with the least awareness of pain, discomfort and movement. This may well be medial shaft rotation (Fig. 8.29) which should be performed with as large a pain-free amplitude as possible both slowly and smoothly. While this treatment movement is being performed very gently the therapist must repeatedly ask the patient if any discomfort is felt. If it is, the oscillation should be performed further back in the range and with a smaller amplitude and with a degree of dis traction of the joint surfaces if there is still discomfort.

Figure 8.29

Hip joint: medial rotation in side lying.

Figure 8.30 side lying.

Hip joint: longitudinal movement (-) in

The question must then be asked again. The patient must not feel any movement nor anything resem bling discomfort during the first treatment if it is to have any chance of reducing the pain and improving the active range of movement.

If this accessory movement is repeatedly ineffect ive the second most pain- and discomfort-free accessory movement should be used. For the hip joint this may well be longitudinal movement in the line of the femur (Fig. 8.30). A third choice may be lateral movement (Fig. 8.31) or anteroposterior! posteroanterior movement (Figs 8.32, 8.33). 2. If careful assessment of the second treatment ses sion shows that there has been some lessening of pain and some small improvement in the pain-free range of movement, then the technique described above can be repeated. Progression may be slow, but if improvement has been shown by assessment,

Principles of selection and progression of mobil ization / man ipulation tech niques

Figure 8.31

H ip joint: lateral movement in si de lying.

Figure 8.33

H ip jo int: posteroanterio r moveme nt in s ide lying.

Figure 8.34

H ip jo int: m e dial rotatio n in supine.

Figure 8.32 H ip jo int: a nteroposterior moveme nt in side lying.

the amplitude of the technique can be made larger and it may also move into part of the range that is painful. If the joint movement-related pain and the active range of movement improve, then the acces sory movements or shaft rotation can be made larger and larger, moving further and further into range (Fig. 8.34), even though it may be a little painful, lmtil a stage is reached when full ampli tude grade III movement can be performed. 3. A stage will be reached when grade III + maximum staccato movement can be performed with min imal discomfort and at this stage the patient's active pain-free hip flexion should be at least 60% of total hip flexion. The trea tment movement, if necessary, can be changed to an appropriate physiological movement performed slowly, smoothly, gently and carefully, Witllout pain at first as a grade II - . For the

hip this may well be in the direction of hip flexion and adduction (Fig. 8.35). The amplitude should be as large as possible, but initially it should be pain free.

1 95

1 96

M A ITLA N D ' S P E R I P H E R A L M A N I PU LATI O N

[ 4 . As the pain-free range improves still further, the movement can be taken further into the range and into a controlled degree of discomfort. 5. Gradually the amplitude and speed of the move ment can be increased until a strong grade III + movement can be performed without pain. At this stage the patient should be more or less symptom free (Fig. 8.36). These guidelines on treating painful joints with passive movement techniques can be extended to any joint. However, the point at which to change from vigorous accessory movement in the neutral position to physio logical large amplitude movements short of pain is not often so clear cut. If there is any doubt in the mind of the therapist, it is wise to repeat the accessory move ments a few more times and make them as vigorous as possible. Then the change to physiological movements can be made, with caution initially. On reassessment, if the joint has become more painful or the active range has worsened, the physiotherapist should revert to

Figure 8.35

accessory movements for a few more sessions. Then if the change is again made, it should be a successful transition. These guidelines are associated with movement related joint pain as has been discussed. The progres sion through to full recovery rarely takes place in this classic sense. The physiotherapist should be aware of all the other physical, genetic, environmental and psy chosocial influences, contributing factors and barriers that will influence the rate and extent of the patient's recovery. These factors will need to be addressed if the well-recognized recovery pathway is to be optimized. These factors and their influences on joint pain recov ery will be discussed further later on in this chapter.

Group 2 : description, initial treatment, desired effects, progression, example of movement diagram (Fig. 8.37, a lso see Fig. 8. 1 3) Description: clinical situations which fall into group 2 •

A painless joint which prevents normal activity beca use it is stiff.

•

When the joint is stretched it feels tight, and per haps even a little painful, but the main complaint is one of stiffness, not pain.

•

The patient goes to the doctor because he cannot tuck his shirt into the back of his trousers or comb his hair - he does not go to the doctor because of pain.

•

Pain may be experienced, for example, as a sharp stab or pull when the stiff movements are stretched, but as soon as movement is released the pain goes.

Group 2

H i p joint: flexion / adduction grade 1 1 - .

t t

STIFFNESS

Groups

Group Figure 8.36

Hip joint: flexio n / adduction grade 1 1 1 + .

Figure 8.37

Group 2.

41

Principles of selection and progression of mobil ization! manipulation techniques

Selection and progression of initial treatment for group 2 Painless stiff joints require mobilization at the limit of the existing range in all possible directions until full active and passive ranges of movement are restored. Therefore all physiological movements which are stiff can be used as treatment movements and, more import antly, all of the accessory movements at the limit of each physiologically stiff range are used. For example, if tl1e glenohumeral joint is painlessly stiff, the accessory movements of the head of the humerus in the glenoid cavity (i.e. posteroanterior, anteroposterior, laterally and longitudinally) may be carried out as a stretching proced ure while abduction of the shoulder is held at the limit of its stiff range (Fig. 8.38). The same accessory move ments may be used at the limit of other stiff ranges such as horizontal adduction (flexion), flexion or tl1e combin ation of extension, adduction and medial rotation as in the hand-behind-back position. If too much stretching is given, the structures may become sore; this is natural, but there should not be a painful exacerbation. When joint soreness is produced by too much stretching, large amplitude movements, in the same direction as the treatment and which approach the limit of range more gently, can be extremely useful in reducing this treatment soreness and at the same time continuing to treat the resistance. To intersperse grade III- movements between grade IV movements is an effective way of easing off soreness while stretching into the stiffness. The guidelines for treatment when a painless stiff ness restricts a patient's function are as follows: •

•

Apply small amplitude oscillatory stretching move ments for approximately 2 minutes, gradually attempting to increase the physiological range using grades IV, then IV +, and even IV + + .

•

Then, while holding the joint a t the limit of the range, perform all the accessory movements that are available in this position. These accessory move ments should be small amplitude, strong stretching and oscillatory (Figs 8.39, 8.40).

•

Repeat this procedure, alternating between physio logical and accessory stretching movements at the

Figure 8.39 fu ll flexion.

Glenoh u mera l joint: longitudinal movement in

Choose one of the stiff, functionally limited physio logical movements and take the joint to the limit of its available range (shoulder flexion/quadrant).

Figure 8.38 abduction.

Glenohumeral joint: longitudinal movement in

Figure 8.40 Glenohumeral joint: posteroanterior movement in flexion.

1 97

1 98

MAITLA N D ' S P E R I P H E RA L M A N I P U LATI O N

effective if more emphasis is placed on physiological stretching, even to the extent of omitting the acces sory movements. •

The average time spent passively moving joints that are not excessively painful is approximately 4-5 minutes at a time. Treatment for group 2 patients can be carried out daily or on alternate days if soreness escalates. Treatment can gradually be withdrawn as the home programme of stretching exercises is stepped up.

Desired effects of treatment F i gure 8.41 adduction.

Glenohu mera l joint: hand-behind-back position,

limit of the available range three or four times dur ing the initial treatment session or until the desired effect of gaining more functional range has been achieved. Assessment of progress can be made dur ing each treatment session and from treatment to treatment. •

If treatment soreness is created by this repeated stretching, it can readily be relieved as described earlier, i.e. use the physiological movement which has been used for stretching as a large amplitude move ment short of the stretching range so that little or no pain is felt. This grade ill- movement should be car ried on at least until the patient is no longer experi encing treatment soreness.

•

As the chosen physiological treatment movement improves in range, other functional movements should also improve. However, an all-round gain is not always guaranteed so it is sometimes necessary to change to a different physiological movement (Fig. 8.41) but still follow the same guidelines of stretching the physiological movements and the accessory movements alternately at the limit of the available range.

•

When the patient's joint is markedly restricted in range, it may be necessary to stretch more than one physiological movement and its accompanying accessory movements. However, when possible

opposite movements in sequence should be avoided. Anyone who has treated a stiff frozen shoulder will know that often when the joint is stretched into flexion, the hand-behind-back movement becomes more restricted, then, when the hand-behind-back movement is stretched, the flexion becomes more restricted. In such cases treatment may be more

• •

• •

To stretch a joint which is stiff but not painful. To retain range with repeated minor injury or after an exacerbation of osteoarthritis. To stretch a normal joint to make it more mobile. To restore range to help proprioceptive or general rehabilitation.

Progression of treatment movements There may be a feeling that the joint should be stretched more strongly in an endeavour to separate whatever tight or adhesed structures are restricting range. However, this should not be done unless the patient's doctor agrees that it is necessary and the patient must be fully informed, with written consent being obtained from the patient. This progression falls into the category of manipulation of the conscious patient. Evidence suggests that manipulation (under anaes thetic) may help to improve the recovery from frozen shoulder (Reichmister & Freidman 1999). M a n i pu lation of the conscious patient Manipulation of the conscious patient may be considered: •

after further use of grade IV techniques, coaxing and stretching into stiffness or a degree of protec tive muscle spasm whicl1 may be present (balance the force of the stretching with the degree of pain felt during the technique)

•

after consultation with the referring doctor and the informed consent (written) of the patient, when one of two manipulation techniques can be used: 1. A technique involving a sudden, very small amplitude thrust in the same direction as the stretching technique which reproduces the patient's symptoms. The stretching should go from a grade IV to a IV+. Finally the thrust should be superimposed onto this stretch. This form of manipulation is best applied to the small

Princi ples of selection and progression of mobilization / manipulation tech niques

joints of the hand and foot where range is limited by stiffness and not muscle spasm. 2. A technique involving stiff painless large joints which may also be protected by some degree of muscle spasm. In such cases a controlled, steady stretching should be used rather than a sudden thrust. The patient must be positioned so that he is unable to move and so that the physiotherapist can feel, in detail, what is happening in the joint during the stretching technique. The patient's eyes and hands should be watched closely for an assessment of the amount of pain or dis comfort he might be feeling while the joint is being stretched. Once a tearing is felt the physiotherapist needs to decide instantly whether to push through the tear or whether to ease off the pressure, believing that a stretch at a later date will be possible. The decision to push on or ease off is guided by the amount of pain or discom fort felt by the patient (Is he likely to accept further stretching?) and by the type of tear felt. A 'dry blotting paper' feel, where it is proposed that one thick adhesion has ruptured, is more likely to result in a favourable outcome. Full range will be restored quickly. The manipulation should be followed up by relief of treat ment soreness and strictly adhered to home exercises if the favourable outcome is to be fully achieved. A 'wet blotting paper' feel is when a soft weak rupture is felt through a larger range. In such cases it is better to do little at one stretch. During training, such techniques should be per formed initially under supervision so that the clinician can appreciate the detail needed to find the exact direc tion to perform slow, sustained stretching and experi ence the feel of the adhesions tearing. The technique for this type of manipulation should be carried out as follows: •

Starting position /localization of forces: the patient should be stabilized with the physiotherapist's body and arm, one hand should be supporting and feeling around the joint to be manipulated while the other hand stretches the joint.

•

Application of forces: a grade IV stretching is applied to the joint in the stiffest direction. The stretch is applied gradually until a point is reached when any protective spasm starts to release. It is usual at this point for the abnormal structures to release or for the adhesions to tear and the range becomes full. There may be a sharp snap, an extended tear through a short range or an extended sloppy tearing through

Groups

3a PAIN and STIFFNESS

3b STIFFNESS and PAIN

Group 4 Fi g ure 8.42

I

Group 3 treatment

a larger range. This last response often does not pro duce a good result and the patient needs to exercise conscientiously despite experiencing a degree of pain (Maitland 1978).

Group 3 (a and b) : description. initial treatment. progression. example of movement diagram (Fig. 8.42, also see Figs 8. 1 4, 8. 1 5)

Description: clinical situations which fall into group 3 (a and b) This is the largest group of patients with neuromusculo skeletal disorders referred to physiotherapy. These patients have joints which are both stiff and painful. Patients with both stiff and painful joints are the most challenging to treat. They require the phYSiotherapist to be precise in discerning the behaviour of both the pain and the stiffness and in determining their interrelation ship. Another d1allenge is to determine whether tl1e pain and resistance are in fact associated with each other or whether they are part of separate joint disorders. The physiotherapist should, wherever possible, know the diagnOSiS and underlying pathology. This knowledge is necessary in order to interpret and understand the interrelationship between the pain and resistance. For example, if a patient injures the medial ligament of the knee, when abduction of the tibio femoral joint is assessed passively immediately after the injury the therapist would expect pain of early onset and early limiting (group 1). A week or so later when abduction is tested, pain may still be the limiting factor but this may well correspond proportionally to an increase in resistance (group 3a). After a few more weeks resistance will probably be the limiting factor to the movement with an associated amount of pain (group 3b). Eventually the movement may not be pain ful but just stiff at the end of range (group 2).

1 99

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M A ITLA N D ' S P E R I PH E RAL M A N I P U LATI O N

L A n essential prerequisite is to know whether the

pain is the dominant component (group 3a) (see Fig. 8.14) or whether the loss of range is due to joint stiffness more than pain (group 3b) (see Fig. 8.15). This will influ ence the physiotherapist's evaluation of how quickly or how slowly the joint signs will change with treatment: •

•

Where pain is dominant, in group 3a, the initial treatment and expected response should be similar to those expected for group 1, i.e. gentle techniques in the comfortable part of the painful range in order to lessen the patient's pain and permit a greater active range of movement. As pain improves, the physical resistance may also show signs of improv ing. This occurs more readily where resistance has a soft feel but not where the resistance is harder or has a bone-on-bone feel to it. Physical resistance in group 3a will vary widely in feel and may or may not improve as the pain improves with gentle techniques. If resistance does not improve as the pain lessens the patient then fits more readily into group 3b where pain is less dom inant. With less severe pain, treatment will not cause exacerbation and techniques that aim to improve both active and passive range should be used, simi lar to those used for patients in group 2.

Through detailed examination and reassessment of changes taking place, the physiotherapist can develop an understanding of how different treatment move ments can be effective in any given clinical situation.

R2 (IV+++) P2 (severe)

c

D

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ro c

I

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1,12

i?:·e Q) > Q) (f)

A

Yo

P1

(local) Figure 8.43

%R1

L

3f4

B

Range Domi nance of pain or stiffness u nclear.

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Range Stiff range, 60% of which is pain free (60% of available range).

Figure 8.44

Selection and progression of initial treatment for group 30 and 3b If the dominance of pain or stiffness is unclear (Fig. 8.43), the treatment movement should be directed towards influencing pain initially rather than trying to increase the range of movement limited by stiffness. When treating pain, the aim is for the active range to increase as the pain recedes. If this is the case the guidelines to follow are exactly those explained for treating pain in patients who fit the group 1 criteria. The exception is that when changing from accessory to physiological treatment movements, this should be considered when the pain-free range has reached 60% of the available stiff range rather than 60% of what would be normal range (Fig. 8.44). Start with an initial treatment to determine what happens to the joint signs and symptoms when pain alone is treated. What is being determined here, and for later use, is the behaviour of the pain and how it may limit the use of any stretching-type techniques. By examination of the patient's joints, the behaviour

of the pain, the most restricted movements and the pain felt when these movements are stretched can be determined. The painful/stiff movements should be correlated with the patient's loss of function, as well as establish ment of whether it is the pain or the stiffness that is limit ing function. The treatment direction chosen should be the one that corresponds to the patient's loss of func tion, i.e. the movement which reproduces the patient's symptoms or has comparable signs (Chapter 6). If stiffness is quite marked, the treatment of pain will only effect a small degree of improvement and will quickly reach a stage where progress, as determined by reassessment, ceases. When this occurs, the treatment of pain should be discontinued and treatment of stiff ness emphasized, as in group 2 but with a slight differ ence. If the patient feels pain with the stiffness (as they almost certainly will), then the physiotherapist must appreciate its extent and its site in order to be alert as to

Principles of selection and progression of mobil ization/ manipu lation tech niq ues

c

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D

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� :0

� :� I .i:!' .�

V2

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V.

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(local)

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Grade IV: stretching into some pain / discomfort.

what the patient is being subjected. Pain felt during the movement should be respected. The more easily the pain is reproduced the shorter should be the treatment time and the gentler the technique. When the comparable movement is used as the treat ment movement and where the intention or desired effect is to stretch out the stiffness, a gentle grade N - is preferable, the physiotherapist being alert to changes in the patient's symptoms during the technique. The first treatment, therefore, should be firm but not excessively painful though it must reproduce a degree of the patient's symptom (Fig. 8.45). Also when directing treat ment to resistance, excessive treatment must be avoided and treatment soreness monitored. Initial treatment of resistance should be directed towards one of the stiff but less painful directions. Assessment after 24 hours or so will answer the fol lowing questions: •

•

• •

Is directing treatment at the resistance going to be the most effective approach? Can the treatment movement be taken further into the range without provoking too much pain? Is it necessanj to go deeper into the range? Should another technique be used?

If there is no progress the treatment can be repeated or another movement can be tried, followed by reassess ment. Alternatively, a second technique can be added, followed by reassessment of the effects of using this combination of treatment movements. When further improvement in the joint range stops or slows and pain moderates conSiderably, the treat ment movements should be taken deeper into the range so that a degree of stretch is applied to the resistance (N- to N to N+ to N + + to N + + +). Initially this should be of short duration.

If pain is felt by the patient, very small amplitude oscillatory stretching movements should be used at a fairly constant position in the range. If the pain is less troublesome a larger amplitude can be used and this will lessen the possibility of treatment soreness. If pain is only reproduced with firm pressure then it is firm pressure that must be applied. The joint can be stretched strongly three or more separate times, each stretch lasting 1-2 minutes. Many different movements which are stiff should be used during one treatment ses sion as long as the effects of each technique on the active range are reassessed. Further progression of treatment is then guided by the assessment of treatment effects at the follow-up visits. More than one site of pain arising from different joints or different areas (different components) should be treated separately. This situation often arises in the hand and the foot. Treatment soreness can be relieved by using large amplitude movements in the painful direction but short of pain/soreness. In the same way, pain associated with a joint that needs to be stretched can be relieved by using large amplitude movements in the stretching direction or other physiological directions. Improvement of these patients will occur in one of two ways: either pain and resistance will diminish until a pain-free full range is achieved, or pain recedes and resistance becomes a harder resistance which will only change if treatment is progressed along the lines of group 2 patients, i.e. stiffness alone. This should include the consideration of manipulation if stiffness does not resolve. It goes without saying that active functional stretching should also be an integral part of the rehabili tation process. However, when treating stiffness in group 3b, where pain is still a factor to consider, both physiological and accessory movements should be used but differently from group 2 when there is stiff ness alone: •

Accessory movements at the physiological limit should still be used but the physiological position in which the accessory movements are performed should be decreased in its position in range in rhythm with the increase in the accessory movement.

•

The more intense the pain the greater should be the in-rhythm reduction of the physiological position.

•

As the pain recedes in response to treatment so the physiological position is not reduced in range.

•

This can be progressed, when pain is significantly lower, to performing the accessory movement while simultaneously increasing the physiological range as in group 2.

201

202

M A IT LA N D'S P E R I P H E R A L M A N I PU LATI O N

Clinical example •

Gr P 4

If

Caudad longitudinal accessory movement of the glenohumeral joint in abduction is the treatment of choice.

•

As the longitudinal caudad accessory movement of the head of the humerus in the glenoid cavity is increased, the glenohumeral abduction is reduced by 5-10°.

•

As the caudad longitudinal movement of the head of the humerus is increased, the arm and elbow are taken into abduction in parallel with the accessory movement.

•

As the caudad longitudinal movement of the head of the humerus is increased, the arm and elbow are kept still, thus producing a further increase in glenohumeral abduction at the same time.

Treatment of a stiff and painful joint, if done too strongly or at the wrong time, will be unsuccessful and cause WUlecessary pain and bring the treatment into disrepute. Nevertheless, it is an important skill for the manipulative physiotherapist to master because the effects can often be dramatic. Therefore it is important

Momen ry pain

Groups

Figure 8.46

C

G roup 4.

,-----�I----,-I--�I---,

P' (intensity)

to take the careful steps necessary to ensure that the full

potential

of

manipulative

physiotherapy

D

:

R' (IV-)

is

reached with patients in this clinical group.

I

Group 4: description, initial treatment, progression, example of movement diagram

A

Description: clinical situations which fall into group 4

Figure 8.47

P1(loc)

Selection and progression of initial treatment for group 4 The combined movement which reproduces the patient's pain should be the movement chosen in treat ment. It should be performed as a mixture of grade IV

R1

B

40% of 1 st carpometacarpal EI trapezium

t

(Fig. 8.46, also see Fig. 8.1 6)

A patient may have a sudden jab of pain at the base of the thumb while beginning to lift a kettle. The pain is fleeting and can occur on some occasions but not on others. This is an important group of patients who are often poorly or unsuccessfully treated. Examination must divulge the joint signs which also reproduce the patient's symptoms (usually combined physiological and accessory movements or combined movements with compression). Sometimes it takes two or three sessions to find the relevant joint signs. It is often difficult to decide whether the joint hurts because it is being stretched or whether the joint is actually painful.

I

Treatment of patients with momentary pain.

and ill movements for several minutes (Fig. 8.47). If the treatment is effective the patient will respond quickly and improvement will occur by at least the third visit.

Clinical example A patient may drop things because of a $harp, severe, momentary pain at the base of the thumb when grip ping, say, a dinner plate. The comparable sign in this case may be a posteroanterior movement of the first carpometacarpal joint with the joint held at the limit of extension and the joint surfaces firmly compressed together (Fig. 8.48).

Spasm There are four main type of spasm which can be pre sent as associated joint signs: • •

handling spasm as a response to movement

Principles of selection and progression of mobil ization / manipu lation techniques

c

S2 (IV+) D I

I

I

R' (strength)

I

Y2

P ' (minor intensity)

:z:. "55 >

CD (f)

A

I Y.

I Y2

5° knee extension

I 3f4

A

P1 R 1 S1 B

Muscle spasm, restriction of knee extension and pain

Figure 8.49

Muscle spasm, restriction of knee extension and pain.

Spasm as a response to quick movements at the limit of a mildly aching, stiffjoint Figure 8.48 Posteroanterior movement of the first carpometacarpal joint.

•

•

as a response to quick movements at the limit of a mildly aching, stiff joint as the limiting factor of the available range.

Handling spasm Muscle spasm may be caused unnecessarily during treatment of painful joints, if the painful joint is badly positioned or carelessly held by the physiotherapist or moved unevenly, roughly or without due respect for pain during treatment. To avoid such situations, care ful positioning of the patient, competent handling and well-controlled techniques are essential requirements.

Spasm as a response to movement When muscle spasm occurs as a constant minimum response to movement no attempt should be made to thrust forcibly through the spasm. In treatment the spasm is best influenced by tiny (grade IV) amplitude movements that gently nudge at the muscle spasm, gradually attempting to move further into the range. If there is no inlprovement, nudging movements should be used in an accessory movement that is slightly restricted by spasm. If this is not effective, the opposite movement to the physiological movement most restricted should be used with grade IV movements at the limit of this range. Joints which exhibit this kind of spasm are often slow to respond to treatment and do not readily respond to relaxation techniques either.

Spasm may present in patients witll mildly or inter mittently aching joints. On examination one or more movements may be slightly stiff and painful, such as knee extension (Fig. 8.49). If passive movements are examined at the usual speed, part of the abnormal find ings may be missed. However, if quick, sharp move ments are used at the limlt of the range, slight muscle spasm may be felt as a response to the test movement. When this response occurs, the treatment movement must be performed so that it almost produces this response. The further away the treatment movement is from producing this response, the less likely is the treat ment to be successful.

Spasm as a limiting factor of the available range Muscle spasm (or holding) in group 3 patients may be the factor limlting range. This type of spasm occurs at the limlt of the available range, is very strong and occu pies only a small part of the range. By treating the pain of a stiff/painful joint and assessing its effects, such treatment will give a good indication of the behaviour of the patient's pain and will also show the degree of irritability of the joint disorder. However, when such spasm is the dominant sign that can be found on exam ination of the joint movements, treatment of pain alone is unlikely to help and therefore movement through range to spasm is likely to be more effective, i.e. the joint should be moved through a physiological range up to the point where spasm starts and there perform very small amplitude movements (grade IV) in con junction with active relaxation techniques. Oscillatory movement is not always desirable (because of irritability or latent exacerbation) and con trolled, sustained stretching techniques may be more valuable. This applies to treating painful joints whose

203

204

M A ITLA N D 'S P E R I P H E RA L M A N I PU LATI O N

[ range i s limited b y protective spasm (or structural tightness/ adhesions): •

•

•

•

•

The physiological movement which is restricted and painful is the movement to be used. It is taken to the comfortable limit of range and at that point the physiotherapist's grip is adjusted in order to: 1. have a full control of the movement 2. be in the most economical position to sustain the position 3. prevent the patient moving too much and there fore the therapist losing control of the movement. The chosen movement is then moved slowly into resistance with the physiotherapist being prepared to retreat 1° (1 mm) if the patient winces. With skill, experience and concentration this retreat can be timed to occur just before the patient winces (the patient thus recognizes the skill of the operator and gains confidence to allow further progression, irre spective of pain). Eventually the stretch position can be sustained for 1-2 minutes or more which gives the structures or protective spasm more time to become less painful and more compliant. Consequently the movement can be taken a further degree (millimetre) or so and held until the pain, resistance or spasm reduces again. At this stage small oscillatory smooth movements are performed at this range. They are very grad ually increased in amplitude but always reaching the same end position until a 20-30° movement can be performed. This treatment sequence can then be followed up by the patient attempting the same range of stretching actively. If the range of movement does not improve further and if the spasm shows no signs of relaxing, it may be necessary to consider manipulation under anaes thetic. However, it may be preferable for the manipu lation to be carried out on the conscious patient so that the patient can give feedback and information to direct the exact technique to be used. Manipulation under pethidine is a far more preferable choice. How ever, other factors related to the patient's personality may sway the judgement in favour of manipulation under anaesthetic.

Selection of techniques: clinical grouping examples Group •

7

68-year-old retired miner, now runs marathons for a hobby.

• •

•

•

•

•

Jarred his right hip while digging over his allotment. Immediate, severe pain in his hip causing him to limp badly with only partial weight-bearing possible. The following day the hip was very sore, with pain radiating from the groin down tl1e front of the leg, very painful to walk and flexing the hip was severely limited by pain. Has not been able to lie on his right side due to pain; comfortable lying on his left side. Five days after injury NSAlDs have helped but hip is still very painful. Choice of technique would be grade I or II accessory movement of the hip in the pain-free left side lying position.

Group 2 •

•

• •

•

56-year-old cleaner with a now stiff but painless frozen shoulder. Shoulder flexion, abduction and hand-behind-back functionally restricted by stiffness by 20-30°. Complains of functional restriction rather than pain. Choice of technique would be combinations of grade IV to IV + stretching techniques towards the end of range (e.g. quadrant, medial rotation), along with accessory movements stretching at the limit of the physiologically restricted movements. Treatment of corresponding components such as stiffness in the cervicothoracic spine and scapulothoracic regions.

Group 30 •

•

•

•

•

45-year-old ex-professional footballer with degenerative osteoarthrotic changes of his left knee related to medial meniscectomy 20 years ago. Flare-up of knee pain with swelling after a long walk, stiffness into knee extension. Cannot really get knee comfortable but easiest in slightly bent position. Treat with accessory movements in slight flexion initially, then, after increasing pain-free amplitude, progress to small amplitude grade IV- stretching into extension, respecting and monitoring the effects on the behaviour, site and qualities of the pain. Gradually progress into the resistance until grade IV + + + pain-free extension can be achieved.

Group 3b •

20-year-old office worker with a chronically stiff and painful left ankle after a bad sprain playing bad minton 6 months ago.

Principles of selection and progression of mobil ization / ma n i pulation techn iques

•

Ankle feels stiff and painful when walking up slopes, going up stairs or squatting down.

•

Both dorsiflexion and inversion of the ankle are stiff and painful locally across the front of the ankle.

•

•

•

Pai n Accessory neutral without discomfort • Accessory neutral into discomfort • Accessory neutra l into pain • Physiological large amplitude without discomfort • Physiological large amplitude into discomfort • Physiological large amplitude into pain •

Treatment of choice would be AP or PA grade IV small amplitude stretching with the ankle at the limit of dorsiflexion as firmly as the pain allows, ini tially releasing the dorsiflexion a few degrees as the accessory stretch is applied, then, as the pain settles, stretching the accessory movement without releas ing the dorsiflexion and finally stretching the acces sory movement at the same time as increasing the stretch into dorsiflexion.

Stiffness Physio l ogical limit of range • Accessory l imit of physiological range •

Pai n / stiffness As for pain • As for stiffness (modified)

Treatment soreness can be eased using large ampli tude movements in the direction of the stretch (Le. dorsiflexion).

•

Similar or other accessory movement techniques can be applied in the same way with the ankle held in inversion.

•

Group 4 •

A 23-year-old cricketer who often experiences a momentary sharp, severe jab of pain in the back of his elbow when he has to throw a cricket ball from the boundary.

•

Joint signs were found and the exact pain was repro duced when the elbow was held in extension! adduction with pronation to the limit, and then dis traction of both the radius and ulna along the fore arm line was performed as a grade IV + .

•

Box 8 . 1 Recorm.nen4ed the � of pal'"

The symptoms began to resolve quickly after the third treatment which involved stretching into the pain for 2 minutes three or four times each session.

Box 8.1 summarizes the movement techniques used in the treatment of pain and stiffness.

THE SOURCE O F THE SYMPTOMS (CAUSE OF THE SOU RCE) One of the prime objectives for the manipulative physio therapist is to establish the source and the cause of the source (joints or vertebral segments which may be con tributing to the development of a disorder in another joint or vertebral segment) of the patient's symptoms. Chapter 10 reviews neuromusculoskeletal disorders and common or recognizable pain patterns. Such pro filing can be useful in helping to establish where the patient's movement-related symptoms are emanating from and therefore where and how treatment techn iques need to be directed.

Momentary pain Combined physiologica l ! accessory, limit

When considering choice of treatment technique it is worth noting that through qualitative research it is known that some joints respond better to some tech niques than others. And also through quantitative research it is important to be aware of the effects that treatment techniques can have on both the intra- and periarticular structures within a particular joint.

The joint to be treated It is necessary to consider the choice of technique in relation to the joint which is the source of the patient's symptoms because not all joints respond to the same movement in the same way. For example, accessory movements of the small bones in the hand and foot are more valuable than accessory movements in the hip. There are two factors which make one movement a better technique than another: 1.

the ease with which the movement can be performed and controlled by the operator (e.g. shoulder flexion is much easier to control and perform passively than is shoulder abduction)

2. the relationship of the technique to the normal movement of the joint (e.g. longitudinal movement of the head of the humerus is much more a part of normal shoulder movement than is longitudinal movement of the radius at the elbow or wrist). It is also the case that techniques will differ according to the classification afforded to the patient's symptoms and signs. Techniques for groups 1 and 3a would not be

205

206

M A ITLA N D 'S P E R I P H E RA L M A N I P U LATI O N

adequate as treatment for group 2, 3b or 4 . Likewise techniques for group 2 would be ineffective for group 4. The value of each technique used in treatment must be aSSiduously checked throughout the course of treat ment and this is done by checking the symptoms and signs repeatedly throughout. Sometimes it is necessary to perform a technique twice before an adequate assessment of its value can be made. However, this assessment must be clearly made before the technique is discarded or used in combination with another. Table 8.1 lists the joints that are frequently more effectively treated by the indicated movement. This table does not mean that other techniques should not

Table 8 . 1

be used but it may be a useful guide to which tech niques may need to be assessed first.

IN TRA-ART ICULAR AND PERIARTICULAR J OI N TS Synovial joints can be clinically subdivided into intra articular and periarticular (Maitland 1991) (Fig. 8.50). •

Intra-articular structures which may be a source of symptoms consist of adjacent articular cartilage and subchondral bone, the joint space, synovial fluid and synovial membrane (including plicae), the inner

Joints commonly treated

Joint

Group

Most valuable techn iq ues

Least valuable techniques

Glenohumera l

1 , 3a

PAl longitudinal

Abduction

Acromiohu meral

2, 3b, 4

Arm-by-side: neutral pain-free F l O, O/ lock PAl longitudinal in a or limit

Acromioclavicu lar

1 , 3a 2, 3b

PAl longitudi nal in neutral pain-free Longitudinal in elevation F l O, O/ lock

Sternoclavicu lar

3

F l O, AP, longitudinal

Elbow

2, 3, 4

E, E I Ab, E I Ad F, Fl Ab, F I Ad Pronation I supination PA head of radius, olecranon movements

Wrist/hand

1 , 3a 2, 3b

Accessory radiocarpal, i ntercarpal AP/ PA at the physiological limit or combined with compression Radioulnar AP/PA with compression Digit accessory movements

Hip 2, 3, 4 Knee I patella 2, 3, 4

Footl a n kle 2, 3, 4

Temporomandibular

1 , 3, 4

Rotation F/Ad with rotation and compression Tibiofemoral AP or rotation in neutra l Patellofemora l distraction E, E lAb, E I Ad. F, FlAb, F I Ad Rotation in different physiological positions Patella: long itud inal movements with compression Ankle accessory movements AP/ PA in neutral PF, DF, rotation Accessory movements in physiological subtalar rotation, Ab, Ad I ntertarsal AP/ PA Transverse movements Med. / Lat. Longitudinal caudad

Longitudinal

Principles of selection and progression of mobilization/ manipu lation tech n iques

207

J one-third of the joint capsule which has close affinity to the synovium and any other intra-articular struc tures such as menisci. •

Periarticular structures which may also be a source of pain consist of the outer two-thirds of the joint capsule, collateral or supporting ligaments and muscle tendons which cross the joint.

The evidence for intra-articular pathology and pain is clear (Van Wingerden 1995), as is the evidence for peri articular pathology and pain (Hunter 1994). Chapter 10 reviews intra- and periarticular dis orders and how to identify them clinically. This section will review the evidence base behind the use of passive mobilization/manipulation for intra- and periarticular

joint disorders and provide treatment guidelines which will include: •

•

•

the use of painless oscillatory movement to influence signs and symptoms originating from intra- and periarticular structures movements with compression loading to help restore the function of articular cartilage the use of stretching techniques into the bite of pain to affect minimally restricted periarticular structures.

Intra-articular joint structures and function (Fig. 8.51 ) Articular cartilage In synovial joints, the opposing surfaces consist of hyaline cartilage or articular cartilage which, in its nor mal state, is macroscopically white, shiny and firm, while microscopically the superficial layer has an unbroken though rippled appearance. Articular cartilage consists of:

PERIARTICULAR STRUCTURES

Capsule Ligaments Muscles

•

Ground substance or matrix which contains proteo glycan, amino acid chains. These glycosamino glycans (Fig. 8.52) help to enhance the nutrition, diffusion, synthesis and bioelectric events taking place within the articular cartilage. They also con tribute to the tensile strength of articular cartilage in resisting compressive loading. Evidence shows that during periods of immobilization the measurable proteoglycan content of the ground substance is reduced (Lowther 1979). During prolonged compres sive loading the proteoglycan molecules increase in size and increase their negative charge. These events act to produce a greater repellent force to counteract the compression (Van Wingerden 1995). The water content of cartilage accounts for about 75% of its weight (Bland 1983).

•

Collagen fibres, 90-95% of which are type II, adding

Capsule

Synovium

Subcondral bone -�-

Joint space Synovial fluid Meniscus

to the hydrophilic and glycolytic properties of articu lar cartilage, as well as its tensile strength. •

INTRA-ARTICULAR STRUCTURES

Subchondrial bone Articular cartilage Labrum Meniscus Ligaments Fat Synovium Figure 8.50 Cli nical subdivisions of synovial joints. Reproduced by kind permission from A. R. Blake, 2004.

Chondrocytes/chondrobLasts which function to syn thesize articular cartilage. In adults this synthesis takes place mainly anaerobically with the help of synovial fluid diffusion processes.

Articular cartilage is made up of several layers or zones of cells which appear to be consistent with the prime functions of articular cartilage in coating the ends of bones which move and load bear. These functions load distribution and deformation - decrease the loading on subchondral bone, as well as providing the cartilage with tensile strength, durability, low friction coefficient,

208

M AITLA N D ' S P E R I P H E R A L M A N I P U LATI O N

Selection Progression Intra-atricular

Immobilization Stress deprivation

Subchondral Bone C fibre innervation Substance p present Joint surface pain

Figure 8.51

I ntra-articu lar structu re

and function. Synovial membrane Synovial fluid Viscous, elastic, plastic Nutritious properties Hyaluronic acid Polypeptides Phagocytosis Thyxotrophic

Mechanical properties Creep Stress relaxation Load distribution Deformation/Durability Low friction coefficient Permeability

Composition

90-95% Type 2 collagen fibres Ground substance (matrix) Proteoglycans

minimized peak stresses, elasticity, permeability and insensitivity. The cells in the surface layers appear flattened. Along with synOVial fluid this contributes to the low friction coefficient, surface to surface contact, fluid film lubrication and boundary lubrication. The superficial zones of articular cartilage are also semi-permeable which helps lubrication and nutritional transport by diffusion. The superficial zones, therefore, function to reduce surface wear. The transitional zone of cartilage is that region where the shear forces encountered by the surface layers when the joint surfaces glide on one another are transformed into compressive forces. As a consequence, there is a greater distribution of the load-bearing forces over a much greater surface area. The deeper layers of articular cartilage contain cells which act like tightly bound cylindrical bedsprings which have a shock-absorbing role as well as nutrition enhancing permeability. There is also a calcified zone whereby there is a tran sition from soft articular cartilage to stiffer subchondral bone. In this region the cartilage anchors itself to the subchondral bone (Fig. 8.53). The subchondral bone is richly innervated and vascularized and is known to contain pain-producing neuropeptides such as sub stance P (Van Wingerden 1995).

Chondrocytes Chondroblasts

Through trauma, overloading, disease or wear and tear full thickness defects may appear in the articular cartilage of synovial joints (Bland 1983). Allogenic chemicals and inflammatory mediators can then sensi tize the nociceptors in the subchondral bone causing pain. Also, as a consequence of raised intraosseous pressure, there may be arteriole collapse in the sub chondral bone leading to osteonecrosis and pain.

Synovial membrane, synovial fluid and the consequences of pathology Synovial membrane lines the joint capsule, intra articular ligaments, tendons and intracapsular bone. Cells within the membrane function to secrete hyal uronic acid which affects the viscosity of synovial fluid. The cells also function to promote phagocytosis and secrete polypeptides and cartilage-degrading enzymes. Synovial fluid has viscous, elastic, plastic and nutri tious properties. It plays a very important role in the movement of joint surfaces on each other. The proper ties of synovial fluid are complex when considered in relation to the part they play in contributing to the low friction coefficient and nutrition of articular cartilage. With regard to movement of a synovial joint, the coefficient of friction between adjacent joint surfaces has been presented as 1 .002 by Charnley (1973) and

Principles of selection and progression of mobil ization / manipu lation techniques

Chondroitin sulfate

\

(a)

/ Keratan sulfate

� Protein core (b )

-O

� � � � _

H

O

H

OH

NH-CO-CH3

OH

Hyaluronic acid

(e)

� � � � C

-O H

O

H

H

H

OH

O_ H

NH-CO-CH3

Chondroitin-6-sulfate

(d)

COO -

_o

CH2-0H

� � � � 0

0

OSO O

H

H

H

OH

o_ H

NH-CO-CH3

-o :

Chondroitin-4-sulfate

:

( e)

CH OH

_O

O

H

OH

H

CH2- S03 -

0

H

OH

H

0 OH H

0

H

0H

NH-CO-CH3

Keratan sulfate Figu re 8.52 (a) Proteoglycan monomer (left) composed of a protein core with the chondroitin sulfate and keratan sulfate side chains. In collagen type I, fragments (right) of the proteoglycan monomer also exist. (b) Hyaluronic acid; (e) chondroitin-6-sulfate; (d) chondroitin-4-sulfate; (e) keratan sulfate. Reproduced by kind permission from Van Wingerden (1 995) and Scirpo Verlag.

between 1 .013 for normal stresses and 1 .2 for higher than normal stresses by Malcolm et al (1975). The viscosity of synovial fluid is different in differ ent joints and it also varies within a joint when there are changes in the type of movement being performed. Clarke (1975) stated that, as a result of experimental work, the coefficient of friction 'decreased with increased load'. For a normal joint to function properly it is neces sary to have normal articular cartilage and synovial fluid. When these two components are normal and a joint is moved passively, with or without compression, any variations that may occur in the coefficient of fric tion will not be perceptible to an examiner. The following figures show the recently dissected hip joint of a heifer being moved through an arc of approximately 30°. This is performed firstly with the joint surfaces gently opposed (Fig. 8.54) and secondly the same movement is produced while the joint surfaces are firmly compressed together (Fig. 8.55). This is the best possible method of manually and mentally appre ciating precisely just how smooth joint movement is when the surfaces and synovial fluid are normal and, more importantly, how the feeling of the quality of the smoothness is unchanged in the normal joint when compression is added. (The experiment is strongly rec ommended to prove the credibility of the fact.) Mow and Kuei (1975) reported that they analysed the fluid mechanics of the squeeze-film action as a function of the viscoelastic parameters of whole synovial fluid, and hyaluronic acid solutions. The theoretical solution showed that normal whole synovial fluid is important in the protection of cartilage, lowering overall pressure in the fluid and increasing the total loaded area of the joint. The important fact that they determined, which relates directly to this discussion, is stated in their words:

It was concluded that the viscoelastic behaviour of the whole synovial fluid, attributable to the hyaluronic acid protein complex, is important in the analysis of the wear of articular cartilage and that lubrication and wear must be considered as two separate but often interrelated phenomena. Barnett (1956) was able to show that by injecting hyaluronic acid into one ankle joint of rabbits, thereby reducing the viscosity of the synovial fluid, and by subjecting the rabbits to long periods of exercising, the injected joints showed much more severe attrition of the articular surface than the control joints. Broderick et al (1976) have shown that there are chemical differences in the synovial fluid of joints

209

210

M A I T LA N D ' S P E R I P H E RA L M A N I P U LATI O N

Figu re 8.53 Articu lar cartilage zones. Reproduced by kind permission from Van Wingerden (1 995) and Scirpo Verlag

Zone 1 Zone 2 Zone 3 Zone 4

Zone 5

Zone 6 Zone 7

§

1

§

§

',bd-ood" , boo, Bone Vascularization

Fig u re 8.54 Joint movement without compression.

Figure 8.55

J oint

movement with compression.

1 1

Tide mark

.

Pri nciples of selection and progression of mobil ization/ manipu lation tech niq ues

affected by rheumatoid arthritis, osteoarthritis, Reiter's syndrome, pigmented villonodular synovitis and septic arthritis compared with the synovial fluid of a normal joint. With the chemical changes in the synovial fluid that occur with osteoarthritis, there may also be a change in the viscosity of the synovial fluid. Thus, as well as provoking attrition of the articular surfaces, changed viscosity may also increase the coefficient of friction. In Clarke's (1975) experimental work he found that when the joint was 'run dry, the coefficient increased 2 to 10 times'. He also stated that the wear of the carti laginous surfaces in the dry runs 'was evident as fis suring and flaking of the surface layer similar to osteoarthri tic fibrilla tion'. McDevitt and Muir (1 977) carried out an experi ment in which osteoarthritis was induced in the right knee of dogs by sectioning the anterior cruciate liga ment. Six or more weeks after the operations they found that gross changes in the cartilage of the affected joints were evidenced by the surface being 'less shiny and softer and was noticeably thicker than the control cartilage' which was white, shiny and firm. Micro scopic changes were noticeable one week after the operation. 'The cartilage . . . one week after operation, was slightly roughened with occasional small clefts . . . The number and depth of the clefts was greater two weeks after operation . . . Fibrillation . . . gradually pro gressed with time after the operation until, after 7 weeks, deep clefts were evident and by 16 weeks erosion of the articular surfaces was complete' (Fig. 8.56).

Clinical application With changes in the synovial fluid and the superficial layers of the articular cartilage there is an accompany ing change in the coefficient of friction. From the time when changes begin, a stage must be reached when, on physical examination of the joint's movements, the normal feel of friction-free movement is replaced by a perceptively less friction-free feel. This clinical change is more readily appreciated when the joint surfaces are held compressed together and moved. Everyone is familiar with the feel of moving a joint which is devoid of all (or nearly all) its articular cartil age. Similarly, we would all accept that some of these joints have a rougher feel when moved than others. We should, therefore, be able to accept th.e fact that a stage must exist when this change in friction first becomes perceptible on physical examination. It is the early stages in the changes of friction-free movement that can be assessed by passive movement and this assess ment can be appreciated earlier if joint surface com pression is utilized during the test movement. The time

Figure 8.56

(a) Normal cartilage; (b) fibrillated cartilage. Figure 8.56a reproduced with special thanks to Dr Stephen Pang and the Department of Anatomy and Cell Biology at Queen 's U niversity Ontario, Ca nada.

at which this change in friction will be perceptible to any particular examiner will depend on the threshold of force perception.

The healing of articular cartilage •

Evidence is now overwhelming that chondrocytes can and do divide and synthesize the macro molecules of cartilage. Osteoarthritic lesions are reversible according to Bland (1983).

21 1

212

M A I T LA N D 'S P E R I P H E R A L M AN I P U LATI O N

•

Articular cartilage i s avascular and is prevented from mounting a vascular response when there is isolated cartilage damage. Healing of articular carti lage is limited by the absence of vessels within the cartilage. Some cartilage defects never heal.

•

Chondrocytes in articular cartilage are capable of cell division. Regeneration of cartilage is slow and occurs most at its margins. However, the rates of syntheSiS in vitro are increased 1 0-20 fold b y mechanical stimulation.

•

Articular cartilage healing after injury depends on the depth of the defect. Healing can occur extrinsi cally. This form of healing is dependent on a synovial reaction or subchondral bone being penetrated at the time of injury. Subchondral capillary injury results in the formation of a fibrin clot which is then replaced by granulation tissue and fibrocartilage. Healing of articular cartilage can also occur intrinsically. This form of healing is dependent on the presence of chondrocytes to synthesize a new matrix. In this case healing is dependent on diffusion of nutrients from synovial fluid. Isolated injury to cartilage which does not extend to subchondral bone heals slowly and incompletely.

Contemporary methods of promoting the healing of articular cartilage are reviewed by Hunziker (2002) who concludes that there are many novel and promis ing biologically based approaches to the enhancement of articular cartilage repair. The vast majority of these approaches are still in the experimental and develop mental stages. The review looks at: •

•

•

•

•

•

spontaneous repair responses in different types of lesions surgical interventions aimed at inducing repair without the use of active biologics surgical interventions drawing on autogenic and allogeneic tissue principles growth-factor-based biological treatments and gene transfer protocols the technical problems associated with repair interventions the role of mechanical factors.

Hunziker acknowledges that the outcome of repair tissue quality in a number of animal experiments is improved by intermittent active or continuous active/ passive motion and that this has been recognized for some time. The conclusion drawn is that ' . . . in human clinical practice, post-operative care and phYSical ther apy will most probably play I}ot inconsiderable roles in determining the healing outcomes' [of the biological based approaches to the enhancement of articular car tilage repair] .

The clinical scientific evidence for the use of exercise, passive mobilization and compression to treat in tra-articular disorders Much of the scientific evidence leading to the under standing of the importance of exercise, passive move ment, and cyclical loading to maintain an ideal functional environment for articular cartilage and to help promote healing of defective cartilage comes from studies on stress deprivation and consequently reversal of stress deprivation, i.e. the effects of immobilization and mobilization on the healing of articular cartilage (van Wingerden 1995). Exercise Lowther ( 1979) concluded that there are metabolic effects of mechanically distorting the cell mem brane of chondrocytes and that there are two differ ent roles of movement, both of which stimulate the cartilage to produce matrix components: diffusion of nutrients into the matrix from the synovial fluid, and chondrocyte membrane deformation similar to that produced during loading of the joint.

•

•

Ekholm (1955) suggested that exercise to the joint appears to increase the penetration of cartilage to nutrients from the synovial fluid.

•

Maroudas et al (1968) proposed that an increased flow of nutrients from the synovial fluid into carti lage is due more to agitation of the fluid film on the cartilage during exercise than to cartilage compres sion and decompression.

•

Lowther (unpublished observation, 1983) referred to this 'agitation' as 'surface stirring', a term which superbly fits the treatment techniques described below.

Passive movement Caterson and Lowther (1978), from their work with sheep, propose that 'alterations in pro teoglycan synthesis and content are the result of nutri tional changes directly related to joint movement and stress'. In other words, cartilage nutrition is maintained by passive movement, without concomitant loading of joint surfaces. The case for the clinical value of adding compression in the treatment of intra-articular dis orders will be explored later in this chapter. Lowther (1983) in an unpublished observation stated that 'one would predict that compression or loading in the joint should be minimized, particularly in the very acute stages of inflammation when the polymorphonu clear cell population in synovial fluid is maximal. When this stage has passed, then load bearing should, on bal ance, be more beneficial than detrimental to recovery of the matrix.' These stages correspond on the one hand to

Principles of selection and progression of mobil ization / manipu lation techniques

the severe restrictive intra-articular disorder and on the

If the work of Salter et al

(1980) is to be believed, the

other hand to those patients who experience minor

relationship between the paffiful osteoarthrotic joints

symptoms on compressive loading.

and the treatment by passive movements may, by

Salter et al (1980) found, when studying the healing of

improving nutrition, have an advantageous effect on

defects in articular cartilage, that an affected joint con

the cartilage (and probably on the associated com

tains a far higher percentage of hyaline cartilage cells

ponents) to the extent that the patient's arthrotic joint

when it is moved passively and continuously (continu

will function better and be less painful.

ous passive motion, CPM) than if the joint is treated

(1991) has proposed that there

by active movement, and far more than if it is treated

Compression

by immobilization. These findings complement the

is sufficient evidence to validate the view that symp

authors' view that controlled passive movement is more

toms may arise from a joint surface disorder and that

Maitland

effective in relieving the pain of intra-articular disorders

there are several clinical circumstances under which

of the osteoarthrotic type than is active movement.

examination of movement of the synovial joint with its

Salter et al

(1975) state that:

surfaces compressed together should be performed. These include:

In order to study the effects of continuous passive motion on the healing of experimental full thickness defects in articular cartilage [they) made a standard experimentaL injury [four full thickness drill hoLes) in the distal joint surface of the femur in twenttj immature rabbits which were then treated by one of three methods: immobilization, normaL cage activity, or continuous passive motion for periods of up to 4 weeks. Healing of the 80 defects was studied closely and histologically. With immobilization, fibrous tissuefilled the defects and there were many joint adhesions. With normal cage activity there was imperfect heaLing by a combination of fibrous tissue and poorLy differentiated cartilage. With continuous passive motion, however, healing through the formation of new hyaline cartiLage (chondroneogenesis) occurred in over half of the defects within 4 weeks. Gebhard et al

(1993) found that in 30 rabbits with

•

when the subjective information suggests the presence of a joint surface disorder

•

when the history indicates that the injuring activity includes joint loading

•

reproducing the patient's symptoms when other test movements have failed to do so

•

when through-range-pain is present and the pain response is greater when compression is added, therefore confirming the presence of joint surface related symptoms

•

assessing any changes in the friction-free feel to joint movement when compression is added

•

determining the most appropriate technique to progress the treatment of a joint surface disorder

•

exploring the most comfortable means of treating a very painful periarticular disorder.

Compression can be applied to any synovial or non

experimentally induced intra-articular injury anything

synovial joint. Many of the techniques are described

less than

16-24 hours of CPM was ineffective in pre venting joint stiffness whereas anything less than 24

elsewhere in this text, such as for the inferior radio

hours CPM was ineffective in reducing joint swelling.

humeral joint (Chapter

Lowther

(1979) goes some way in. challenging the

ulnar joint, the superior radioulnar joint, the radio the ankle (Chapter

12), the hip (Chapter 14) and 16). Compression can also be added

notion as to whether his observations can apply to osteo

easily, with skilled application, to joints such as the

arthrotic joints by summarizing his work as follows:

carpometacarpal, metacarpophalangeal, tarsometatarsal, metatarsophalangeal and interphalangeal joints. It may

Although the cartilage shows degenerative changes, these tend to be focal. Since inflammation of the synovial membrane is not a major feature, the joint capsuLe and Ligaments are not subject to the same enzymatic damage; continued Load-bearing will not affect the capsule and tendons, but may increase the rate of deterioration of the cartilage surface. However, movement of the joint is essential to maintain cartilage nutrition for as long as possible, and to minimize adhesions and bony fusion which tend to increase as the cartilage surface degenerates.

also be necessary on occasion to use functional weight bearing positions in which to apply mobilization tech

8.57), 8.58) or the hip joint (Fig. 8.59).

niques, for example, the tibiofemoral joint (Fig. the ankle joint (Fig.

Compression can be applied further to the gleno humeral joint as follows (Fig. •

Patient starting position:

8.60):

supine lying in the middle

of the plinth with the elbow flexed. •

Therapist starting position: standing by the side of the plinth facing across the patient's body.

213

214

M A I T LA N D ' S P E R I P H E R A L M A N I P U LATI O N

Figure 8.59

Hip compression in side lying.

Figure 8.57 Mobilization of the tibiofemoral joint i n weight bearing position.

Figure 8.58 position.

Mobil ization of the ankle joint in weight-bea ring

Figure 8.60 Glenohu meral movement with compressio n : (a) l o w a n g l e ; (b) h i g h angle.

Principles of selection and progression of mobi l izatio n / ma n ipu lation tech n iq ues

•

•

Localization of forces: the examiner should fully sta bilize the patient's arm against the side with the examiner 's arm. The palm and heel of the exam iner's other hand should be placed around the greater tuberosity of the humerus with the forearm directed at right angles to the glenoid cavity. Application of forces: the examiner then moves slightly so as to abduct and adduct the patient's arm through an arc of 30° from approximately 20° of abduction to 50°. The arc should be oscillated firstly without any pressure being exerted by the examiner's hand against tlle greater tuberosity of the humerus and then repeated with pressure against the tuberosity compressing the head of the humerus into the gle noid cavity (Fig. 8.60a). As the arm is taken further into abduction, ilie compression is effected by the left hand and the righ t thigh pushing from the elbow along the line of the shaft of the humerus, in this case (Fig. 8.60b). The resultant vector of these forces pro duces a compression of the head of the humerus in

the glenoid cavity at right angles to ilie surface of ilie fossa. The smoothness of movement should be com pared, as should ilie pain response in the com pressed and non-compressed situations. Compression can be applied to the patellofemoral joint (Figs 8.61-8.64) as follows: •

Patient starting position: ilie tibiofemoral joint should be positioned in extension and also in different pos itions of flexion. The reason for this is iliat in different

Figure 8.63 Cephalad movement with compression with the knee flexed.

Figure 8.61 Cephalad movement with compression with the knee extended.

Figure 8.62

Caudad movement with compression with the knee extended.

Figure 8.64 Caudad movement with compression with the knee flexed.

21 5

216

M A I T LA N D ' S P E R I P H E R A L M AN I PU LATI O N

L positions o f tibiofemoral flexion the undersurface of the patella will have different points of contact with the femoral condyles. •

Therapist starting position: standing by the side of the couch facing across the patient's body.

•

Localization of forces: one hand should cup around the patella in order to direct the movement. The other hand should be placed so that the heel of the hand is in contact with the margin of the patella at a point relevant to the direction of movement required. When compression is required the hand which is cupped around the patella is used to apply pressure through its anterior surface while the other hand moves the patella. The examiner's elbows should be positioned in line with the movement direction to be performed.

•

He complained of intermittent severe sharp pain brought on by movement, particularly if he knocked his toe, even lightly. Such pain would last for several minutes before subsiding, and even following this interval he was well aware that symptoms were more easily provoked than at other times.

•

He responded well to initial physiotherapy interven tion but then treatment ceased to produce further improvement.

•

On re-examination his normal functional movement ranges were full and comparatively pain free. How ever, when the metatarsophalangeal joint was sta bilized in a position midway between the limits of flexion, extension, abduction, adduction and rotation and the joint surfaces compressed firmly together, his pain could be completely reproduced with small abduction-adduction movements or small rotary movements (Fig. 8.65).

•

These pain-reprodUCing movements were then used as passive movement treatment techniques, initially with a degree of compression sufficient to cause only minimal discomfort. As improvement occurred the techniques were progressed in both vigour and duration.

•

Assessment was made at each visit by asking the patient to stub his toe gently into the palm of the examiner 's hand and monitoring the relationship

Application of forces: the patella should be moved cephalad, caudad, medially, laterally and in a direc tion of axial rotation (especially with the medial bor der of the patella moving anteroposteriorly into the femoral intercondylar area). The findings regarding smoothness of movement and pain response should be compared with the patient's complaint and the normal knee.

•

•

Application in treatment: patellofemoral disorders which are mechanical or degenerative in origin respond well to treatment by passive movement and a degree of compression which permits movement without pain or with only a small amount of discom fort. The technique is performed as described above and the movement is oscillated for 1-2 minutes. Assessment of changes effected is then carried out and the degree of compression used in treatment is based on the assessed response. A stage may be reached where strong compression is used without increase in discomfort. The patient should, by then, notice improvements in both symptoms and function.

The following example is of the later stages of treat ment of a 20-year-old male with a painful right metatarsophalangeal joint of the big toe: •

Three months previously, while playing association football, he kicked the ball while at the same time an opponent blocked the kick.

•

The patient described the injury as a 'stubbed toe' without any flexion or extension involvement.

•

The injury caused severe pain in the metatarso phalangeal joint of the big toe. This pain gradually subsided over the following month but then remained unchanged.

Figure 8.65

Physiological movements with compression.

Principles of selection and progression of mobi l ization ! manipulation techniques

between the pain response and the degree of com pression required to provoke this response. •

The response to treatment was very good. After 2� weeks he could stub his toe firmly with only the slightest discomfort.

Noel et al (2000) have presented a preliminary clinical observational paper based on adding compression to mobilization in rehabilitation after knee surgery. First of all they review an existing protocol for the clinical application of compression proposed by Van Wingerden (1995). This protocol suggests that: •

•

•

compression should be carried outfrom end-of range motion into the range of motion 3-5 series of 15-25 compressions should be carried out daily dynamic movements such as walking or cycling should be carried out as home exercises.

Noel et al then took 30 patients following anterior cru ciate ligament (ACL) reconstruction and looked at how quickly they reached a target of 130° of knee flex ion (normally 4 weeks). One group of 15 was assigned to an active rehabilitation programme and one group of 15 was assigned to an active rehabilitation pro gramme and mobilization under compression at the start of each rehabilitation session. The protocol for the mobilization with compression was as follows: • •

•

•

•

•

•

•

The patient was positioned in supine lying. A sand bag was placed under the knee proximal to the pa tella. The knee was flexed to full available range of movement into flexion. Progressive compression was applied to the knee through the tibia via the calcaneus. The amount of compression was adapted to the patient's response to avoid pain. The knee was moved, under compression, through a range of 10-15° from full available flexion towards extension. At the end of each movement the compression was released as the knee was returned to full available flexion and the process repeated. Four series of 20 mobilizations with compression were performed. Each series was followed by four to five full range passive mobilizations.

The results of the paper by Noel et al show that only one patient dropped out of the control group and three out of the experimental group and that the experimen tal group reached the target of 130° of flexion in half the number of sessions compared to the control group,

with the largest gains coming in the first two sessions. The authors then go on to discuss the potential impli cations of adding compression to joints in terms of its potential effects on synovial fluid function and the car tilage matrix. Evans (1998) has succinctly reviewed the changes that occur in synovial joints with ageing, Le.: •

•

• • •

articular cartilage becomes thinner, yellow and less elastic ligaments are less elastic and rupture at lower stress levels the whole joint is stiffer and weaker proprioceptive afferents are fewer and less competent the blood supply to the joint becomes less competent and, consequently, so does the healing process.

Evans goes on to explain that articular cartilage nutri tion occurs by rebound suction. The spongy joint sur faces are squeezed together and synovial fluid is swept across aLL the joint surfaces. He proposes that 'sweep and squeeze is the name of the game'. He then goes on to rec ommend what should be encouraged and what should be avoided to lessen the consequences of ageing. •

To be encouraged are: any movement; exercise or movement which achieves compression of all artic ular cartilage (full range, close packed, combined movements); regular cyclical load-bearing exercise or movement.

•

To be avoided are: long term immobilization, espe cially if this is non-weight-bearing; excessive impact loading (on hard surfaces, with weight and at speed); excessive shearing type stresses across the joint.

Selection and progression of treatmen t for intra-articular disorders including severe restrictive intra-articular pain and minor symptoms with compressive loading The clinical profile for intra-articular disorders is detailed in Chapter 10 along with the pattern recogni tion and expectations for recovery of the all the cat egories of osteoarthritis. Severe restrictive intra-articular pain Patients who have marked restriction of movement due solely to pain felt within the joint.

•

•

The greater the severity of pain, the greater will be the restriction of joint movement inhibited by pain. The disorder also has a high degree of irritability, i.e. it takes very little to provoke severe pain, and

21 7

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M A ITLA N D'S P E R I P H E R A L M A N I P U LAT I O N

this increased pain takes considerable time to sub side to its usual level. •

Examination and treatment need to be kept to a minimum.

•

The aim of the treatment technique is to perform the largest possible amplitude of movement which the joint can accept without exacerbation, be it an acces sory movement or a physiological movement. The larger the amplitude of the treatment movement possible, the better is the effect.

•

When a movement is markedly restricted by pain alone, the first choice of treatment technique is to use an accessory joint movement while the joint is positioned in its most comfortable position.

•

Figure 8.66 shows a posteroanterior gliding move ment of the head of the humerus in relation to the glenoid cavity while the arm is supported with pil lows in its most comfortable position. This position is usually a mid-range position of all the joint's accessory and physiological movements.

•

At the first and second treatment sessions when pain is severe and irritable the posteroanterior accessory movement must not: - produce any feeling of discomfort or awareness of uncomfortable joint movement during the performing of the technique - cause any aching in the joint.

•

Posteroanterior movement is not the only accessory movement that can be used; lateral movements of the head of the humerus, longitudinal movement caudally or anteroposterior movements may also be effective in reducing the severe restrictive intra articular pain.

•

To these movements can be added a shaft rotation movement of the humerus in a mid-range 20° arc, even though this is not an accessory movement.

•

During the performing of the passive movement technique the physiotherapist must: - be totally aware of what the patient feels within the joint from the moment the technique is commenced - be totally aware of any changes in what the patient feels as the technique is continued.

•

Four elements are used in making these assessments: 1. the verbal communication between physiothera pist and patient, achieved by continually asking questions regarding the effects on the joint symp toms while the technique is being performed 2. sufficient awareness to notice any nuances in the non-verbal communication (e.g. frowning, squeez ing the eyes tightly shut, flinching, clenching the fists) 3. while performing the technique the physiothera pist must be aware of even the most minimal muscular protective response, brought into play as an automatic subconscious means of protect ing the joint from discomfort 4. the therapist must also be aware of any changes in the feel of friction-free movement while per forming the technique.

The effectiveness of the technique can be measured by determining: subjective changes 'in' the shoulder during the performing of the treatment technique 2. subjective symptomatic changes 'in' the shoulder following treatment 3. objective changes in range and quality of active movement as a result of treatment 4. the time taken for any increased symptoms from testing (3) to subside, compared with the pretreatment measurement. 1.

Such approaches to treating severe restrictive intra articular disorders can reduce pain and improve move ment rapidly if selection of the patient is correct. If the disorder is an active disease in the acute inflammatory stage, however, this will not be the case. Such techniques may be considered to be 'surface stirring' without load, to which Lowther (unpublished observation 1983) refers.

Fig u re 8.66 Posteroanterior movement of the hu meral head while the a rm is placed i n its most comfortable position.

M inor symptoms with compressive loads Such patients present with minor symptoms of intermittent aching in a joint, felt only when the joint has to cope with

Principles of selection and progression of mobil ization / manipulation techniques

heavy work or when it has been subjected to passive sustained compressive forces, such as lying on the shoulder or hip at night. Patients with minor symptoms on compression fit into the severe restrictive intra-articular group but at a different or less intense stage. The continuous passive motion described by Salter et al (1980) would not improve the patient's symptoms or the physical cap acity of these troublesome joints. However, if those same movements are performed with the joint sur faces firmly compressed together, as described earlier, then the technique can be effective. Maitland (1985a) gives examples of the clinical importance of adding compression when examining and treating synovial joints (by kind permission of the publishers): 1. Clinical experience related to pain response is demonstrated by the following example. A painful metatarsophalangeal joint of the big toe is paSSively rotated in a small amplitude (say 10°) oscillatory manner in mid-range. As the oscillatory movement is performed in mid-range, no ligaments or any part of the capsule should be stretched or put under ten sion. Then if the same oscillatory movements are performed with the opposing joint surfaces com pressed together, exquisite pain is provoked; yet when the same movements are performed without compression, no pain occurs. The examiner is there fore drawn to the conclusion that there must be some mechanism whereby pain is evoked from the joint surfaces or the subchondral tissues.

compressed is readily appreciated by the examiner and by the patient (Fig. 8.67). These examples, along with the presented pathobiolog ical and clinical evidence, adds strength to the proposal that passive movement of a joint should sometimes be performed with the adjacent surfaces compressed.

Periarticular joint structures and function •

Flint (1976) and Gillard et al (1977) have demon strated the importance of intermittent tensional forces on the maintenance of the structure of the Achilles tendon in rabbits.

•

Lowther (1979) reports that 'it seems likely that . . . tensional forces are important for the maintenance of ligaments and tendons in the joint and perhaps in the joint capsule itself, since Akeson et al (1973) demon strated increased stiffness and matrix changes in the joint capsule from immobilized rabbit joints'.

•

Frank et al (1984) acknowledges that motion and stress appear to help in the quality of healing of ligaments after injury.

2. Clinical experience related to smoothness of move

ment is based on the premise that if a normal synovial joint is moved passively back and forth through an arc, irrespective of whether joint surfaces are com pressed together or only lightly opposed, the move ments will have an identical feel of being smooth and friction-free. When patients have joint surface disorders, however, a resistance to tlle movement through range can be felt when the surfaces are moved while being compressed together. For exam ple, ask any yOWlg person with a normal ankle to lie prone Witll one knee flexed to a right angle while you face the leg and hold the bare foot firmly in both hands. Stabilize the grip against your chest and chin. In this position rock your trunk from side to side so that the person's ankle is oscillated in a 30° mid-range arc of dorSi/plantar flexion. The ankle movement should be felt to be just as smooth whether minimal or maximal body weight is trans mitted through the foot. If this same test movement is carried out on an osteoarthritic joint, the loss of friction-free feel when the joint surfaces are

Figure 8.67 Ankle dorsi- and plantar flexion with compression.

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M AITLA N D ' S P E R I P H ERAL M A N I P U LATI O N

•

Hunter (1994) states that research has shown that calculated and controlled motion of healing soft tissue influences the healing process, giving an improved functional outcome.

•

Van Wingerden (1995) details the effects of mobil ization on injured ligaments, i.e. increased synthe sis, proliferation of fibre orientation maturation, increased tensile strength, return to normal proper ties and characteristics.

Again there is a clinical application to parallel this evi dence which can be related to the two extremes of pain and functional loss from ligamentous or capsular injury, damage or change. Treatment by passive move ment, therefore, can be applied to patients whose dam age is recent and quite painful when stretched and patients whose disorder is of a longer standing and more chronic nature (Maitland 1985b). On the one hand mobilization techniques can be used to comple ment and maximize the healing potential; on the other hand techniques can be used to remobilize capsular and ligamentous tissue or reintroduce such tissue to movement it has lost.

Recent periarticular damage •

Use techniques consisting of small amplitude pas sive movements performed slowly, with full aware ness of the pain response, and repeated in groups of approximately five movements.

•

These movements aim to apply gentle intermittent stretch provoking only minimal discomfort.

•

The groups of intermittent stretching can be per formed many times, provided there is no increase in the pain response with the movement.

•

Assessment of the effects of the passive movement treatment is made over the 24-hour period follow ing treatment and the information gained guides how the intermittent stretching should be modified at subsequent treatment sessions.

•

An increase in pain indicates that the stretches should be even more gentle. An increase in range and a reduction in pain indicate that the movement can be performed deeper in the range producing the same pain response as the previous treatment.

•

Special techniques to influence the pain after injury (Chapter 2) and movement to help to create an ideal environment for healing of the ligament or capsule (desired effects) can be applied as soon after the injury as is practical. Hunter (1994), however, sug gests that the gentle stretching techniques to help in

the recovery of the tensile strength of the soft tissue can be started from the fifth or sixth day after injury as this is when collagen begins to be laid down. The stretches should be progressed gradually until healing is complete.

Chronic periarticular stiffness with minor pain The treatment principles of stretching techniques are almost identical to those described above in these patients. The exception is that the stretching needs to be much firmer. Many physiotherapists are unaware of how strong some passive movement techniques

Intermittent tensional forces may be required to be stronger in order to be more effective than if such forces were not applied. The guideline to how strong the technique needs to be is primarily based on the necessity to produce a sharp 'bite' of pain, given that the kind of periarticular disorder being considered here is not one where the structures are disadvantaged by disease, recent surgery or disruption. The stretch should be gradually and progressively increased until the 'bite' of pain is achieved for the technique to be effective. The number of stretches into the 'bite' should be few in number (4-6), not sustained once the 'bite' has been achieved and slowly built up in tension. The patient must do stretching at home to retain the increased range of movement gained from treat ment. Such home stretches should be performed in the same manner as treatment, allowing sufficient time between stretches into 'bite' for the discomfort to totally subside. Damage does not occur, despite the 'bite' of pain, provided that the passive movement is momentary and intermittent. Figure 8.68 shows an example of stretching ankle dorsiflexion where the movement is gradually taken near to the limit of the range, then taken into a momen tary 'bite' of pain and immediately released. Figure 8.69a shows the position the patient should adopt in stretching into dorsiflexion as a home exercise. While keeping the heel on the floor the knee should gradually be pushed further forwards until pain is reproduced. This position should then be sustained until the pain subsides. The knee is then moved further forwards, again pausing for the pain to subside, until the limit of range is reached. Having performed this routine of pro ducing 'bite' two or three times, the patient should then, before releasing dorsiflexion, attempt to lift the ball of the foot off the floor without uplifting the heel (Fig. 8.69b). The patient should continue trying to lift the ball of the foot until eventually the whole foot is lifted need to be.

Principles of selection and progression of mobilization / manipulation tech n iques

221

] off the floor at the maximum dorsiflexion active range (Fig. 8.69c). After completing the routine, when releas ing the dorsiflexion the patient is likely to experience quite severe sharp pain, but it quickly disappears with repeated active, loosely performed, dorsi/plantarflexion movements. The desired effects of treatment will have been achieved if the chronic stiffness and pain diminish.

SELECTION AND PROGRESSION OF TECH NIQUES BASED ON THE ONSET, INJURING MOVEMENT, AND T HE STAGE AND STABILITY (LABILITY) IN THE NATURAL HISTORY OF THE DISORDER ------

Figure 8.68

(a) Figure 8.69

Selection and progression of treatment based on the aspects of the history of the disorder may be influ enced more in relation to the vigour and the duration of the treatment rather than the technique itself. Knowledge of such factors as the onset of the symp toms (traumatic, spontaneous, episodic, gradual), the extent of damage and the mechanisms involved with any injuring movement, the stage in the natural history of the disorder (pathological development) and the degree of current activity or stability lIability of the dis order, may guide thinking related to the changes and rate of change in symptoms that can be expected to take

Passive dorsiflexion stretch into 'bite'.

(b)

(c)

(a) Passive ankle dorsiflexion ; (b) active ankle dorsiflexion for the position of maximum passive dorsiflexio n ; (c) active ankle dorsiflexion.

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M A ITLA N D'S P E R I P H E R A L M A N I PU LAT I O N

place with treatment. This understanding will influ ence the way treatment techniques may be changed and progressed. Selection of techniques based on the history of the disorder may relate more to the desired effects which need to be achieved with treatment such as: •

•

•

•

creating an ideal environment for healing and to complement the healing process after a severe ankle sprain kick-starting the recovery after a long period of immobilization following a wrist fracture restoring full range of movement in the stiff painless stage of adhesive capsulitis maintaining function in a patient's elbow after an active episode due to rheumatoid arthritis.

Knowledge of the injuring activity, injuring movement and the extent of the damage so caused will influence both the selection of the treatment direction, the expected rate of progression and even the eventual outcome. A patient who has a minor strain of the medial ligament of the knee after a twisting injury will recover much quicker with gradual stretching into the rotation-injuring direction than a patient who has rup tured an anterior cruciate ligament and undergone reconstructive surgery and who will require mobiliza tion over several months related both to the injury and to the effects of surgery. Many neuromusculoskeletal disorders have a nat ural history and go through predictable stages of recov ery, flare-up episodes or lability. The key in selection of techniques is to establish which stage in the natural history the disorder is in at present and select the tech nique, vigour and duration that are appropriate to the current stage or pathological activity of the disorder. For example: 1.

An osteoarthritic hip of longstanding duration with episodes of inhibiting pain, and currently being within a painful episode, would require techniques aimed at pain relief. The degree of activity of the inflammation would influence the technique used (painless accessory movements if very active; pain less physiological movements if not very active) and its rhythm (slowly and smoothly if very active; quicker if not very active).

2. An inactive capsular disorder that is stable and late in its stage of progression would require stretching techniques, both physiological and accessory end of-range movements. 3. A recent sprain (a day or two ago) that has occurred for the first time and that is stable in terms of reaction to the sprain, will require very slowly performed

movements in the clirection of the sprain and into a very small degree of 'hurt'. At a late stable stage of the reaction to the sprain other physiological move ment techniques can be added; later still, more local ized techniques and moderately firm accessory movements are added.

SELECTION AND PROGRESSION OF TECHNIQUES BASED ON PATHOBIOLOGICAL MECHAN ISMS (DIAGNOSIS, PATHOLOGY, MECHAN ISMS OF SYMPTOM PRODUCTION , RECOGNIZABLE SYN DROMES) Where a definitive diagnosis of a patient's disorder is possible, the choice of passive movement techniques will be influenced. Take for example a patient with a locked knee due to a torn medial meniscus. The desired effect of any technique in such a case would be to restore the joint to its pain-free full range status. To achieve this desired effect, the therapist must choose a movement or combination of movements that gap the medial joint space, followed by repeated physiological movements of rotation, flexion, and extension. How the technique is performed (grade and rhythm) will still depend on the information gained about the behaviour of the symptoms. Similarly, the specific movements used to 'unlock' the knee will depend on the history of how the knee locked and any previous episodes and the presenting signs. Another example of diagnosis affecting the choice and progression of treatment is 'frozen shoulder' which has three distinct stages of severe pain, stiffness with less pain and stiffness without pain. Each stage requires quite different treatment techniques based on the history, and signs and symptoms. Diagnosis influences the choice of technique in another way. If a patient has rheumatoid arthritis with obvious changes to the joint and its supporting struc tures, yet has a strained wrist and is, as a result, unable to lift objects that could be lifted easily prior to the injury, any passive movement treatment (any treatment at all really) must take into account the underlying tissue weaknesses caused by the rheumatoid arthritis. Thus certain pathologies and diagnoses will place restraints on treatment. A reverse situation occurs with the diagnosis of 'frozen shoulder' i.n its third stage (Corrigan & Maitland 1983). This stage calls for posi tive firm treatment techniques whose desired effect should be to markedly increase the range of movement. During the cycle of any pathological process whether it be a 1-week-old fractured neck of humerus (group 1) or a stiff osteoarthritic hip (group 2 or 3b) the joint signs which present will correspond to one of

Pri nciples of selection and progression of mobilization/manipu lation tech n iques

the clinical groupings described earlier i n this chapter. Also during this cycle the joint signs will change with time as will the clinical group to which the joint signs correspond. In such cases selection and progression of the techniques can be changed accordingly. For example, a patient may present with a severely painful 'tennis elbow' (groups 1, 3a) which requires pain-free small oscillatory movement (posteroanterior movement of the head of radius) to influence the severity of the pain with elbow extension. After a few weeks this severe pain may have subsided and the patient is left with discomfort and stiffness when straightening the elbow (groups 2, 3b), in which case these signs and symptoms are more likely to resolve if the elbow is gradually (respecting pain - group 3b) stretched into elbow extension and extension/adduction, extension/ abduction. Once again it should be emphasized that scrupulous assessment of symptoms and signs through out treatment is essential if techniques are to be adapted effectively. The importance of an understanding of the mech anisms involved in the prod uction of the patient's symp toms and the influence this will have on the selection and progression of passive movement treatment tech niques has come to light due to the work, for physio therapists, by Gifford (1997) and Butler (2000). These mechanism categories (nociception, peripheral neuro genic, central pain, sympathetically maintained pain and affective/cognitive dimensions) are reviewed in Chapter 10. The manipulative physiotherapist must be aware of the way that passive movement techniques can also influence and perpetuate tl1ese mechanisms and therefore affect the way and the rate that the patient recovers from a disorder and any future disorders or episodes, i.e. the way the therapist deals with the cur rent episode can influence the way a patient will sample and deal with any fuhue episodes or disorders (Gifford 1998). Techniques therefore should be selected which take into account not only the restoration of the dis ordered neuromusculoskeletal tissue to as normal a state and function as possible, but also how the patient will remember the experience of having the acromio clavicular joint oscillated in order to relieve the pain of an acute injury or the hip stretched into flexion/ adduction to the 'bite' of pain in order to improve the aching and restricted movement being experienced. Likewise, the therapist must be able to deal with the allodynia (hypersensitivity) around an injured lateral ligament of tl1e ankle in conjunction with mobilizing the ligament itself, i.e. involvement of the peroneal nerve should be suspected, investigated and dealt with (Butler 2000). Sensitivity and sympathetic maintained pain around the elbow should be considered in patients

with lateral epicondylalgia who have not responded to locally directed treatment. In such cases movement impairments in the thoracic spine or peripheral neuro genic tissues may be contributing to this mechanism and need to be addressed and dealt with before the local tissue can fully recover. A patient who is suffering with anterior knee pain may have lost trust in the knee because it is constantly giving way due to pain. The patient may be fearful of certain activities and has developed maladaptive avoid ance strategies such as going down stairs one at a time. Of course, this will perpetuate the symptoms and be a barrier to recovery. It is the job, therefore, of the manipu lative physiotherapist on the one hand to identify the local impairment, which may be a patellofemoral intra articular disorder, and deal with it and on the other hand gradually help the patient to regain trust in move ment by explanation, rehabilitation and reassurance that once the pain has settled the giving way will grad ually diminish and then normal functional movement will keep the knee healthy and less likely to be a prob lem again in the future. Each peripheral region (Chapters 11-17) contains a review of common and recognizable syndromes par ticular to that region which have recognizable histories and often respond in predictable ways to mobilization techniques. Other categories of disorder which are worthy of note in terms of selection and progression of techniques are: •

•

• •

arthritides (Chapter 10): - osteoarthritis - subclinical arthritis - rheumatoid arthritis - post-traumatic arthritis fractures - impacted fractures - non-uniting fractures - fracture sites hypermobility locked joint loose bodies.

Osteoarthritis The physiotherapist most certainly has a role to play in the treatment of the osteoarthritic joint (Fig. 8.70). This is so even when the joint (e.g. hip) may in future require surgical replacement. •

When a patient has pain within the hip and has marked radiological cl1anges in the hip (loss of joint space and flattening of the head of the femur) it is still possible to both reduce the pain and improve the quality of its movements and its ranges.

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Phase 3

90° hip / knee flexion position. The result was good and she could walk long distances without discomfort and could use stairs quite well. She was pleased and treat ment was discontinued except for her own exercising and a single 6-weekly 'maintenance treatment' session. One year later she had a fall, landing on her hip. This triggered off an exacerbation of her osteoarthritic

Figure 8.70

Arthritides: treatment.

symptoms. This time she gained nothing from the same physiotherapist and hip replacement surgery was per formed. The surgeon's postoperative comment was particularly poignant: 'I have never seen the structures

•

In the initial stages while pain is the primary factor,

surrounding the hip in such a healthy state, it was quite

accessory movements produced by pressures applied

remarkable.'

to the greater trochanter are the first choice. •

The patient is positioned to lie on the sound side with both hips and knees flexed comfortably and the upper foot and leg fully supported with pillows between the legs.

•

Care needs to be taken to support the foot and ankle

than usual. This example reveals a second and significantly important aspect to manipulative physiotherapy for the painful osteoarthritic hip. The same applies to other similar disordered synovial joints.

so that the femur 's shaft rotation is in a neutral

Another point is raised by this experience. When

pain-free position - frequently this is not cared for

treating any synovial j oint that has radiolOgical evi

adequately. The same treatment care is taken as for group •

She had a good result from the surgery, responding to treatment and recovering at a decidedly quicker rate

1 or 3a patients.

Assessment is carried out impeccably and a written (even graphed) record is kept b y the patient as it is an essential component of the analysis of the state

dence of osteoarthritic change, even if a periarticular structure is the part being treated, the intra-articular changes should also be given the advantage of grades II or ill- treatment which may stimulate nutrition and better function.

of the disorder and its likely prognosis with manipu lative physiotherapy. •

The ultimate aim with such a disorder is to be able to perform large amplitude, brisk, shaft rotations in the side lying position described above, or to be able to reach a stage of large amplitude hip flexion adduction movements (from an extension adduc tion or even just an adduction position in the same flexion position).

•

Subclinical arthritis Subclinical arthritis is discussed at length in Chapter 10. Its management - particularly in relation to what the physiotherapist has to offer both in terms of treatment and in suggestions for other treatments that can be undertaken - is properly and valuably the therapist's role. Its mobilizing treatment would be in the group

1

category as is that for 'jointy people', where the tech

The patient should be taught loose pendular exer

niques would be directed at the pain. Such joint disorder

cises to be carried out three or four times a day, and

is slower in its response than is the mechanical variety of

even at night if wakened by pain.

arthritis; in fact it is its slower response that is one of the

There is another reason for saying that the physiother apist has a role in treating these patients, as shown by the following example. A woman has a radiologically bad osteoarthritic hip and was having a degree of pain that led the surgeon to say that a hip replacement operation was necessary. The patient did not want this and was referred to a physiotherapist for treatment. Because the degree of

leading factors in its differentiation. If it responds only slightly in the first four sessions, the improvement may well be enhanced by anti-inflammatory medication. (Mechanical inflammation is often helped less by anti inflammatory medication.) If the result of combining medication with mobilization is still incomplete, an intra-articular injection of hydrocortisone could be expected to be very successful.

attainability was sufficiently low to allow flexion adduction movements to be used for treatment, these were performed and progressed as for group 3b patients

Rheumatoid arthritis

as described earlier. Shaft rotation as grade ill was

Passive movement techniques are never successful in

added in both the flexion-adduction position and the

relieving pain caused by an active rheumatoid arthritis.

Pri nciples of selection and progression of mobil ization / manipu lation techniques

However, i f the rheumatoid arthritis i s not active and the patient complains of pain or aching of more recent origin, there may be a mechanical reason or minor recent trauma which is responsible for the pain. Under these circumstances gentle grade IV- techniques should relieve this pain. Firm techniques should never be used on joints exhibiting rheumatoid arthritic changes because the ligaments and tendons around the joint are structurally weakened by the rheumatoid disorder.

Figure 8.71

Osteoarthrotic and post-traumatic arthritis

Non-uniting fractures

Pain resulting from osteoarthrotic joints or from long standing traumatic arthritis can be very readily improved by large amplitude movements within range.

(Reproduced from McNair, J. and Maitland, G. D. (1983) The role of passive mobilization in the treatment of a non-uniting fracture site - a case study. Presented at the International Conference on Manipulative Therapy, and reproduced by kind permission of the Manipulative Therapists Association of Australia.)

•

•

•

When pain is severe, movements of large amplitude should be used but they should be performed painlessly as accessory or rotary movements in a neutral position. As pain recedes, large amplitude physiological movements should be used, initially without provoking pain. As the condition continues to improve the large amplitude movements can be taken into pain and probably to the end of the available range of movement.

Fractures Impacted fractures •

Injuries that result in fractures (Fig. 8.71), for exam ple of the surgical neck of the humerus, are usually severe enough to cause damage to ligaments and capsule, thus laying the basis for a stiff gleno humeral joint.

•

Passive accessory movements of the glenohumeral joint in its neutral and supported position (see Fig. 11.44) can play an extremely vital part in retaining maximum movement without any stress on the frac ture. The significance of this early treatment cannot be overemphasized: it is extremely important to real ize that a good functional range can be retained with out the fracture being subjected to stress (see p. 230).

•

Abduction is a very important glenohumeral move ment. The movement can be performed as part of treatment in all fractures of the humerus if the full length of the humerus is supported throughout the movement with one arm, while one or more fingers of the other hand assess movement between the head of the humerus and the acromion process.

Phase 4

Fractures: treatment.

To date, passive mobilization has always been directed towards creating movement at a joint, by applying mechanical pressures to the adjacent bones, the aim being to relieve pain and increase range of movement. However, since 1982 we have had the opportunity to apply certain passive mobilization techniques to the adjacent bone at a fracture site. Here the aim was to stimulate union at a particular fracture site which was already showing signs of non-union on X-ray and the medical specialist was considering surgical intervention. This presents a challenge in two areas:

1 . That of fracture management which has historically and classically disallowed movement of fractures. 2. That of 'end-feel', where originally there was no predictable concept of 'end-feel' to the movement since we, as physiotherapists, have not as yet developed a bank of knowledge or skill of 'feel' in this area. Thus the choice of technique in this case did not purely follow our usual principles of applying techniques in that it was not based upon the behaviour of symptoms through range of movement or at rest. Instead it was based upon the following: 1.

The recognition of the patient's ability to appreciate 'fracture site pain', as distinct from all other types of pain, during movement of the fracture. 2. An academic extension of the concept of accessory movement and 'end-feel', with a knowledge of the orientation of the fracture lines and its internal fixation.

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[ CAS E STU DY A 40-year-old m a n, who had been shot, was adm itted to the Royal Adelaide Hospital on 1 7 September 1 98 1 . H e h a d a n entry w o u n d just u nder h i s xi phisternum and had some bleeding from his left el bow, which was unstable. The bullet had passed through his left elbow joint and entered his chest. H e was resuscitated and underwent a laparotomy on the day of admission. The X-rays taken on the day of admission are shown in Figu res 8.72 and 8.73. On the fol lowing day ( 1 8 September 1 98 1 ) his elbow was explored i n theatre. The fi ndings were a fractu red latera l epicondyle and a fractured olecranon with the articular su rfaces of the el bow joint slightly scoured. Fou r pieces of lead a n d frag ments of loose bone a n d carti lage were found in the a rea. The lateral epicondylar fracture was red u ced 'with a good match of a rticu lar su rface' and held with K-wi re fixation. The fractured olecranon was reduced with 'anatomical a pposition of the fragments' and held with tension wire fixation. Fig u res 8.74 and 8.75 show the X-ray views take after surgery. His elbow was then encased i n a plaster-of-Paris cast which mainta ined satisfactory reduction as shown i n Figures 8.76 a n d 8.77. H e made a good recovery and was discharged 1 0 days later (29 September 1 98 1 ) . An orthopaedic fol low-u p of his el bow was a rra nged on 5 November 1 98 1 . After removal of the plaster-of-Paris cast, at this fol low-up,

Figure 8.72 X-ray: lateral view taken o n date of admission (17 September 1 981 J.

Figure 8.74 X-ray: lateral view taken after surgery on 1 8 September 1 981 .

Pri nciples of selection and prog ression of mobil izatio n / m a n i p u lation techniques

t h e patient received treatment for his elbow t o i m prove h i s range of movement. At a subsequent orthopaedic fol low-up on 1 0 December 1981, about 4 months after i njury, his ra nge of movement was considered to be 'functional' with a fixed flexion deformity of 65' and his active flexion l imit was a l most fu l l range, at 1 35'. His ra nge was reported to be i mproving with physiothera py. The fol low-up X-ray report (radiogra phs taken on 1 0 December 1 98 1 ) noted that the olecranon fracture showed signs of u nion, while there was som e 'rounding off of the lateral epicondyle fragment, with associated widening of this fracture site. Figures 8.78 and 8.79 show the X-ray views taken at this orthopaedic fol l ow-up. The senior orthopaedic registrar reported that the epicondylar fracture was progressing to non-union and, upon further d iscussion with the orthopaedic surgeon i n charge o f t h e patient it w a s decided t h a t i n 1 month's time (on 1 5 January 1 982) the K-wires woul d be removed and replaced with a compression screw. The surgeons were particu la rly concerned because the fracture was caused by a bul let, which causes heat damage to the

Figure 8.76 1 98 1 .

X-ray: lateral view taken o n 25th September

Figure 8.77 1 98 1 .

X-ray: anterior view taken on 25th September

227

228

M A I T LA N D'S P E R I P H E RA L M A N I P U LAT I O N

L

Figure 8.78 1 98 1 .

X-ray: lateral view taken on 1 0th December

bone cel ls and ca pillaries within t h e Haversian system, d i m inish ing the usual fractu re haematoma and thus the chance of u n ion. Avascu l a r necrosis of the lateral epicondyla r fragment was therefore a l i kely com plication. Meanwhile, the orthopaedic su rgeon gave his consent to a trial of passive mobilization of the latera l epicondyle w h i le the K-wires were in situ, with a view to sti m u lating union. Passive mobil i zation commenced on the 1 6 December 1 981 . This was 3 months after the incident, when the signs of non-union were present on X-ray. The patient was treated daily for a pproximately 1 month. Treatment consisted of su pporting his arm in a comfortable degree of flexion (about 65') with the patient supine; g ripping his lateral epicondyle between the thumb and index finger; then mobilizing the epicondyle. The techn ique used ca n be described as a combined anteropostero-a nterior movement (Fig. 8.80), accompa nied by com pression of the lateral epicondyle i nto the h u merus (Fig. 8.81). The compression was a medially d i rected grade IV+ + + sustained pressure, w h i l e t h e a nteroposterior-anterior pressure was a grade IV g l ide. This very sma l l ampl itude g l iding was obviously modified by the presence of the three K-wires, wh ich probably caused the g l iding pressure to i nclude a tipping action. The compression component,

Figure 8.79 1 981 .

-

X-ray: anterior view taken on 10th December

Antero posterior pressure

,

t

Postero-anterior pressure Figure 8.80

Lateral view: lower humerus with K-wires

in situ.

which was the main component of pressure, was not affected by the presence of the K-wires since it was directed al most para l lel to their orientation. There was not a lot of movement present and the 'end-feel ' could only be described as tight and sl ightly 'gritty'. The degree

Principles of selection a nd progression of mobil ization / manipu l ation techn iques

o f treatment was infl uenced b y the intention t o provoke a sma l l degree of 'fracture site pain' intermittently. This was deemed essential since it confirmed that the tech nique chosen was effectively creating movement at the fractu re site. On 1 4 January 1 982, about 1 month after passive mobil ization was i nstituted, the patient was readmitted to the Royal Adelaide Hospita l and X-rays were ta ken. These showed signs of union over a sma l l a rea of the fracture site ( Fig. 8.82).

The surgeons felt that removal of the K-wires and screw fixation was sti l l indicated, but that treatment might be modified dependent u pon fi ndings at surgery the next day. His ra nge of elbow movement was assessed, i n theatre, as 1 0- 1 40· flexion, showing i ncreased ra nge, and u po n removal o f the K-wi res the surgeon was unable to manually move the lateral epicondyle. The su mmary of the surgery states that there was u n io n t h roughout and therefore a l l i nternal fixation was removed.

Discussion

Figure 8.81 Anterior view: lower h umerus with K-wire fixation of lateral epicondyle.

As mentioned previously, this application of passive mobilization in a controlled way to a fracture site, instead of a joint, challenges the historical and classical management of fractures as advocated by Hugh Owen Thomas (1834-1891). He along with his pupil, Robert Jones, laid down the ideals of orthopaedic fracture management as rest, support and immobilization. These ideals influenced orthopaedic practice for the first half of this [20th] century. The concept of compressing fractures by early weight bearing, for internally fixed lower limb frac tures, was first advocated by Delbet in 1906 but was not universally accepted until 1929 when Bohler in Vienna adopted this practice. However in recent years, particularly in the last decade, many authors have researched the healing of bone in the presence of compression and electrical currents. Interestingly, authors such as Peacock and Van Winkle (1976) ascribe a possible piezoelectric property Figure 8.82 X-ray: lateral and anterior views taken on 1 4th January 1 982. This was 1 month after passive mobilization and the anterior view appea rs to show union at the epicondylar fracture site.

229

230

M A ITLA N D 'S P E R I P H E RA L M A N I PU LATI O N

L

(1979) has

to the crystalline nature of bone, enabling i t to act

relation to the 'Resters' and 'Movers'. Jull

as a stress transducer. Bone healing is thought to be

very clearly described the application of mobilization of

enhanced in the presence of small electrical currents

joints following fractures.

which are produced when the crystalline components of

Treatment of ununited fractures since the example

bone are distorted by mechanical compression. Many

described above has been equally successful and the

authors have subsequently also studied the effect of electrical currents on bone union (Hassler et al

1977,

majority had been unsuccessfully treated by electrical stimulation beforehand.

Panjabi et al

1977). Of particular interest, an article by (1979) outlined a biomechanical study

surgeons that the use of passive movement techniques,

of the effects of constant and cyclic compression on frac

such as those described above (McNair & Maitland

Yasuda

It is considered in Adelaide by some orthopaedic

ture healing in rabbit long bones. Their findings showed

1983), would hasten the union of intervertebral fusions,

that constant compression, as in internal fixation, pro

if applied immediately after the surgical procedure.

duced a stronger bone during the early phase of healing. They also found that there was a

27% reduction in the

healing time of bone stimulated by cyclic compression.

Hypermobility Hypermobility is very helpfully discussed by Beighton

Conclusion

(1983). Hypermobility (general and local), instabi 1976)1 are explained in Chapter 10, as are pain inhibition and

et al

While the result of union in this case study indicates that passive mobilization of the fracture site, at best, either stimulated or aided union, and at worst, did not prevent spontaneous union, it is important to empha size that care was taken to make compression the major component of pressure and that the amplitude of anteroposterior-anterior gliding was minimal. It is

lity, and stable-instability (Williams et al

apprehension. 'Sprains', including ligamentous tear ing and rupture can also be considered under this heading of hypermobility. In terms of treatment, the following should be considered: 1.

When a patient who is generally hypermobile has

also worth emphasizing that passive mobilization was

symptoms arising from one of the hypermobile

3 months after fracture when signs

joints, it is treated in exactly the same manner as that

not instituted until

of non-union were present on X-ray. Thus the type of technique and the timing of treat ment must be considered in any future study of the role of passive mobilization in the management of fractures.

described for a hypomobile joint.

2. A joint that becomes hypermobile through training, as for a ballet-dancer, may not reach a stage with the training to be sufficiently hypermobile for the expertise required. If the person has great potential

Fracture sites

in the chosen field, the physiotherapist can help gain

The above leads one to treating fracture sites from the beginning . It is the practice in China for fractures to be supported in bucket splints which are removed by the patient on a daily basis when he moves his limb a small number of times. The splint is then replaced for the remainder of the day. With multiple unstable fractures in one limb, such a procedure may not be contemplated. However, it is common practice to have a patient with a fractured femur walking in a plaster or Thomas splint.

the extra range required by techniques described for group

2 patients. The techniques would be sup

plemented by training sessions, but a longer period of warm-up is required and also a longer period of time on the one functional movement being treated. Obviously, active control of this increased hyper mobility is essential and incorporated into the patient's treatment and training sessions.

3. Stable-instability and pain inhibition usually occur

Therefore, to have the patient in a non-weight bearing

together and is common in the knee. When present

(or partial weight bearing) calliper or a bivalve plaster

in the knee, there is an extension-lag, and over

should be acceptable. If then a skilled physiotherapist

pressure of extension combined with tibial antero

removes or partially removes the splint and uses pas

posterior

sive movement in the manner described above, which is

consists of:

successful with non-uniting fractures, it should shorten

(a) Knee extension with anteroposterior movement

the time needed for splinting. Equally important,

into a tolerable degree of hurt as a grade

pressure

is

painful.

The

treatment

a better range of movement . and function of the joints affected by the fracturing incident is achieved if the joints encased in the support would also be moved. Professor Salter's articles

(1982, 1985) are a 'must' in

J.G.P and Sperryn, P.M. (eds.) Sports Medicine, London, Edward Arnold, pp. 441 and 586 ( 1 976)

1 Williams,

Principles of selection and progression of mobil ization/ manipu lation techniques

IV- progressing to grade I V + (and later IV + + )

range and totally painless. (Other directions of

interspersed with grade III- movements.

movement would also form part of the treat

(b) Accessory movements, and especially tibial

ment.) Once the unstable direction of the knee

shaft rotation, are used at the comfortable limit

is painless (and all other movements are pain

of knee extension, as grade III- movements.

less) re-education can be promoted as rapidly

4. Apprehension movement is treated by performing

as possible.

that movement slowly, nudging at the point of the 'apprehension', endeavouring to coerce the range to increase painlessly; that is, without apprehension being provoked. Very slow grade IV- movements are used which are sustained at the position of the point of the apprehension, and then functionally released. This is the passive movement aspect of the management. To this has to be added re-education of the muscular control of the movement.

Locked joint loose bodies Although the term 'locked joint' is not ideal, it does serve to differentiate such a disorder from other types of movement restriction. A particular movement(s) of a joint, when it is locked, is blocked from being able to be moved into a range by an obstacle 'in' the joint. The movement cannot be improved by stretching, as would be so if it were stiff. Something is obstructing

5. Sprains can be considered at two levels - those that

the movement. To improve or restore the movement,

cause partial ligament tears (e.g. sprained ankle),

the blocking object has to be moved out of its position.

and those that rupture a ligament (e.g. rupture of

Of course, if it can be moved out of its blocking pos

medial ligament of the knee):

ition it can also move back again; thus to mobilize and

(a) For the sprained ankle variety, as well as 'ice,

successfully free the movement passively is not neces

compression,

elevation',

passive

movement

sarily going to be a lasting success.

should be utilized. The movements should be

Loose bodies and menisci can be structures that can

slow, smooth, grade III-. All directions includ

block movement of a joint and to move them requires

ing all joints from the inferior tibiofibular joint to

specific techniques.

the interphaJangeal joints should be performed

The joint must be distracted or opened to allow

but the main emphasis should be placed on the

movement of the offending mechanical focus within the

'injuring movement'. It should be the first move

increased joint space. While the joint is opened on the

ment used in the routine and should be repeat

painful side it should be moved back and forth in direc

edly performed, being interspersed by the other

tions that will move the bones to which the loose piece

movements referred to. The 'injuring move

is attached. By continuing the movement or varying the

ment' should be extremely slowly taken to the

movements as dictated by progress, or lack of progress,

point where the 'hurt' begins and then held

the obstruction may be moved into a painless position,

there for some seconds before releasing - this is

allowing the joint movement to become free.

repeated at least four times hoping to be able to

Cyriax and Cyriax (1983) and Corrigan and Maitland (1983) discuss and describe techniques.

move gradually a little further into the range. If the available range increases well into the proce dure, during the holding phase of the technique, a tiny movement may be attempted to gain more movement. This extra added movement should not be held if the hurt increases markedly into a very painful range.

SELECTION AND PROGRESSION OF TECHN IQUES BASED ON DYSFUNCTION , MOVEMEN T IMPAIRMEN T AND COMPARABLE MOVEMENTS/I N J URING MOVEMEN TS

The session of 'injury movement' interspersed

6) of every

with general movements would take as long as

The aim of physical examination (Chapter

20 minutes. It should be repeated as a slow active

patient is to reveal one or more movements (both

home exercise movement in the elevated pos

active and passive) which are comparable with the

ition at intervals of 1-2 hours. Here it is important

patient's symptoms and where possible reproduce the

that the patient be taught how to monitor the

patient's symptoms.

effect of the movement so that an exacerbation is avoided.

Active functional movements demonstrated by the patient (functional demonstration) as being abnormal

The treatment for a complete rupture of the

or which caused the injury are always assessed in

medial ligament of the knee (referred to above),

terms of range/pain response /and quality. The amount

uses much the same as in (a). The aim is to

of range lost and the factors which cause this loss will

make the unstable abduction of the knee a large

determine what technique is used in terms of direction,

231

232

M A ITLA N D ' S P E R I P H E RA L M A N I P U LATI O N

[ grade, speed, rhythm and duration. For example, a behind the back, it is only possible to take the hand to

t'! .a

the hip because of severe pain in the shoulder. The

c

I

�

:0

directed at treating the pain at its source with gentle,

2 'f::

pain-free, small amplitude, slow, smooth, oscillatory accessory movements. Contrast this with the patient

.2:-

Q) (f)

joint. The technique required for this patient's dys

A

function should include physiological and accessory

When a comparable passive movement is found,

Y2

.� >

minor discomfort in the right temporomandibular

a movement diagram (Appendix

P' (local intense)

Y2

'T

who cannot open the mouth fully due to stiffness and

the mouth opening movement.

0

'"

choice of treatment technique, therefore, should be

small amplitude stretching techniques at the limit of

R2 (IV+++)

C

patient may demonstrate that, in trying to put a hand

Figure 8.83 abduction.

R1 v..

P1

%L

B

(local) Range Group 4: knee full flexion, medial rotation and

1) is used to qualify

the extent of the movement restriction and the factors limiting the movement. If this examination of passive movement is carried out with care and detail the movement diagram can be a valuable tool to classify ing the patient's movement impairment into one of the clinical groups described earlier and therefore guide the selection and progression of techniques: •

the diagram of a comparable movement for a patient from group

1 would show that it is pain that 60% of normal

limits active movement to less than (see Fig. •

8.12)

a patient in group

2 would have movements repre 8.13 where it can be seen that

sented as in Figure

movement is limited and that pain is absent or minimal •

•

although patients in group 3 vary widely, the impor

The treatment movement is depicted by a double

tant fact is that, as the severity of the pain increases,

headed arrow directed horizontally. The amplitude of

the strength of the resistance also increases (Figs

the movement is depicted by the length of the arrow

8.14, 8.15)

and the position in the range is depicted by relating the

finding a movement comparable in group

4 is

sometimes very difficult. Frequently only one com parable movement can be found. Sometimes physi ological movements are normal and it is only when accessory movements are tested in combination with physiological movements that a comparable movement is found.

8.84 represents a treatment tech 20° amplitude movement performed 30° short

performed. Figure nique of

of full elbow extension. One or all movements of a painful, stiff and painful, or stiff painless joint may be used in equal and varying degrees. The treatment technique applied to such joint

For example, a patient with minor knee symptoms may have a full painless range of all physiological knee movements. When full flexion is combined with medial rotation and abduction, however, pain is elicited and the movement is found to be stiff. This therefore is the comparable movement (Fig.

arrow to the AB base line representing the range or direction of movement into which the technique will be

8.83).

Furthermore, the amplitu.de and position in range

disorders should be considered from two aspects: 1.

which movement should be used to best achieve the desired effects

2. how should the movement be performed with reference to its amplitude, rhythm and position in the range in order to fulfil this requirement.

can then be depicted on the movement diagram in its

This choice will primarily be affected by the joint

appropriate place in relation to how much pain is to be

affected, the symptoms and signs and the pathology,

provoked or how far into resistance it should carry.

as has already been highlighted.

Pri nci ples of selection and progression of mobil ization / ma n i pu lation tech n iques

SELECTION AN D PROGRESSION OF TECH NIQU ES I N FLUENCED BY PRECAUTION S AN D CON TRAIN DICATIONS TO TREATMEN T Chapter 7 details the factors which will be precautions and contraindications to treatment by passive move ment (mobilization/manipulation).

Between the third or fourth treatment session and the final analytical assessment, the manipulative physio therapist should be able to answer the following questions about a patient's disorder in the quest for a prognosis: •

•

Factors which may influence the expected rate and extent of recovery (contributing factors and barriers to recovery) Most movement-related neuromusculoskeletal disorders have a natural history, fairly predictable rates of recovery and predictable responses to treatment using pass�ve mobilization treatment techniques (e.g. frozen shoulder, knee ligament sprains, episodes of symptoms related to overuse of osteoarthritic joints). The challenge for the manipulative physiotherapist, however, is to establish why a disorder is not recovering and respond ing to treatment in a way that would be expected for that particular disorder. TI1ere may be a number of rea sons why a patient's pain, stiffness, spasm, weakness, etc. are recovering slower than expected or that a point is reached where there is no further improvement. These factors will need to be identified by in-depth questioning, retrospective assessment (Chapter 5) and further detailed examination. Any barriers to recovery should then be dealt with, if possible, either in conjunc tion with treatment of the evident joint signs or sep arately before returning to treating the joint signs. These barriers to recovery will influence the way treatment is selected and progressed according to the guidelines proposed for each of the clinical groups 1, 2, 3a, 3b, 4 and associated signs. Figure 8.85 represents a model of how contributing factors can influence the natural his tory of the disorder and how barriers to recovery can interfere with the ideal progression of treatment of movement-related joint signs.

•

•

•

•

•

•

•

A generalized prognosis can be made by answering these questions in cases of recognizable patterns and reCOgnizable pathology. Specific hypothesis categories should also be considered to enhance the prognosis, as follows: •

•

The influence of prognosis on the selection and progression of treatment 'Prognosis is the forecast of the probable course of a case of disease or injury, or it is the art of making such a forecast' (Short Oxford Dictionary 1980). Jeffreys (1991) informs us that 'prognosis . . . is an art, or a skill, not a science. It concerns probabilities not certainties and it refers to the individual not the gen eral . . . Fortunately, although individuals differ in their response to insult, their ailments follow recognizable patterns and it is possible to form general predictions of the natural history of disorders.'

What is the diagnOSis and what pathobiological mechanisms are involved? What is the source or cause of the source of the patient's symptoms? To what extent is movement impaired and function limited by the symptoms? To what extent is severity or irritability of symptoms limiting movement and activity? What predictions can be made about the natural history of the disorder based on its onset, stage of pathological development and pathological stability/lability? What predisposing factors are influencing the course of the disorder (pre-existing pathology, weak link, the nature and extent of injury, age related processes, general health state, physique, occupation, genetic predisposition, etc.)? What factors are contributing to a favourable or unfavourable prognosis? Is the disorder one that will be easy or difficult to help based on the examination and response to treatment? What do we understand about the patient's nature and response to injury and illness (adaptive/ maladaptive behaviour)?

•

•

disorders which are easy or difficult to help (e.g. complex region pain syndromes) the nature of the person (stoic, excessive complainer, pain tolerance, hostility towards the medical profeSSions, ethnic/social group, genetic components, slow healers, expectations of treatment, psychosocial 'yellow flags') the nature of the disorder (intra-/periarticular disorders, mechanical osteoarthritis/inflammatory osteoarthritis, acute injury/chronic degenerative, nociception alone/nociception with peripheral neurogenic or central sensitization) the body's capacity to inform and adapt (the way the patient 'feels' about their disorder often correlates well with the other prognosis hypothesiS categories - for example, 'I've had

233

234

M A ITLA N D ' S P E R I P H E RA L M A N I PU LAT I O N

[

A model of pRIgnISIIon of mobIIIzaIIanImI • • •

The ideal road to rac:overy - tissue based FaclorB diverting Ideal racovery bIopsychoaociaI The journey can begin at any point depending on the present stage of the disorder In lis naIInI history -

A to B Is the Ideal road to racovery (e.g. a sprained ankle from lis lraUmatic origin to lis resolution )

Ideal road to recovery (A to 8) - tissue based The role of mobilization/manipulation Clinical groupings

Factors which may divert ideal recovery and which will need addressing along the way A (Onset)

• •

Group 1 •

Accessory I II •

Group 3a

Contributing factors

•

Previous injury Established pathology Medical conditions, e.g. diabetes

Group 3b

Accessory and physiological III I At limit, respecting pain •

Combined accessory and physiological at limit into 'bite' of pain (IV)

•

The cause of the source

Alignment faults Stiffness in joints above and below Ergonomics

Group 2 •

The nature of the person

Unrealistic expectations for recovery Return to activities too soon Fear avoidance Slow healer •

Figure 8.85

Potential barriers to full recovery

Chronicity Pathology Other yellow flags Anomalies/Structural impairments

A model of progression of mobilizati o n / manipulation.

knee pain for 20 years so I know I'll never totally •

Other components

Neurodynamic mechanosensitivity Muscle length/Strength changes

Group 4

8 (Resolved)

Other pain mechanisms

Neurogenic inflammation/ maintained sympathetic output

Accessory II Physiological II

Accessory and physiological at limit (IV) Manipulation

Psychosocial yellow flags

Unhelpful thoughts, behaviours

In summary, prognosis is a forecast of thefuture history

get rid of it.')

of a patient's disorder based on the probability of

contributing factors and other barriers to

physical, psychological and functional recovery of

recovery (structural anomalies, systemic d isease,

the patient and the disorder. Therefore consideration

general health problems such as diabetes,

should be given to:

ergonomic/socioeconomic en vironmen ts such as keyboard workers, heavy manual work, low income) •

expertise of the physiotherapist, especially in the fields of communication and handling.

1.

the natural history of a particular disorder - is the disorder running its course?

2. the response to manipulative physiotherapy treatment - has the progress been acceptable?

Pri nciples of selection and progression of mobil ization / manipulation techniques

�

, lid The basis ,'" � � �·I

Box 8.2 • • • • • •

•

3. what is acceptable to the patient - has the main

.'

Signs/sym ptoms (cl in ical g roupings) Com parable movements (dysfunction) Sou rce of symptoms (cause of the sou rce) Stage in natu ral history Pathobiological mechan isms Contributing factors, precautions and contra indications, barriers to recovery Prognosis

problem been solved?

4. is there need for prophylaxis - is a home programme needed to complement or maintain recovery; is 'top-up' treatment required periodically?

5. prognosis should at all times be realistic. Box

8.2 outlines the basis of selection and progression

using hypothesis categories.

References Akeson, W. H., Woo, S. L-Y., Ameil, D. et al. 1973. The connective tissue response to immobility: biochemical changes in periarticular connective tissue of the immobilized rabbit knee. Clinical Orthopaedics, 93, 356-422 Barnett, C. H. 1956. Wear and tear in joints. An experimental study. Journal of Bone and Joint Surgery, 38B, 567-575 Beighton, P., Grahame, R & Bird, H. 1983. Hypermobilih) of Joints. Berlin: Springer-Verlag Bland, J. H. 1983. The reversibility of osteoarthritis: a review. American Journal of Medicine, 74, 16-26 Bohler, 1. 1950. Cited by Platt, H. Orthopaedics in Continen tal Europe 1900-1950. Journal of Bone and Joint Surgery, 32B, 574-584 Broderick, P. A., Corvese, N., Pierik, M. G. et al. 1976. Exfoliative cytology interpretation of synovial fluid in jOint disease. Journal of Bone and Joint Surgery, 58A, 396-399 Butler, D. S. 2000. The Sensitive Nervous System. Adelaide: NOI Group Caterson, B. & Lowther, D. A. 1978. Changes in the metabolism of the proteoglycan from sheep articular cartilage in response to mechanical stress. Biochimica et Biophysica Acta, 540, 412-422

Charnley, J. 1973. Communication to a symposium on biomechanics, Institution of Mechanical Engineers, London 1959. In Gray's Anatomy, 35th edn., p. 193. London: Longman Clarke, 1. C. 1975. Friction and wear of articular cartilage a pendulum/SES system. Journal of Bone and Joint Surgery, 57A, 567 Corrigan, B. & Maitland, G. D. 1983. Practical Orthopaedic Medicine. London: Butterworths, pp. 78-149 Cyriax, J. H. & Cyriax, P. J. 1983. Illustrated Manual of Orthopaedic Medicine. London: Butterworths, pp. 51-98 Delbet, 1. C. 1950. Cited by Platt, H. Orthopaedics in Continental Europe 1900-1950. Journal of Bone and Joint Surgery, 32B, 574-584 Ekholm, R 1955. Nutrition of articular cartilage. Acta Anatomica, 12, 77

Evans, P. 1998. Ageing, degeneration and trauma in joints. Physiotherapy, 84, 564-565 Flint, M. H. 1976. The role of environmental factors in connective tissue ultrastructure. In The Ultrastructure of Collagen, pp. 60-66. Springfield, IL: C. C . Thomas Frank, c., Akeson, W. H., Woo, S. L-Y. et al. 1984. Physiological and therapeutic value of passive motion. Clinical Orthopaedics and Related Research, 185, 113-125 Gebhard, J. S., Kabo, J. M. & Meals, R A. 1993. Passive motion: the dosage effects on joint stiffness, muscle mass, bone density and regional swelling. Journal of Bone and Joint Surgery, 75A, 1636-1647 Gifford, 1. S. 1997. Pain. In Rehabilitation of Movement: Theoretical Basis of Clin ical Practice, ed. J. Pitt-Brooke. London: W. B. Saunders Gifford, 1., ed. 1998. The mature organism model. In Topical Issues in Pain - Whiplash: Science and Management. Fear Avoidance Beliefs and Behaviour. Adelaide: NOI Group

Gillard, G. c., Merrilees, M. J., Bell-Booth, P. G. et al. 1977. The proteoglycan content and the axial periodicity of collagen in tendon. Biochemistry Journal, 163, 145-151 Hassler, C. R, Rybicki, E. E, Diegle, R B. & Clark, 1. C. 1979. Studies to enhanced bone healing via electrical stimuli. Clinical Orthopaedics and Related Research, 124, 9-11 Higgs, J. & Jones, M. A. 2000. Clinical Reasoning in the Health Professions, 2nd edn. New York: Butterworth-Heinemann Hunter, G. 1994. Specific soft tissue mobilization in the treatment of soft tissue lesions. Physiotherapy, 80, 15-21 Hunziker, E. B. 2002. Articular cartilage repair; basic science and clinical prospects. Osteoarthritis and Cartilage, 10, 432-463 Jeffreys, E. 1991. Prognosis in Musculoskeletal Injury: A Handbook for Doctors and LaWl)ers. London: Butterworth Heinemann Jull, G. 1979. The role of passive mobilization in the immediate management of the fractured neck of humerus. Australian Journal of Physiotherapy, 25, 107-114 Lowther, D. A. 1979. The Effects of Compression and Tension on the Behaviour of Connective Tissue in Aspects of

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M A I TLA N D ' S P E R I PH E R A L M A N I P U LATI O N

[ Manipulative Therapy, Melbourne: Lincoln Institute of

Health Sciences, pp. 15-21 Lowther, D. A. 1983. Unpublished observation. Maitland, G. D. 1978. Demonstration of patient I: shoulder manipulation (50 mins), and Demonstration of patients II and III (55 mins). Videotape numbers 17 and 18. Postgraduate Teaching Centre Hermitage, Medizinische Abteilung, Bad Ragaz, Switzerland CH 7310 Maitland, G. D. 1985a. The hypothesis of adding compression when examining and treating synovial joints. Journal of Orthopaedic and Sports Physical Therapy, 2, 7-14 Maitland, G. D. 1985b. Passive movement techniques for intra-articular and periarticular disorders. Australian Journal of Physiotherapy, 31, 3-8 Maitland, G. D. 1991. Peripheral Manipulation, 3rd edn. London: Butterworth-Heinemann Maitland, G. D., Hengeveld, E., Banks, K. & English, K., eds. 2001. Maitland's Vertebral Manipulation, 6th edn. Oxford: Butterworth-Heinemann Malcolm, L. L., Fung, Y. c., Woo, S. L-Y. et al. 1975. Steady state dynamic friction properties of cartilage - cartilage interfaces. Journal of Bone and Joint Surgery, 57A, 567 Maroudas, A., Bullough, P., Swanson, S. A. V. & Freeman, M. A. R. 1968. The permeability of articular cartilage. Journal of Bone and Joint Surgery, SOB, 166-177 McDevitt, C. & Muir, H. 1977. An experimental model of osteoarthritis: early morphological and biochemical changes. Journal of Bone and Joint Surgenj, 59B, 24-35 McNair, J. & Maitland, G. D. 1983. The role of passive mobilization in the treatment of a non-uniting fracture site - a case study. International Conference on Manipulation Therapy, Manipulative Therapists Association of Australia Mow, Van C. & Kuei, C. K. 1975. The effect of visco-elasticity on the squeeze film action of lubrication of synovial joints. Journal of Bone and Joint Surgery, 57A, 567 Noel, G., Verbruggen, A., Barbaix, E. & Duquet, W. 2000. Adding compression to mobilization in a rehabilitation

programme after knee surgery: a preliminary clinical observational study, Manual Therapy, S, 102-107 Panjabi, M. M., White, A. A. & Wolf, W. W. Jr. 1979. A biochemical comparison of the effects of constant and cyclic compression on fracture healing in rabbit long bones. Acta Orthopaedica Scandinavica, 50, 653-661 Peacock, E. E. & Van Winkle, W. 1976. Wound Repair, 2nd edn. Philadelphia: W. B. Saunders Reichmister, J. P. & Freidman, S. L. 1999. Long term functional results after manipulation of the frozen shoulder. Maryland Medical journal, 48, 7-11 Salter, R. B. 1982. Presidential address. journal of Bone and Joint Surgery, 64B, 251-254 Salter, R. B. 1985. Motion versus Rest: Why Immobilize joints? Proceedings of the Manipulative Therapists Association of Australia, Brisbane, pp. 1-11 Salter, R. B., Simmonds, D. E, Malcolm, B. W. et al. 1975. The effects of continuous passive motion on the healing of articular cartilage defects - an experimental investigation on rabbits. Journal of Bone and Joint Surgery, 57A, 570-571 Salter, R. B., Simmonds, D. E, Malcolm, B. W. et al. 1980. The biological effects of continuous passive motion on the healing of full-thickness defects in articular cartilage. journal of Bone and Joint Surgery, 62A, 1 232-1251 Shorter Oxford Dictionary. 1980. Shorter Oxford Dictionanj on Historical Principles, 3rd edn. Oxford: Oxford University Press Thomas, H. O. 1950. Cited by Osmond-Clarke, H. Half a century of orthopaedic progress in Great Britain. Journal of Bone and joint Surgery, 32B, 622-623 Van Wingerden, B. A. M. 1995. Connective Tissue in Rehabilitation. Vaduz: Scirpo Verlag Williams, J. G. P. & Sperryn, P. M., eds. 1976. Sports Medicine. London: Edward Arnold, pp. 441- 586 Williams, P. L. & Warwick, R. 1980. Gray's Anatomy, 36th edn. Edinburgh: Churchill Livingstone Yasuda, 1. 1997. The classic-fundamental aspects of fracture treatment. Clinical Orthopaedics and Related Research, 124, 5-9

237

Chapter

9

Recording

THIS CHAPTER INCLUDES: •

Key words for this chapter

•

Glossary of terms for this chapter

•

Recording principles

•

Recording examples for various stages of the physiotherapy process.

KEY WORDS Recording, reassessment, SOAP notes.

GLOSSARY OF TERMS SOAP notes - recording of therapy sessions must include detailed information, yet must be brief and provide a simple overview. Within this concept use has been made of

the so-called 'SOAP' notes (Weed

1964,

Kirk

1988). The acronym

SOAP refers to the various parts of the assessment process:

1.

Collection of �ubjective information

INTRODUCTION

Assessment and treatment require an in-depth written record of the findings and results at each session. Ideally, documentation which is systematic, consequent and easy to (re-)read in a short time provides the physio therapist with a framework that should lead the therapist throughout the overall therapeutic process. Systematic records serve as a mnemonic and a means of communication to other professionals. They sup port the physiotherapist in various ways: • • •

to reflect upon the decisions made to control the actions taken if necessary, to quickly adapt the therapy to a changing situation.

2. Collection of Qbjective information

3. Performing an gssessment

4.

Develop and formulate a p-Ian

POMR - problem oriented medical records, containing SOAP acronym.

Hence, written records are essential in the process of ongoing quality management. It is argued that many physiotherapists consider documentation of sessions as a necessary evil. As a consequence many records frequently seem superficial and incomplete (Cohen 1997). Although probably recording will not be encountered with a lot of positive expectations in learning the 'art of physiotherapy', there are various reasons why physiotherapists should consider the recording of the sessions they shape: •

Records serve as a mnemonic for the physiother apist of what has been done, thought and planned.

•

Systematic recording serves clinical reasoning and learning processes: committing thoughts to paper

238

MAITLAND'S PERIPHERAL MANIPULATION

•

forces therapists to think more precisely and accur ately and to become aware of their own reasoning processes. It enhances reflection and monitoring decisions made and actions taken.

overview. Within this concept use has been made of the so-called 'SOAP' notes (Weed 1964; Kirk 1988). The acronym SOAP refers to the various parts of the assessment process:

Committing the essence of examination and treat ment findings to paper is a valuable learning expe rience in itself. It forces one to identify the things that are essential, and record them, and leave out the less important information.

Collection of subjective information Collection of objective information 3. Performing an assessment 4. Develop and formulate a plan.

•

Committing thoughts to paper, with systematic recording, helps to clear the mind as the information and impressions gained throughout are organized.

•

Recording of patient information, actions and plan ning steps support the development of clinical patterns in memory. Therefore recording may be an essential process in the development of experiential knowledge (Higgs & Titchen 1995, Nonaka & Takeuchi 1995).

•

Ideally, the records should document the trail along which assessment and treatment are moving.

•

Comprehensive, systematic patient records may serve as a basis for clinical case studies.

•

Records may be a mnemonic for the patient as well. In some cases, the patient may have forgotten how the disorder has been improved immediately fol lowing a treatment. If for other reasons a few days later the symptoms recur, the patient may easily interpret the condition as unchanged. Examination of the record made immediately following the treat ment may guide the physiotherapist as well as the patient in the reassessment of the patient's condition over the whole period directly after the last session until the moment that symptoms increased again.

•

Records aid communication in team collaboration. If a colleague is absent from work, the physiother apist may be able to continue with the initialized course of treatment, provided the records are such that they are understandable.

•

Recording for legal reasons - in many countries phys iotherapists are enforced by law to store their patient records for a certain period of time. Furthermore, physiotherapy records may be used in litigation.

•

An increasing number of professional associations declare documentation as an integral part of the physiotherapy process (OPV 1998, WCPT 1999, Heerkens et al 2003).

SOAP notes

Recording of therapy sessions must include detailed information, yet must be brief and provide a simple

1.

2.

It is not mandatory to follow the guidelines and abbre viations as set out in this book; however, some method must be determined to suit the patient's comments and the therapist's pattern of thinking. The basic elem ents of the SOAP mnemonic may serve as a useful format to follow all the steps of the therapeutic process in a brief and comprehensive way. It has been argued that the term 'objective' in the SOAP notes is somewhat awkward, due to the fact that the physiotherapist values the subjective experience of the patient while performing the test movements. Furthermore, it is argued that the physiotherapist as the 'measuring instrument' will give attention to those aspects of a test which seem most relevant at the time, and thus true objectivity in test procedures may not exist (Grieve 1988). It has therefore been decided to replace the term 'objective examination' with 'physical examin ation' (PIE). There has been criticism that SOAP notes within problem oriented medical records (POMR) would con fine the physiotherapist to focusing merely on biomed ical data (French 1991); however, if the physiotherapist pays attention to key words and specific key phrases of the patient which are indicative of the individual ill ness experience, they may be recorded in parentheses and integrated in the documentation, thereby incorpor ating elements of the individual illness experience into the records. At all times patient records should include the find ings as well as the steps in planning - a trail is laid of what is done and what is thought. Recording encom passes ideally: •

• • •

information on examination and assessment procedures treatment interventions and results (reassessments) planning steps and hypotheses formulated important key words or phrases of the patient.

ASTERISKS

During the subjective examination the patient may state certain facts related to the disability which may prove to be valuable parameters for reassessment procedures.

Recording

Box 9.1

Use of asterisks

conditions need to be fulfilled. Patient records need to be: •

Asterisks are an invaluable aid in assessment

•

procedures. The use of an asterisk in recording

•

highlights the following aspects:

• •

•

Primary symptoms or activity limitations

•

Signs that reproduce a patient's symptoms

•

Other important comparable signs that will be

•

Other information that is important

followed up in reassessment procedures •

Key issues that need to be followed up

•

'Asterisk as you go along' indicates that it is important to immediately highlight relevant findings once they have been obtained rather than in retrospect. If the findings have been recorded straight away it will influence the physiotherapist in the further procedures of examination and assessment.

These should be highlighted in the records immediateLy, and an 'asterisk' sign may be used. Although the use of asterisks is not mandatory, it may speed up the whole process. They are time savers, reminders and indicators of highly important facts for the particular person. Identifying these main assess ment markers with a large, obvious asterisk not only enforces a commitment but also makes reassessment procedures quicker, easier, more complete and there fore more valuable. Using asterisks is just as valuable for the physical examination parameters as it is for the subjective exam ination. Similarly, making use of the asterisks progres sively during the physical examination rather than after is recommended. The same applies to each subsequent session. At times it seems that the term 'asterisk' has become jargon; however, it is not meant in such a way. People teaching and working with this concept may frequently use the term 'subjective and physical examination aster isks'. Mostly this refers to information of subjective and physical examination parameters which will be reassessed at regular intervals over the whole thera peutic process in order to monitor progress in rehabili tation and the effects of treatment (Box. 9.1).

CONDITIONS

Some people may prefer other ways of recording. However, regardless the method of recording, some

•

organized clear comprehensive simple to (re)read written concisely, in telegraphese homogenous, consequent.

SOME REMARKS WITH REGARDS TO RECORDING

It is important to record related information even when the findings indicate normality. By their having been recorded, reference at a later date shows that the par ticular questions have been asked or physical examin ation tests have been carried out. Recording normal findings on a 'record sheet' is a quick and simple procedure. For example, if a patient has pain in the shoulder area and the therapist has examined the acromioclavicular joint comprehensively and found it to have normal painless movements, all that might be recorded is: Ale.l.I. The point is, it must be recorded. There is much more to be recorded from an initial consultation than for subsequent sessions. However, the same detail is required and so the same details and abbreviations can be used. People have likes and dis likes about these symbols - this does not matter, pro vided the criteria for comprehensive recording are met. Questionnaires as well as 'cheat sheets' as they are often termed, have advantages and disadvantages. The primary considerations are that they should not be regimented and they should not be detailed. A cheat sheet that has a list of questions requiring ticks and crosses, should not be used. They are inflexible and destroy independent thinking on the part of the exam iner, and they completely obliterate any chance of fol lowing the patient's line of thought or the pursuit of hypotheses in greater detail.

RECORDING OF SUBJECTIVE EXAMINATION FINDINGS

With each patient there are many questions and answers that need to be entered in the recording, even if it is only to show that the question, which was important, has in fact been posed and answered. It is a safe procedure to utilize the patient's words during the recording of subjective examination findings. For example, if a patient complainS of a pulling in the

239

240

MAITLAND'S PERIPHERAL MANIPULATION

2

CD @ Always together CD if CD ++ @ No relation

Figure 9.1

Example of a body chart.

arm while lifting the arm above the head, this needs to be recorded as the patient said it, rather than the physiotherapist's language of 'symptoms or pain with flexion', as this may immediately narrow down the physiotherapist's thinking. Key words and phrases indicative of the personal illness experience may be put in quotation marks. It has been emphasized that such key words and phrases may be essential information to the shaping of the therapeutic process, hence they have to be recorded accordingly. Organization of the information in the main cat egories of the subjective examination is essential to keep an overview over the process of subjective examin ation. While asking questions regarding the 'main pro blem', it is possible that the patient gives information on history mingled with, for example, bits of symptom atic behaviour. In such cases it is relevant to leave suf ficient space on the paper to organize and record the information under sections 'history' or 'behaviour'

rather than writing down every bit of information in a chronological manner. This will help the physiother apist to keep an overview over the whole process of subjective examination, even if the communication technique of 'paralleling' has been chosen (Chapter 3).

Body chart •

Frequently, after establishment of the patient's main problem and receiving a more general statement about the perceived disability, the area, depth and nature, behaviour and chronology of the symptoms are clarified and recorded on a 'body chart' (Fig. 9.1).

•

Reference to such a body chart provides a quick and clear reminder of the patient's symptoms and main problem.

•

A well-drawn body chart helps to generate hypoth eses on the sources of the movement dysfunction or

Recording

Current

I

I

Hx

� Since when

� Since 4 weeks

I

I

I

I Details on onset of symptoms

�

•

•

•

�

J

Same. Does not bother DLA much

Could continue judo training

No medic., or other Rx

I

I Now: onset

1

I

8

Went to GP because 'annoying'

GP-+PT

Time line: current history.

symptoms as well as on the neurophysiological pain mechanisms. Additionally, first hypotheses with regard to precautions and contraindications may be made. •

I

I Progression since onset

Judo: fall on side -little pulling, groin Sy.G) little bit day 1, over c. 7 days difficulties twith gardening, judo, stiffness a.m.

Figure 9.2

I

In principle, the body chart is drawn by the physio therapist to facilitate recording and memory.

OccaSionally, in patients with chronic pain states, the body chart may be drawn by the patient. If dif ferent colours are used, as a metaphor for the pain experience they may become a guide in reassess ment procedures. If the information on a body chart is recorded con sistently at the same place all the time, self-monitoring mechanisms are more easily activated. If the physio therapist forgets to ask certain questions, this may be noticed more easily when re-reading the information. The use of Arabic numerals in circles for the differ ent symptom areas simplifies later recording: if there is a need to refer to the symptom areas, the numerals can be used rather than lengthy descrip tions of the symptom areas.

Always record the same information on the same spot of the body chart. This enhances self-monitoring - on re-reading the information it will be easier to discern if certain details are missing.

Behaviour of symptoms and activities

As described in Chapter 6, the information on the 'behaviour of symptoms' is essential to the expression of many hypotheses. Furthermore, the information usually serves in reassessment procedures of subse quent sessions. Therefore the information needs to be recorded in sufficient detail.

If activities or positions are found which aggravate the patient's symptoms, this has to be recorded meticu lously. However, any easing factors also need to be writ ten down straight away, on the same line as the activity which provokes the symptoms. This may sound pedan tic to some; however, it will give the physiotherapist an immediate overview as to which activities and positions the patient has developed as useful coping strategies and with which ones the patient may need some help. Some examples are:

* CD i

* CD * CD

Gardenin g, pulling weeds, in squat position; after 10' PI CD, after 20' CD+ � Gets up, walks around (few steps, shuttles leg): CD� 100% immed. May continue gardenin g. i Putting on socks, in standing - activity possible as usual � CD � 100% immed. as soon as leg is put down. i Lying in bed - prone, right leg pulled up. Wakes up c. 03:00 CD+ � Does not know how to ease. Gets up, walks c. 20' CD 'acceptable'

History

At times it may be difficult to keep an overview of all the information regarding the history of a patient's problem and to monitor if all the relevant data have been obtained. This may happen particularly in those circumstances where there have been more episodes and the problem has been recurrent for many years. Although not mandatory, the physiotherapist may draw a line indicative of the course of time to keep an overview of both the current and previous history (Figs 9.2, 9.3). RECORDING O F PHYSICAL EXAMINATION FINDINGS

Physical examination findings need to be recorded in sufficient detail and systematically in order to allow

241

[

242

MAITLAND'S PERIPHERAL MANIPULATION

Previous Hx

I

1995 - after marathon

- after c. 1 week gone

I

I

2000

� �

I

2002

I

2003

- after judo championship

- gone after 1 week

� �

2004 - after judo training (current Hx)

Between episodes: no symptoms, no disabilities Current episode: does not disappear with little stretching exercises as in other episodes

Figure 9.3

Tim e line: previous hist o ry.

for quick referencing during subsequent reassessment procedures. Making use of symbols helps speed up the process and enhances quick referencing (Table 9.1).

ACTIVE MOVEMENTS

When recording the range and quality of movement and the symptomatic response to that movement, one should develop a pattern of recording and stick to it. By doing so, more facts can be remembered, while at the same time leaving the therapist's mental processes more time to take in other details. Active movement findings can be recorded as follows:

This indicates that the range of abduction has been 170°, with a deviation of the movement between 120° and 170° of abduction; symptom reproduction occurred at the active end of range without application of over pressure. With correction of the deviation in the move ment, the range decreased until 130° of abduction and the pain was clearly increased. *

Hip F 130°, loc P groinrv_, CDrv+

This example shows that the overall range of hip flex ion was 130°, without any deviations in the quality of the movement; local symptoms were produced with a light overpressure ('IV-'), symptom reproduction occurred with stronger overpressure ('IV+'). PASSIVE MOVEMENTS

This example means supination (sup) has a normal range and quality of movement (the first tick, ./) and has no abnormal pain response when overpressure is applied (the second tick, ./). It is suggested relating the first tick (./) to move ment responses such as range and quality of move ment and the second tick (./) to symptom responses which occur during the test movement. It may be indi cated with a grading of IV -, IV or IV+ how firm the overpressure has been. This is particularly relevant in those cases where the phYSiotherapist wants to test the movements with a certain amount of overpressure; however, factors in the 'nature of the disorder' (Chapter 5) may limit the phYSiotherapist in applying maximum overpressure. A movement cannot be classed (or recorded) as nor mal unless the range is pain free both actively and pas sively. Further overpressure applied at the limit of the available range should not cause pain other than nor mal responses. Abnormal findings may be recorded as follows: *

Ab 170°, Dev. Ventr. 120--- 170°, CD act. EOR Corr. Dev. 130°, CD++

With passive movement the behaviour of pain, resist ance and motor responses (spasm) is monitored. The physiotherapist is particularly interested in how these components behave and relate to each other. This is a very detailed examination procedure and may be con sidered as a part of the 'art of manipulative physio therapy'. Most simply, but not mandatory, would be the drawing of a movement diagram, as delineated in Chapter 7 and Appendix 1. Otherwise abnormal find ings regarding the behaviour of P1 and P', Rj and R2, including their relationship, may be recorded verbally. If certain passive movements are classed as normal, the same method (./,./) as with active movements may be used. However, if relevant abnormal findings are present, this method is not suffiCiently comprehensive.

Example: SLR ®: Rj: 50°, L R2 70°; Pj pulling hamstr. c. 55°, P' only little (3/10). =

This example indicates that the physiotherapist first felt an increase in resistance with c. 50° of SLR, the movement was limited by resistance at c. 70° of SLR, only a little pulling sensation was provoked in the hamstrings area. Figure 9.4 illustrates the associated movement diagram.

Recording

Totally e. 6' 'Comfortable'; after 4' R} to L, especially with I After c. 6' no further changes in P or R

RECORDING OF TREATMENT INTERVENTIONS

Before performing a treatment technique, the planning and the reasoning for its selection should be recorded. Next, the treatment and its effect should be written down. This needs to include sufficient details in order to be able to refer back at later stages when making ret rospective assessments. The treatment record for a passive mobilization technique should contain: • • •

• • • •

•

the position of the patient ' the position of the joint selected treatment technique(s), including inclinations of the movements grade(s) of the technique rhythm in which the technique was performed duration (in number of repetitions or time units) symptomatic responses and the patient's reactions while the intervention is being performed ('assessment during treatment' - see Chapter 5) reassessment immediately following the technique (it is usually helpful to make comparisons or statements as to which parameters have improved and which ones have stayed unchanged).

It is essential not only to record the treatment by pas sive movement in detail but also active procedures, exercises or physical applications (e.g. ultrasound requires the same depth of recording). Treatment is followed by a reassessment in which patients are asked to make a comparison of any changes of symptoms or in their sense of wellbeing resulting from the technique. This is then followed by a reassessment of the affected physical examination tests. Ideally, the records of the physical examination find ings include a brief appraisal of the results in comparison with the assessment just before the application of the treatment technique. Finally, at the end of a treatment session, the clini cian should commit to paper thoughts on how treat ment needs to be modified at the next session. Such an analysis not only forces the clinician to reflect on clini cal reasoning processes, but also stimulates memory of the last treatment session.

•

Other forms of treatment: In

sitting: do F/Ad hip R and L 5x, e. 10", until slight pulling buttock 'Comfortable'

•

C/O: 'same' P /E: F 160°, (1) IV ++ © ('feels much freer, I can move higher') HBB: range & P ISQ Plan: repea t same Rx;

Ultrasound

Sitting, knee extended Rx:US 3 MHz, large head; 1:2 int. 2 1.0 W /cm ; 3'; on tender spot, medially knee No pain

C/O: 'lighter than before to stand' PIE: Lx F: 2 cm, Lact EOR © Hip F: 130°, (1) IV+ © Plan: do ex. at/work; at least 3x/day A P buttock starts. 1-2 series; 5x/30" each leg C/O: 'not tender now' P /E: Squat: full range. L© E/AB: '/, (1) IV+ ©

(It is frequently useful to compare the results and to mark which elements may have improved following the intervention)

INFORMATION, INSTRUCTIONS, EXERCISES, WARNING AT TH E END OF A SESSION

Any information or instruction given during the treat ment, any exercise that the patient should perform as a self-management strategy needs to be recorded as well. At the beginning of a treatment series it is often important to warn the patient diplomatically for pos sible exacerbations. This also needs to be recorded.

Example •

Passive movement:

Rx G/H, Supine In: 150° F (before P1) Do: I, c: IV- to IV Smooth rhythm, reI. quick

Exercises

•

•

Examples:

if HBB remains ISQ, do ace. mvt in EOR HBB

•

Warned about possible increase; however, if spot gets smaller, may be a good sign. Should observe and compare: - mornings getting out of bed - changes in stiffness? - working in garden - anything different from before? - nights - anything changing in sleep pattern? - effect of exercise, if pain occurs? Instruction (e.g. remembers anything particular about fall during judo?).

243

N

t � » -i r » z o VI

Table 9.1

Recording symbols

.." m ::0

F

Flexion

E

Extension

Ab

Abduction

Ad

Adduction

:J �

Medial rotation

HF

Horizontal flexion Horizontal extension

HBB

Hand-behind-back

Inv

Inversion

Ev

Eversion

DF

Dorsiflexion

PF

Plantarflexion

Sup

Supination

Pron

Pronation

EI

Elevation

De

Depression

Protr

Protraction

Retr

Retraction

Med

Medial

Lat

Lateral

OP

Overpressure

PPIVM

Passive physiologicaI intervertebral movements Passive accessory intervertebral movements

ULNT

; t r

Lateral rotation

HE

PAIVM

.." ::c m ::0

Spine

Peripheral joints

Upper limb neural tests

Central posteroanterior pressure (PAs)

/ with a CD inclination

Central anteroposterior pressures (APs) Unilateral PAs on CD

< with a medial inclination

L

Unilateral APs on the CD

+--

Transverse movement towards CD

�

Rotation towa rds CD

'\

LateraI flexion towa rds

......

Longitudinal movement (state cephalad or caudad)

�

Unilateral PAs at angle of@ 2nd rib

� -t

CD

Further laterally on @on 2nd rib Unilateral APs on @

CT

/

Cervical traction in flexion

CT

t

Cervical traction in neutral (sitting)

IVCT

t

Sitting

IVCT /

Lying

IVCT /10 3/0 15

Intermittent variable cervical traction in some degree of neck flexion. the strength of pull being 10 kg with a 3-second hold period, no rest period, for a treatment time lasting 15 minutes

» r-

� » z .." C r » -i o Z

LLNT

Lower limb neural tests

LT

Q

Quadrant

LT 30/15

Lock

Locking position

F/Ab

Flexion abduction

F/Ad

Flexion adduction

E/Ab

Extension abduction

E/Ad

Extension adduction

Distr

Distraction

; t

Lumbar traction Lumbar traction, the strength of pull being 30 kg for a treatment time of 15 minutes Lumbar traction with hips and knees flexed:

LT crk 15/5

15 kg for 5 minutes IVLT 50 %

10

Intermittent variable lumbar traction, the strength of pull being 50 kg, with no hold period and no rest period, for a treatment time lasting 10 minutes

Posteroranterior movement Anteroposterior movement

......

Transverse movement in the

!

Gliding adjacent joint

direction indicated

>-+-<

surfaces Compression Longitudinal movement:

Ceph

Cephalad

Caud

Caudad

Longitudinal movement is the direction of movement of a joint in line with the longitudinal axis of the body in its anatomical position. When that same movement is performed in any other position than the anatomical position, that movement of the joint is still called longitudinal movement even though it is not now in line with the longitudinal axis of the body Spinal data reproduced by kind permission from Maitland,

G. D.,

Hengeveld,

E.,

Banks,

K. & English, K. 2001. Maitland's Vertebral Manipulation, 6th edn. Oxford:

Butterworth-Heinemann

:%J /"1) n

�

0.. :> ID

N .j::. (.71

246

MAITLAND'S PERIPHERAL MANIPULATION

[

c

R2 (IV++)

D

• •

� :::> ro c

• •

I

�

•

P /E: additional tests as planned Plan: e.g. stick to plan as stated after Rx 2 Rx 3a (as above) .. . Rx 3b (as above) .. . Plan

:0

El Y2 :� I i?:' .� >

RETROSPECTIVE ASSESSMENT

Q) en

A

Y4

R, % P, L'Y. (locally hamstring-area)

B

Range

Figure 9.4

Movement diagram.

RECORDING OF FOLLOW-UP SESSIONS

When recording follow-up sessions, the first words must include a quotation of the patient's opinion of the effect of the previous treatment. This quotation must be worded in such a way that it is a 'comparison' rather than just a 'statement of fact' (Chapters 3 and 5). The subjective reassessment is then completed in which the physiotherapist clarifies those activities that serve as parameters and have been highlighted with an asterisk in the records of previous sessions. Following the subjective reassessment the record includes the physical examination tests which are being reassessed. These too are recorded as compari sons with the previous findings. Changes in the physical examination findings will hopefully agree with the findings of the subjective assessment, so reinforcing each other. This will then make the total assessment more reliable. Also during reassessment of physical examination tests it may be necessary to record key words and phrases; in the rehabilitation of, for example, shoulder problems it may be a good sign if the patient makes the spontaneous remark: 'the arm is mine again'. The following pattern may be used in recording follow-up sessions: •

•

•

Date, time of the day, Rx 3, DB (indicating third session on eighth day since the initial consultation) C/O spontaneous information: 'better', 'felt lighter than before' C/O follow-up of subjective parameter: putting on socks today cf. yesterday: no pain ( unusual! First time in 3 weeks!) PP P/E: reassessment of physical examination parameter (including statements of comparison with after/before the previous treatment)

The record of retrospective assessment has to stand out from other parts of the treatment so that the informa tion can be easily traced on reviewing progress in later sessions. This is particularly important when a patient has an extensive disorder and considerable treatment. To be practical, time must be a consideration, but not at the expense of detail and accuracy. Especially within retrospective assessment, in the written record three requirements should be respected: 1.

To stand out from other data (to be highlighted so that it is readily seen on checking back through the record). 2. To state with what time frame the comparison is made (e.g. Rx 5 cf. Rx 1). 3. To emphasize spontaneous information. Retrospective assessments should include the follow ing information and comparisons: •

•

• •

•

•

•

•

=

• •

•

General wellbeing compared with, for example, four sessions ago Symptoms compared with, for example, four sessions ago (know indicators of change - see Chapter 5) Level of activities compared Effect of interventions so far (P/E and passive movements) Effect of instructions, recommendations and exercises so far What has the patient learned so far -'what was particularly relevant to the patient? Comparison of all the relevant physical examination parameters compared with, for example, four sessions ago Which interventions brought which results? (certain physical examination findings may improve more with some interventions than with others) Goals for the following phases of treatment (process of collaborative goal setting: redefinition or confirmation of agreed goals to treatment, interventions and the parameters to measure if the objectives are being achieved).

Recording

WRITTEN RECORDS BY THE PATIENT

There are times when it is necessary for a patient to write a running commentary of the behaviour of the symptoms. For example, a patient may be a poor histor ian in which case he may be asked to write down how he feels immediately following treatment, how he feels that night and how he feels on first getting out of bed the next morning. Some people may feel this is encour aging a patient to become overly focussed on his symptoms. However, if the patient is asked not only to record how he feels, but also the level of activities, medication intake and possible self-management inter ventions, such a record may become a highly valuable teaching instrument which aids both the patient and the physiotherapist. There are many different types of pre-printed form that can be used. However, it is essential that the forms leave space for information regarding: • •

• •

symptoms activities before and during the increase of symptoms activities throughout the day /week employment of self-management strategies to influence wellbeing, including the effects of the interventions.

When a written record by the patient is used, it should be handled by the manipulative physiotherapist in a particular sequence: 1. On receiving it from the patient, it should be laid down. 2. The patient should be asked to give a general impression of the effect of the last treatment. 3. The subjective assessment of the effect of the last treatment should be taken through to its conclusion. 4. The written record can then be assessed and any discrepancies clarified. CONCLUSION

Although recording of examination findings, treat ment interventions and results, and regular planning, may not be the most interesting part of learning, it is an essential element of the quality of the overall therapeu tic process. It monitors the phYSiotherapist throughout the process and allows quick adaptation of interventions, if needed. When recording is accurate and succinct, and can be correctly interpreted by another person reading it, it is an invaluable self-teacher and may support physiotherapists on their path to expertise and main taining this.

References Cohen, L. 1997. Documentation. In Chronic Pain Management

for Physical Therapists, ed. H. Wittink & T. Hoskins Michel. Boston: Butterworth-Heinemann

French, S. 1991. Setting a record straight. Therapy Weekly, 1, 11

Kirk, D. 1988. Problem Orientated Medical Records: Guidelines for Therapists. London: Kings Fund Centre

Nonaka,1. & Takeuchi, H. 1995. The Knowledge-Creating Company. New York: Oxford University Press

Grieve, G. P. 1988. Critical examination and the SOAP

OPV 1998. Broschure Berufsbild Physiotherapeut. Vienna:

Heerkens, Y. F., Lakerveld-Hey, K., Verhoeven, A. L.

WCPT 1999. Description of Physical Therapy. London: World

mnemonic. Physiotherapy, 74, 97

J. et al.

2003. KNGF - Richtlijn Fysiotherapeutische Verslaglegging.

Amersfoort: KNGF

Higgs, J. & Titchen, A. 1995. The nature, generation and verification of knowledge. Physiotherapy, 81, 521-530

Osterreichischer PhysiotherapieVerband

Confederation of Physical Therapy

Weed, L. 1964. Medical records, medical education and

patient care. Irish Journal of Medical Science, 6, 271-282

247

249

Chapter

10

Peripheral neuromusculoskeletal disorders

THIS CHAPTER INCLUDES: •

Key words for this cha pter

•

Glossary of terms for this cha pter

•

An explanation and classification of neuro I musculoskeletal diso rders

•

How to recognize movement related and non-movement related disorders

•

The natural h istory of

•

neuro I muscul oskeletal disorders •

Typical syndromes and pathologies relevant to mani pulative

The structu res at fault and their

physiotherapy

c l i nical profiles

•

Clinical profi l ing

•

A review of mechanisms of

•

The art of prognosis ma king

symptom production

•

•

The c l inical significance of

Differential dia gnosis of systemic disease.

recognizing prima ry and secondary hyperal gesia

KEY WORDS

primary hyperalgesia, secondary

non-responders, prognosis,

Disorder, syndromes, mechanisms,

hyperalgesia, responders,

differential diagnosis.

brick wall, natural histo ry, structures,

GLOSSARY OF TERMS Abuse - a function or activity which results in physical abuse beyond reasonable limits. Affective mechanisms - cognitive mechanisms and emotional states which influence the p rocessing and u l timately the experience of pain and i llness. Allodynia - pain due to a stimulus that does not normally provoke pain, such as touch or movement. Barriers to recovery - factors which influence the natural history of a pa rticu l a r disorder such that recovery or the expected rate of recovery is affected. Barriers to recovery may include: fea r of

movement because of the pain

heaviness or the feeling of hot

experience; poor functional

water being poured down the a rm

sta bility once movement has been restored; medical conditions which slow down or p revent fu II recovery. Central sensitization - electrical and chemical events which take place in the processing of inputs to the central nervous system, such as nociception.

or leg. Hypermobility - a n excessive ra nge of movement (e.g. at the knee or elbow ) for which there is adequate muscu l a r cont ro l , thus providing stability. Instability - an excessive range of

In such instances, cells in the dorsal

abnormal movement for which

horn of the spinal cord, for example,

there is inadequate protective

become more sensitive to nociceptive barrages resulting in the triggering of pain states more easily or the enhancement of ongoing pain states. Disuse - due to laziness or after enforced rest. Dysaesthesia - an unpleasant but not painful sensation such as

muscular control. Misuse - a function or activity that is performed aw kwardly or in a silly way. Natural history - the recognizable and expected course of a pa rticular disorder from onset to recu rrence, ch ronicity or recovery and the

250

MAITLAND'S PERIPHERAL MANIPU LATION

[

expected rate of recovery of such a

such events. For some reason, in

or clinical diagnoses and typically

diso rder.

some cases, outflow is m a intained

respond in a predictable way to

after the event or perceived event,

manipulative physiotherapy

New use - some activity not performed previously or not

resulting in the perpetuation of the

(e.g. impingement, lateral

performed for a long time.

sympathetic response. This may

epicondylalgia).

Overuse - a limit to how far the body

lead to maintained pain states. Sympathetic outflow can be

of predisposing factors to the

brea king point.

measured indirectly t h rough, for

development of a pa inful

example, alterations in skin

neuromusculoskeletal disorder

Sympathetic outflow - activation of the sympathetic nervous system in response to noxious, injurious or

temperature and conductance. symptoms and signs which fall into

perception of the occurrence of

recognizable clinical presentations

This chapter provides a framework which will assist the manipulative physiotherapist in recognizing dis orders which will respond in known ways to passive movement treatment techniques. The aim of the chapter is to categorize the most common neuromusculoskeletal disorders treated by manipulative physiotherapists. The word disorder is used to cover any complaint from which any patient may suffer and be referred or refer themselves for physiotherapy. This includes disorders:

•

•

which can have an accurate diagnostic title/ recognizable pathology

•

which present as recognizable syndromes

•

whereby the physiotherapist may need to assist in differential diagnosis. For example, abdominal pains, chest pains, headaches and limb pains where it is not clear whether symptoms are originating from the neuromusculoskeletal system or from sys temic disease.

Neuromusculoskeletal disorders, therefore, can be classified as follows when deciding whether manipu lative physiotherapy should be considered as a treat ment option:

•

•

•

com binations.

potentially harmful events, or the

•

•

(strain or sprain). Often occur in

Syndrome - a collection of history,

INTRODUCTION

•

Use categories - a classification

can adapt. eventually reaching

Movement or non-movement related Natural histories (insidious, traumatic) Structures at fault (the clinical profile of articular, muscular, neural tissue disorder) Mechanisms of symptom production (primary and secondary hyperalgesia) Recognizable syndromes (their clinical profiles/pain patterns)

Prognosis (disorders which are easy /difficult to help) Differential diagnosis (clues to non neuromusculoskeletal disorders affecting the limbs).

MOVEMENT-RELATED AND NON-MOVEMENT-RELATED DISORDERS To

classify

neuromusculoskeletal

disorders

into

movement-related and non-movement-related complements the paradigm of physiotherapists as experts in move ment (Sahrmann 2001). For the manipulative physio therapist such classification is important in relation to scope of practice. In turn the clinician will then have evidence for the application of movement-related ther apies and will be able to gauge expected outcomes in relation to such therapies (Box 10.1).

Movement-related disorders A movement-related disorder can be defined as: 'any complaint which any patient may suffer and which has

Movement related •

Movements impa ired

•

Physiological! accesso ry! com bined

Non-movement related •

Symptoms not influenced by movement

Peripheral neuromusculoskeletal disorders

some relationshlp to movement (activity limitation due to movement impairment) at some stage during its nat ural hlstory'. Thls includes the quality and/ or quantity of functional movement or functional positions being affected by pain, stiffness, spasm and weakness, as well as associated movement-related impairments such as fear of movement or loss in trust of movement, paraes thesia, anaesthesia, dizziness, etc. Manipulative physiotherapists using thls (and other) concepts have the ability to identify and deal with movement-related disorders through the clinical decision-making process, specifically through the use of the brick wall concept (Chapter 1) and through the assessment process (Chapter 5). Both the theoretical and the clinical side of the brick wall can be utilized in detail to identify movement related disorders. Conversely, the same categories can be used to differentially diagnose disorders which often mimic neuromusculoskeletal disorders (symp toms in the spine or limbs) but whose symptoms bear little or no relationship to movement and neuromus culoskeletal movement-related functions.

Mechanisms of symptom production Gifford (1997) outlines pain mechanisms whlch are rele vant to the rehabilitation of movement and which should be identified and specifically dealt with by phYSiotherapists as part of the desire to maximize the individual patient's movement potential. The clinical pattern for each mechanism is also detailed by Butler (2000) and includes the follOWing. •

strong stimulus-response relationshlp (active and passive joint movement/muscle contraction or muscle length testing should be symptomatic). •

•

•

•

•

Central pain mechanisms - due to central sensitization and processing or sampling of input affected by nociceptive barrage. Such mechanisms are affected by descending modulation such as cognition, emo tion and chemical activity (there is a weak stimulus response relationshlp). One example is phantom pain. Mobilization may help to remove the nociceptive barrage, otl1erwise processing needs to be influenced to recondition movement (Shacklock 1999a).

•

Sympathetic and motor mechanisms (efferent/ output) due to prolonged maladaptive muscle activity, sym pathetic outflow, endocrine activity and in1mune responses. All these factors must be suppressed back to normal to allow homeostasis. This will include: 1. mobilization of locally affected tissue to reduce nociceptive activity, mechanical inflammation and immune responses; this may also influence maladaptive muscle activity 2. mobilization of the thoracic spine and ribs to affect sympathetic chain activity (Slater & Wright 1995) 3. recovery of normal ranges and quality of movement through stretcrung and re-education.

intra-articular (inner capsule, surface opposition) periarticular (outer capsule, ligaments, tendons crossing joints) muscular (contractile, non-contractile, supporting elements) neural (intra-, extra-, entrapment, supporting elements) others (bone, bursae, fat pads, fascia, blood vessels).

Movement-related diagnoses and pathology Corrigan and Maitland (1983) identify orthopaedic con ditions whlch are likely to respond best to treatment by mobilization/manipulation including: •

•

•

•

injury / trauma to joints, muscles, nerves and their supporting tissues inflammation associated with trauma or mechanical disorders degenerative changes associated with ageing, wear and tear or disease disease whlch is inactive and results in pain and restriction of the neuromusculoskeletal system.

-

•

Movement-related structures

•

Peripheral neurogenic pain due to nerve injury with accompanying allodynia/hyperalgesia/ dysaesthe sia as well as neurological signs (symptoms repro ducible with neurodynamic testing) (Greening & Lynn 1998, Butler 2000).

Identifying movement-related disorders from the theoretical side of the brick wall Maitland (1 992) identified the types of structures involved as:

Nociception - tissue-specific symptoms which have a

•

including depression and low mood. These mecl1anisms often, but not always, have their origins in musculoskeletal injury and movement impairment. These patients need good cognitive-behavioural management (Harding 1997) but one must remember that they still probably have a movement impairment(s) whlch has developed from maladaptive mechanisms and whlch, in skilled hands, needs to be mobilized. This in turn could contribute to the patient regaining trust in movement and therefore having an effect on the way the symptoms are processed.

Affective mechanisms

-

251

252

MAITLAND'S PERIPHERAL MANIPULATION

[

Temporomandibular joint (Chapter 17)

•

Carpal tunnel syndrome

•

Intracapsular disorder (reciprocal click, closed lock)

•

Osteoarthritis/rheumatoid arthritis

•

Trauma (e.g. whiplash)

•

Dental malocclusion

•

Work-related upper limb disorders

•

Cervical predisposition

•

Sudeck's atrophy

•

Generalized hypermobility

•

Inferior radioulnar dysfunction

•

Growth/developmental disorders

•

Dequervain's tenosynovitis

(interphalangeal/ metacarpophalangeal)

•

Myofascial pain

•

Overuse (e.g. at the dentist)

Shoulder complex

Hip •

(Chapter 11)

•

Subacromial impingement

•

Shoulder instability

•

Frozen shoulder/adhesive capsulitis

•

Groin strain

•

Juvenile disease (Perthes/slipped epiphysis)

•

Bursitis (psoas/subtrochanteric)

•

Fractured neck of humerus/greater tuberosity

•

Osteoarthritis (glenohumeral/acromioclavicular)

•

Osteoarthritis (tibiofemoral/patellofemoral) Ligament injury (medial/cruciate)

Knee complex

(Chapter 15)

•

Subluxed acromioclavicular joint

•

•

Scapulothoracic dysfunction

•

Internal derangement (meniscal/loose bodies)

•

Sternoclavicular joint pain and stiffness

•

Chondromalacia patellae

Elbow complex

(Chapter 12)

•

Lateral epicondylalgia (tennis elbow)

•

Golfer's elbow

•

Fractures of the head of radius/ olecranon

•

Olecranon bursitis

Wrist and hand complex

(Chapter 13)

•

Osgood-Schlatter's disease

•

Femoral/tibial/intra-articular fractures

Foot and ankle •

(Chapter 16)

Fractures (malleolar/calcaneus phalanges)

•

Ligament sprains

•

Osteoarthritis (talocrural, subtalar , st MTP)

•

Colles/Smith's fractures

•

Achilles tendonitis

•

Scaphoid/metacarpal fractures

•

Plantar fasciitis

•

Sprained wrist

•

Metatarsalgia

•

Crush injuries/laceration/burns

•

Biomechanical dysfunction

•

symptoms which correspond to neuromusculoskeletal struc tures (know your surface anatomy and patterns of referred pain). 'The aching is in my shoulder and I feel a band of pain around my upper arm when I try to comb my hair.' (Fig. 10.1) .

•

Behaviour of symptoms (including tl1e degree o f sever ity and irritability relevant to the stage of the disor der and their relationship to ilie amount and type of activity provoking ilie symptoms - do features fit?) symptoms whid1 are responsible for or are comparable wiili movement impairment and activity limitations diurnally. 'My ankle is stiff when I first get up in ilie morning; it hurts to walk down stairs. I limp when going up ilie slope into my office at work.'

•

Present and past history symptoms and functional limitations related to injury, compromise or benign

Clinical syndromes Each region of the upper limb and the lower limb has clinical syndromes which present as typical patterns and recognizable syndromes, and which respond in often predictable ways to mobilization treatment tech niques as outlined in Box 10.2.

Identifying movement-related disorders from the clinical side of the brick wall (history, symptoms, signs) Subjective examination •

(Chapter 14)

Osteoarthritis

The patient's main complaint symptoms (pain, stiff ness, weakness, etc.) an.d functional limitations with a strong relationship to movements, activities or positions. 'I cannot kneel down because my knee hurts when I try to get up again.' -

Site/locality of symptoms (body chart)

-

-

Peripheral neuromusculoskeletal disorders

Figure 10.1

Recognizable

shoulder joint symptoms.

Ache 'Deep in' Intermittent

® Comes on when G)tt

disease of the neuromusculoskeletal system. 'My tennis elbow originally started after I played in a long badminton match against my wife. I think I gripped the racket too hard in the effort to beat her. She still won. Now I get episodes of it when I sit and work on the computer for long periods.' •

Special questions to reveal whether associated symptoms such as dizziness, neurological or other vascular symptoms (e.g. claudication) have any relationship to movement or functional activity. 'The numbness in my little finger is there all the time, the only other time I feel it more is when it wakes me at night. I think I must lie on my arm or something.'

•

detectable changes in quality and/ or quantity of functional, active move ment which correspond to or are comparable with the patient's symptoms (range/symptom response/ quality of movement). 'When I try to straighten my knee I can tell that it does not go back fully com pared with the other knee and it hurts under my knee cap.'

•

Passive movements (movement diagram) passive test

-

Physical examination (movement impairments) •

over to one side and as I can see when you straighten it up this is very painful.'

alignment faults, protective deform ities, anomalies, wasting and asymmetry, all of which may correspond to the patient's symptoms (comparable signs). 'You are holding your wrist

Observation

-

Functional, active movement

-

-

ing of joint accessory movements and physiological movements, neurodynarnics and muscle lengths where the 'joint' signs/neural provocative signs or length changes alter correspondingly with move ment. Where there is a strong relationship between pain, resistance, spasm and movement, passive movements reproduce the patient's symptoms. 'When I bend your big toe like this (passive flexion of the first metatarsophalangeal joint) does the pain increase the more I bend it?'

253

254

MAITLAND'S PERI PHERAL MANIPULATION

•

detectable, objective signs in the neuro musculoskeletal structures which fit in with the nature of the disorder, from the cardinal signs of acute inflammation after injury to the bony and soft tissue thickening around an arthritic joint. 'When I palpate your ankle I can feel that the ligament is a bit swollen and thickened at the spot where you say it hurts.'

Palpation

-

Response to treatment by mobilization/ manipulation Pain emanating from the neuromusculoskeletal struc tures which are being moved in a skilled appropriate manner should subside and allow greater active movement without pain, if the pain is in fact related to movement (groups 1 and 3a, Chapter 7) (Wright & Sluka 2001). 'I see that you can now open your mouth further before it hurts since I performed that gentle treatment on your jaw' ( grade I pain -free small ampli

tude transverse movement medially on the TMJ). Increased resistance to movement due to stiffness of the structures of the movement system will decrease if these structures are stretched in a controlled and appropriate way (groups 2, 3b, Chapter 8) (Hunter 1994). 'I see that you can now lift your arm further since I stretched your shoulder ' (peak of the quadrant, Chapter 11). Protective involuntary muscle spasm due to impair ment of the movement system structures will reduce with appropriate passive movement techniques if this spasm is related to impairment of movement (Chapter 8). 'You do not seem to be holding your knee so bent now after I worked into the bite of pain which seemed to release some of that protective spasm.'

Non-movement-related disorders The manipulative physiotherapist, especially a first contact practitioner, should always be on the lookout for non-neuromusculoskeletal disorders which mimic neuromusculoskeletal disorders. Certain symptoms, signs and patterns of history should ring alarm bells in the mind of the clinician. For example, severe spontan eous hip pain in young obese juvenile males (slipped epiphysis), gripping left shoulder and arm pain with exertion or when under stress (cardiac), pulsating/ cramp in the legs after walking or sporting activities (claudication), to name but a few. Symptoms which do not appear to bear any resem blance to movement, activity or functional positions are less likely to respond to movement-related therapies. The manipulative physiotherapist should have a good working knowledge and experience of other body systems in order to recognize their mechanisms of

symptom production and how disorders of the car diovascular, respiratory, gastrointestinal, endocrine, genitourinary and immune systems can mimic neuro musculoskeletal symptoms. (Physiotherapists often fol Iow a specialized path of professional development too quickly in their careers and therefore miss out on this essential knowledge and experience of health-care pro vision.) Such relevant profiles will be discussed in more detail later in this chapter in relation to the role of the manipulative physiotherapist in differential diagnosis.

NATURAL HISTORIES (INSIDIOUS, TRAUMATIC) Introduction Most common neuromusculoskeletal disorders run predictable or predictably unpredictable courses. The body has an inherent capacity to heal over a fairly pre dictable timeframe (Hunter 1994). Butler (2000), how ever, has highlighted the fact that pain often runs a different natural history from tissue healing and that this should be considered when explaining and pre dicting outcomes. The main factors which influence an individual's recovery from a typical neuromusculoskeletal dis order are the myriad contributing factors or barriers to recovery (Chapter 8) such as 'misuse', 'overuse', or some structural, functional, psychosocial or systemic disease reasons, many of which occur together and interact to affect the way that the disorder progresses (or does not progress) throughout its natural history. Many typical neuromusculoskeletal disorders also respond in a fairly predictable way to mobilization and manipulation and with experience these rates and stages of progression can be recognized. Early intervention after injury or onset of spontan eous episodes can help to modify the disorder's natural history. As discussed in Chapter 8, mobilization/ manipulation techniques are only one part of the manipulative physiotherapy process which can con tribute to: • • •

the quality of repair and healing the facilitation of homeostasis the patient's whole experience (including knowledge, emotions and sampling for future reference).

Grouping the natural history of the disorder can be valuable in the following ways: •

It helps the physiotherapist to develop skills in prognosis in terms of treatment expectations, likelihood of recurrences and the development of preventative measures.

Peripheral neuromusculoskeletal disorders

•

It helps to develop skills in seeking the reason for a particular disorder's onset. To be able to ask the correct questions to extract this most important part of the history requires knowledge about the potential factors involved in the onset of the different groups.

The history of the disorder can be characterized by the insidious or traumatic nature of its onset.

Insidious onset Understanding the cause of the insidious onset is essen tial to understanding the patient's presenting signs and symptoms and assessing the prognosis for recovery (Fig. 10.2). Some patients have a familial or genetic pre disposition to develop certain disorders when other fac tors are present. Other disorders develop as a result of predisposing activities. Then there are those who have had an unrecognized trivial incident. In all three situ ations the patient is often unaware of the reason for the onset of symptoms. Skilled questioning is essential to establish the relationship of any predisposing factor to the presenting symptoms.

Familial/genetic predisposition An example of this is those patients who might loosely be called 'jointy people', often referred to as having 'acute joint awareness' or 'genetic sensitivity'. They have symptoms in different joint areas from time to time. The symptoms may 'come-and-go' for no obvi ous reason and they rarely seek treatment unless the symptoms persist or restrict their normal activities. Tracing familial components to the disorder often reveals somewhat similar symptoms in another sibling or in one of the parents. The actual onset of symptoms for patients in this cat egory is never straightforward, yet it does have a general pattern. The current symptoms for which they seek treatment do have a reasonably standard onset. The onset is either (a) that the patient has noticed developing symptoms during and after performing an activity

Figure 10.2

Causes of insidious onset.

with which there would normally be no difficulties, or (b) that aching has been noticed in different joint areas for short periods (2 or 3 days) over the preceding few months (2-3 months or more). This commonly begins when the patient is in the early thirties. The patient knows of no reason why they should have developed. Delving into the background of the disorder's earlier history might have a dialogue similar to the following: ET There has to be some reason why the symptoms should have begun and somehow we should be able to 'make the features fit'. Q 'Can you recall when you first had any symp toms, however mild they may have been?' ET If he seems to be taking an inordinate length of time trying to answer, I'll help him by giving two extremes for him to choose from. Q 'Are you thinking in terms of weeks or years?' A 'The recent trouble has been about 3 months, but 1 was trying to think about the months, and even 2 or 3 years you mentioned because as a child 1 was supposed to have had what they called 'growing pains'.' Q 'Well, if we say your present problem started 4 months ago, are you saying that 5, 6 or 7 months ago you were totally symptom free?' A 'No, not totally free. 1 have had occasional aware ness of an ache in my shoulder or hip, even my elbow and knee, for a day or two at a time, but other wise 1 would say 1 have been without symptoms.' Q 'Can you relate those 1 or 2 days of aching to anything?' A 'No, 1 don't think so.' Q 'Could you have been doing anything different at the time?' A 'No, not that 1 can think of.' Q 'Might you have been unwell or overtired?' A 'I could have been overtired. 1 am under pressure at work from time to time.' Q 'And have these been at times when you had symptoms?' A 'They could well have been.' ET This isn't getting me far, but there is one useful avenue 1 could follow up. Q 'Do you do different things at the weekends from what you do during the week at work?' A 'Yes, quite different. I work in the garden most weekends.' Q 'And does that cause any symptoms?' A 'Well it does, but 1 feel that more on Mondays.' Q 'And what is it like on Tuesdays?' A 'Much better, nearly all gone - certainly gone by Tuesday evening.'

255

256

MAITLAND'S PERIPHERAL MANIPULATION

L 'And is that pain much the same as your present problem?' A 'Yes, much the same but it is more general.' ET I wonder if he has ever had an episode of pain similar to this episode. I feel I have a responsibility to exclude this possibility anyway. If he has had an acute episode it may indicate that he could have a more 'active' disorder. Q 'Have you at any time had more severe symp toms, perhaps even temporarily preventing you from doing certain activities; may have lasted a few weeks?' A 'No, not at all.' ET Well that clarifies those predisposing possibilities. Q 'Have any other members of your family, parents, brothers, sisters had any aches and pains like yours?' A 'Yes, my sister and my mother have had problems. My mother's is mainly in her hip but my sister has had much the same as me.' ET That's a big help to me. It seems that (a) there may be some familial or genetic predisposition, (b) his body can't, at the moment, take exercise like gardening without complaint, and (c) if the growing pains are part of the history, his disorder, in one form or another, is very longstanding. It influences my treatment goal - I would hope that I can settle his present symptoms to their previous state - I might also be prepared to treat the other symptoms. I know that he can't be made symptom or sign free but I know I have three prophylactic measures that may improve his future: 1. Gravity-assisted, large-range, loose swinging type movements. 2. If his body can accept the gravity-assisted exercises I can add isometric and then isotonic exercises. 3. Perhaps the most useful thing would be to teach another member of the family to passive mobilize gently the symptomatic areas using large-range symptomless movements. This should be explained to him in full so that his expectations are put into their proper perspective. He can then know and understand that his care is an ongoing one for which he can return for treat ment if his own home treatment is not sufficiently successful. Q

Predisposition through use As a distinctly separate group, there are the people who have predisposing activities as the background to the onset of their symptoms. This is a complex section

with many subdivisions and much overlapping. The predisposing components are widely varied and often relate to the office worker who, at tl1e weekend, per forms different and physical activities. It also applies to people playing sport, subjecting themselves to ever increasing levels of their particular activity. This latter group also includes middle-aged people who decide that they should endeavour to become fit by doing a regimen of exercises for the first time. They develop symptoms when the exercising exceeds that to which their bodies can adapt. All of the subdivisions of predisposition through use relate to two factors. The first is the type and vigour of an activity being performed and the second is the state of the structures being used and their abil ity to accept the use. It is this second factor that is fre quently not adequately taken into account. The human body has an enormous capacity to adapt to demands, and if the demands are gradually and progressively increased within the limits of pain, ligaments can thicken and strengthen, muscles can develop and support more strongly, and even bony growths can develop to support around joints and in ligaments/ tendons. The different types of predisposition through use that can exist are: 1. 2. 3. 4.

New use. Misuse. Overuse. Abuse. 5. Disuse. 'New-use' is self-explanatory. It relates to a person per forming some activity that he has either not performed before, or has not performed for a long time. The result from performing this new activity (a) for too long, (b) too strenuously, or (c) beyond the capacities of the structures involved at their present state of health, will be pain. If each part (a-c above) in the 'new use' activity is unfavourable, the resultant pain will be great, and the recovery time will be long. The historical questions that need to be asked are: 'How heavy a job was it?' 'How long did you do it for?' 'Have you ever done this before?' (A 'No.') 'Did you stop because the job was completed, or because you couldn't physically go on with it any longer?' 'Did you feel any discomfort or pain while you were doing it or was it after you stopped?' 'Have you had any symptoms (grades of pain or weakness) in this area before?' (This is seeking

Peripheral neuromusculoskeletal disorders

predisposition by virtue of lowered capacities of the struchlres involved.)

The information needed for the history is:

Q

The answers to these questions, and their relation to the severity and duration of the presenting disorder, provide the information needed to make a treatment success prognosis. 'Misuse' relates to having to carry out a function that was awkward or an activity that was performed in an unnecessarily silly manner, either of which, if per formed without constraints, would have been done

'Can you demonstrate for me now the action that causes the pain?' 'How long have you been doing it in this particular manner?' 'For how long do you do it at a time?' 'How often do you do it?' 'Did the pain first start as a sudden onset at one particular moment?'

If it had a sudden onset, it could be classed as 'abuse'

differently. In other words, the muscles, ligaments and

(see below) superimposed on 'overuse', or as 'overuse'

joints have been stressed by the awkwardness of the

reaching the breaking points of the structures beyond

function.

the body's ability to adapt to the demands.

Under these circumstances, as with 'new use', the

If the symptoms develop gradually over a period of

awkwardness and the severity of the symptoms need

1-3 weeks of daily

to be related to the severity of the activity, and any pre

not quite been reached, but the warning is there, and it

disposition would be determined and interrelated.

soon will be reached if the same demand is continued.

repetition, then breaking point has

There is one objective examination test that may need

The gradual onset of symptoms is an 'overuse' situ

to be carried out and that is to ask the patient to simu

ation. It can normally be remedied if the activity is

late the function that caused the symptoms while the

stopped prior to the onset of pain. When pain is the

therapist tests the structures in this function.

limiting factor, treatment by passive movement should

'Overuse' is another self-explanatory term. All of the structures that together form the human body have a breaking point. Many of these structures in most people can have their breaking point raised by train ing. However, there is a limit to how far the body can

be performed intermittently, slowly, smoothly and gen tly through as full a

range as possible such that no pain

is reproduced. Once the pain is relieved, controlled exercises combined with a gradual increase of the over use activity can be implemented. Fry

(1986) provides

adapt, and this varies enormously from one individual

an excellent paper on this overuse in which he says:

to another. For example, a man whose talent and train

Overuse syndrome in musicians, a common disorder, is characterized by pain and loss of function in muscles and joint ligaments of the upper limb. In wind players the same process can affect the muscles forming the embouchure, the soft palate and the muscles of the throat. Individuals vary in susceptibility, so the threshold of overuse cannot be known in advance ... the condition is typically

ing enabled him to be a successful 'weight-lifter ' and 'bottom-man' in a balancing and acrobatic team had a pain-free life until he was

85 years of age when he

developed shoulder pain from manually clipping edges of a lawn while on his hands and knees. The point of interest was that he was forhmate enough to have a body which, during his active life, could adapt to the demands he placed upon it. His vertebrae had bony bridges between them and his tenomuscular and musculotendinous jlmctions were reinforced by bony components. Yet he had not had a pain throughout his life until the short-lived shoulder pain. The human body is extraordinary beyond our comprehension, a point never to be forgotten. When a patient presents for treatment with symp toms that can be put down to a vigorous 'overuse' situ ation, the problems are only just beginning. People playing high-grade competitive sports, especially if the sport consists of long durations of the activity at a time, are prone to develop symptoms. This is because they exceed the limit of the body's adaptation to the demand. This does not mean that they will not respond to treatment and appropriate retraining, but the mixture of treatment and retraining requires a very sensible understanding attitude by the patient.

brought on by an increase in the duration and intensity

of practice or playing ...

'Abuse', as with the other terms, is self-explanatory. It relates to a person who physically abuses his body (or parts of it) beyond reasonable limits. If the abuse is considered in the 'spontaneous onset' group the his tory will not contain a once-only abuse resulting in sudden injury or pain, but rather it will consist of repetitive abuse until pain is felt. The person usually continues the abuse until he becomes disabled . These abusive actions are those that, no matter how fit or well trained the person performing them is, he would still be classified as abUSing his body. The history is straightforward, but it is necessary to know:

1. How long the abusive activity has been going on for.

257

258

MAITLAND'S PERIPHERAL MANIPULATION

2. At what stage it became symptomatic. 3. How long it was continued before he decided that

1. Poorly shaped femoral condyles that predispose to recurrent subluxation of the patella. The joint is

he could not carry on any longer.

4. Were there any 'predisposing factors' that may indicate that the degree of abuse:

disadvantaged structurally (genetically).

2. The 'overuse' and 'abuse' situations. Here, repetitive stressful asymptomatic use of a joint, such as to the

(a) caused the pain sooner than would have

knee and ankle in people who compete in events such

been the case otherwise; or (b) is the severity of

as the springboard/vaulting-horse, disadvantages

the disability greater than would otherwise have

the joints for their future.

been the case? 5.

Has the abuse effect been further worsened by its

3. A joint sprain that ruptures a ligament, such as the

causing an active inflammatory response?

medial ligament of the knee, renders the joint disadvantaged.

In defence of the person who does perform abusive type activities, it must be realized that he must be get

(2) and (3) have been referred to in the sections on 'new

ting an enormous gratification from whatever it is he is

use', 'misuse', 'overuse' and 'abuse', but they were not

doing. It is not necessarily right to stop him doing it

characterized as being 'disadvantaged'. However, it is

because of the long-term ill-effect it may have. To stop

the first one - the genetically structured joint described

him may have a longer term ill-effect.

above - that is the 'disadvantaged' joint which may be

'Disuse' merely puts the body at a disadvantage at a

the underlying basis for a disorder.

time when the person may be in a position where an active demand is put on him. If the same demand is put on a person who is normally active, symptoms will not develop. In terms of history taking, the require ment is to determine how unfit, in terms of use (dis use), is the part of the body on which the demand is to be put. That is the first approach to the history. The second is to determine the 'disuse' in terms of laziness compared with genetic inability, and to previous injury / disease resulting in forced disuse. The impor tance of this questioning lies in the information it gives about the prognosis of rehabilitation and preventing recurrence of symptoms. The longer the body is subjected to any of the above predispositions (new use, misuse, overuse, abuse, dis

Trivial incident It is common for patients to present with the history of an incident that is trivial. One example of the trivial incident group is when a person leans over the back of the front seat of a car to lift up a parcel from the back seat. This action causes a sharp pain in the shoulder which lasts no more than a second. This incident is for gotten, but the shoulder developed a moderate ache some weeks later. Such a trivial incident produces last ing symptoms; the therapist should look for a predis posing factor.

Traumatic onset

use), the greater is the likelihood that injury will occur.

Sprain and direct injury are included under this main

For example, in relation to the underlying overuse:

heading, and each has its differences.

(a) the greater the vigour and frequency of the overuse,

As with the 'insidious onset' disorders, 'typical' and

and (b) the longer the duration of the overuse (i) per

'atypical' also apply. For example, the common type of

day and (ii) per lifetime, the less the structures being

sprained ankle or the torn medial meniscus of the knee

overused can tolerate, and therefore the less the injur

are typical in their presentation of history symptoms

ing force needs to be to cause disability. Furthermore,

and signs. In contrast, a pedestrian or. cyclist being

when one predisposition through use is superimposed

knocked over by a motor vehicle will not be typical or

on another, the effects are compounded.

regular in the presentation of symptoms and signs. Though they may have parts of their symptoms and signs that resemble regular patterns, overall they will

Disadvantaged joints To repeat, the word joint here is used loosely to cover widely all inert components associated with the mov ing joint. A disadvantaged joint has some structural anomaly for change which renders it prone to cause symptoms if it is subjected tq a stress. The same stress

be very irregular in their presentation (Fig.

pected unguarded movement forced on the part which becomes injured. A sprained ankle is the one that most readily comes to mind. The history is important.

Q

to a 'normal' joint with a normal configuration would not cause symptoms. Examples demonstrate three varieties of 'disadvantage joints'.

10.3).

Sprain indicates that the person has had an unex

'What actually happened? How did you 'go over' on your ankle?'

A

'I don't really know. I was playing football at the time - I had just got hold of the ball and twisted

Peripheral neuromusculoskeletal disorders

Q

of readers: 'Would you have thought of that?' I wouldn't (and didn't).

ET The examiner may have found this out by asking him where his bruising was, to which he would have probably indicated the common areas for a sprained ankle, plus a few more, plus two football boot sprig holes on the lateral-proximal dorsum of the foot. So it becomes obvious that it is necessary to determine in just what directions and how the sprain occurred. This applies to any 'sprain' of any moving part (muscle, ligament, tendon, capsule, nerve). It is then often nec Figure 10.3

Presentation of trauma.

essary to ask the patient to demonstrate the spraining movement as well as other movements that reproduce

to get away from the opposition and just went over on my ankle.'

Q

'Did you go over on the ankle on the inside of the direction to which you twisted?'

(Don't go on to say 'or was it the foot on the outside of the direction you twisted?' To understand the reasoning for stating this, just read out each of the ways of asking the question to yourself a few times and assess which is the easiest to formulate the answer for.)

YOU are concerned . . . is your ... main

problem?' His answer would have been something like 'pain in my ankle when walking on uneven ground or when running.'

Q

In fact the above story is of a real patient: one who had not responded to other physiotherapy which had been applied in a manner to suit the common variety of sprained ankle. It is necessary to be open-minded and alert to what might be atypical. When he described his injury, and was then asked to demonstrate how it happened, he stood up, asked that the right foot be held firmly on the ground, then he twisted his whole body towards the left, and with his left foot facing in almost the opposite direction to his fixed right foot he flexed his body forwards (twisted of course) over his

ET The examiner's question would have been 'What, as far as

the symptoms.

'Show me where you feel this.'

(which he proceeds to

flexed left knee and hip, then tried to pull his right foot off the fixed position on the floor. 'His' pain was repro duced by the movement. Treating this with gentle oscillatory stretches in this position, and gradually increasing the strength of the oscillatory stretches as pain decreased, was the primary treatment which relieved him of his disability.

do; then . . . ) Q

'What caused it?'

A

'I sprained my ankle at footy.'

Make features fit Make features fit - this statement of 'making-features

Two thoughts might come to mind: (a) that spraining

fit' cannot be overemphasized. Just suppose that a

an ankle at football might not be the same as spraining

patient had sprained an ankle a year ago and it had

an ankle when, say, stepping down a gutter; and

still not recovered (say there was still a

(b) the areas of pain he has indicated would probably,

disability)

under these circumstances, be different from the more

sounded to have been reasonably senSibly applied,

common sprained ankle. As the pain isn't totally typ

then the 'features don't fit'. So, why?

ical, detailed questioning is needed. He stated that it

about this sprained ankle?

despite

continued

40% degree of

treatment

which

What is different

One should not just give up

was his ankle on the outside of the direction to which

and say 'you'll have to live with it' without delving

he twisted which he 'went-over' on.

more deeply into the story, previous history, otller associable illnesses, pattern of symptoms, immediate

Q

'Did you fall?'

responses to physical treatment, what the patient's

A

'No, I just couldn't keep going.'

body (in this example, his foot) can tell him about what

ET

Never assume anything.

it likes and dislikes having done to it - there is almost

Q

'Why couldn't you keep going?'

no end to the probing to be done to make sense out of

A

'The other bloke slammed his foot on top of mine

the story - why isn't it getting better? He can't just be

and pinned it to the ground.'

left like this, what can we do?

259

260

MAITLAND'S PERIPHERAL MANI PULATION

As well as probing questioning there is the prob ing physical examination - using combinations of movements, using functional resisted movements at speed, movements with strong compression. There must be something to find, by questioning or examin ing, to make features fit before deciding that it is a hysterical disorder, and there aren't too many of those. Unguarded movements, unprotected movements, and flicking movements beyond muscular protection are among the most difficult disorders to restore to normal. They create a degree of damage that is far greater than one would expect. It is important to remember this when endeavouring to 'make features fit' in relation to treatment response and examination findings. Direct injury is quite different from sprain though sprains may be part of the total injury. Knowing details of the accident provides considerable useful information which may guide treatment, so this forms an important part of the history. Any previous history in the areas injured by the accident often help to 'make the features fit' more exactly. But really, the most important part of the examination (and subsequent direction of treatment) lies in the answers to the questions: Q Q

'At this stage - what is your main problem?' 'What is it that you can't do at this stage?'

An example of this is a young man who had had his right arm from his hand to his shoulder badly squashed in a car accident. Question: What can't he do at this stage (some 9 months after the injury)? He couldn't lift a motor car tyre off the floor. So what? He was a motor mechanic and if he could only lift a car tyre off the floor he could return to work despite his other arm injuries and disabilities. And so it is obvious where the aim of treatment would lie at that stage.

STRUCT URES AT FAULT The manipulative physiotherapist should be able to recognize clinical features of the individual base com ponents of the movement system within what are quite often muiticomponent neuromusculoskeletal dis orders. What follows is a broad profile of each of these components.

Articul ar Uoint) : intra-articular I periarticular •

•

•

•

•

•

•

Typical descriptors - aching, stiffness, sore/tender over injured ligaments. Recognizable areas - 'in' the joint, over ligaments, bands of aching/pain across the joint/around the limb. Functional loss of range, pain/aching with compression of the joint. Onset of problems which corresponds to overuse/misuse/ abuse/new use/ disuse of the joint, injury or compromise involving the joint, joint disease processes such as rheumatoid arthritis. Recognizable patterns of restriction (e.g. capsular pattern of the shoulder, arc of shouJ.der pain). Joint signs correspond with passive physiological and accessory movement. Pain and resistance are strongly related with passive movement.

Periarticu/ar (Fig. 1 0.4) •

Behaviour of symptoms with movement, i.e. symp toms increase proportionally with the amount of stretch applied to the periarticular tissue, whether acute or chronic. Symptoms increase at the end of

in pain-free position

Figure 10.4

Differentiation between intra-articular and periarticular disorders. EOR, end of range.

Peripheral neuromusculoskeleta l disorders

261

] range or end of the available range. Often this stretch corresponds to the injuring movement. •

Behaviour of symptoms with rest, i.e. periarticular structures will not be painful or as painful if they are not in a position of stretch or squash or if they are neither inflamed nor severely damaged.

Intra-articular (Fig. 1 0.4) •

•

Behaviour of symptoms with movement, i.e. symp toms tend to occur through a large section of the range of movement being tested (through-range symptoms). Symptoms will often increase with activities that involve compression of the joint sur faces such as lying on the hip or shoulder. In chronic disorders where pain is not severe, through-range or end-of-range movements on their own may not be painful but they certainly will be if the joint is moved with the surfaces firmly compressed together. Behaviour of symptoms with rest, i.e. the joint will be painful if it is being compressed at rest. Very painful intra-articular disorders will be painful at rest even when the joint is positioned in an unstressed, well supported, neutral position.

intra-articular symptoms will be approximately unchanged or they will be worse. Q 'How does it feel when you first get out of bed?' ET Both may feel stiffer than at other times but the length of time they remain stiff is different. A 'It feels a bit stiff and painful.' Q 'How long does that stiffness and pain last?' OR Q Al ET A2 ET Q A ET

Many joint conditions will have components of both intra- and periarticular disorder. An osteoarthritic hip, say, when it is in an active phase will have a through range pain which can be increased when the surfaces are gently opposed but will also have an increase in end-of-range pain when being stretched.

Differentiation between intra-articular and periarticular disorders with compression sustained Another consideration related to resting pain is that a patient with a chronic intra-articular disorder may have discomfort when lying on the painful joint. On examination of this joint, it should be possible to repro duce these symptoms by compressing the adjacent articular surfaces together and sustaining the strong compression. Periarticular disorders will not be pain ful with this test. In the subjective part of the examination, the fol lowing questions are asked: 'How does it feel when you waken in the morning compared with when you go to bed?' ET The word 'it' is used to allow for spontaneous responses about anything the patient may feel at that time, rather than to restrict his thinking by asking 'How does the pain feel etc.'. In general, periarticular symptoms will be improved, whereas Q

'How long does it take for that to subside to its usual level?' 'Only a short time - it's all right by the time I've had my shower. ' This is not an intra-articular or an inflammatory disorder. 'It gradually settles down.' That is not enough depth of information. 'What length of time are you thinking of, (ET Help him) 10 minutes or more than half an hour?' 'I suppose it's more like an hour or so.' This is likely to be intra-articular and inflamma tory. In fact it is not uncommon for such a disorder to make it impossible for a patient to be able to stay in bed all night. He may well have to get out of bed, at least once, for half an hour or more before the increased symptoms subside enough to allow him to go back to bed. As a side-issue to this, but worth stating here, he should be taught how to do pendular movements which he should do when he is forced to get out of bed. These pendu lar movements should be small range, oscillatory painless movements produced by other parts of the body rather than the prime movers of the joint(s) affected. These movements, if well per formed, will reduce the pain and enable him to go back to bed much more quickly.

Myofascial (muscle) •

•

• •

•

•

Complaints of weakness and reduced strength in the muscle (detailed questioning should reveal whether this is due to disuse atrophy, pain inhibition or neurological conduction loss to the muscle). Soreness, tenderness of the muscle when stretched or squeezed. Aching distally into recognized referred pain areas. Pain reproduced in the muscle when it is stretched (NB: further sensitizing additions of neural tissue will need to be performed to help differentiate the stretch feeling further). History of muscle tear, contusion, overstrain, overuse injury. Quality of movement affected more than quantity.

262

MAITLAND'S PERIPHERAL MANIPULATION

[ • •

•

•

•

Wasting/ fasciculation evident. Alignment faults and dynamic stability faults observable with functional movement. Pain consistent between active movement and isometric testing but not with passive movement. Poorly correlated active and passive ranges (active and passive insufficiency). More elastic end-feel to muscle length testing compared with articular tissue.

Neural (pathoneurodynamics) •

• •

•

•

•

•

•

•

Both mechanical and physiological mechanisms which correspond to each other. Burning lines of pain along nerve courses. Accompanying hyperalgesia, allodynia, dysaesthesia, paraesthesia, anaesthesia. Symptoms accompany mechanical provocation of neural tissue (lengthening, sustained compression). A history corresponding to either obvious nerve injury (compression, laceration, stretch, ischaemia, toxic infiltration, predisposing disease) or slowly developing compromise (keyboard workers, musicians, etc.). Impairment of tissues which interface with neural tissue and could influence normal mechanics of neural tissue. Antalgic postures which reduce the mechanical provocation of neural tissue. Passive neural provocation tests and sensitization are positive in terms of reproducing symptoms or being sensitive to movement. Often muscle protection can be felt as the sign which protects the sensitive neural tissue from further provocation (Elvey & Hall 1999).

MEC HANISMS OF SYMPTOM PRO DUCTION (PAIN MECHANISMS) It is not the intention in this text to review pain mech anisms in any great detail as this has been presented in other physiotherapy textbooks (Gifford 1997, Butler 2000). An understanding of such mechanisms of symptom production, however, is essential for the manipulative physiotherapist to be able to decide how and when manipulative physiotherapy, and in particu lar mobilization/manipulation treatment techniques, should be used in each individual case of neuromuscu loskeletal disorder. What is clear according to Butler (2000) is that all the mechanisms of nociception and peripheral neurogenic pain (input), central sensitization and

psychological/brain sampling (processing) and auto nomic, endocrine, immune, motor and pain control mechanisms (output and homeostasis) interact with each other all the time. Nociception is pain roughly coming from where it is felt or at least where tissue damage and inflamma tion are stimulating nociceptors to transmit impulses that produce the perception of pain in the brain. Referred pain can be a consequence of nociception, whereby - through convergence theory (Watson 1986) for example - pain can be felt in a site removed from the tissue-based mechanisms. Nociceptors can be gen erated by mechanical, chemical or ischaemic stimuli. Greening and Lynn (1998) say of peripheral neuro genic mechanisms that 'studies demonstrate that pain and changed somatosensory thresholds . . . may occur following relatively minor axonal damage . . . ' Once again pain is felt to be coming from the injured nerve; however, dysaesthesia, hyperalgeSia and allodynia are likely to accompany the pain both locally and at other sites and tissues along the nerve course. Central sensitization or dorsal horn cell sensitiza tion and multidimensional processing of nociceptive and peripheral neurogenic input in the central nervous system takes place in all pain states. Central pain tends to persist in chronic pain states. The degree and context of the input, and the conse quent processing of this input, will influence the nature of the output (autonomic, motor, behavioural, endocrine, immune). Gifford (1997) considers this out put to be adaptive in order to assist in the best possible recovery (rest, protect the part, rationalize the pain, staged recovery of normal activity, etc.) or maladaptive which will serve no real purpose in terms of survival and recovery (overprotection, fear avoidance, misin terpreting the pain experience, conflicting advice from peers or medical professionals, enhanced and ampli fied pain experience, etc.). Table 10.1 summarizes pain mechanisms in respect of expected responses to movement. The role of the manipulative physiotherapist in this process can be crucial to recovery and to future responses to any pain experience a patient may have. One key clinical feature of these pain mechanisms which is vital to the correct selection of mobilization/ manipulation treatment technique is the ability of the clinician to recognize primary and secondary

hyperalgesia: •

Primary hyperalgesia is a key feature of nociception and pain emanating from the site of tissue damage and inflammation and the factor which can be most readily influenced by mobilization treatment techniques.

Ta b l e 1 0. 1

S u m m a ry o f m ec h a n i s m s a n d move m e n t responses

Nociception

Peripheral neurogenic pain

Central pain

Mechanical

Nerve injury (mechanically

Centra I sensitization

(inflammatory

enhanced neurogenic

ischaemic)

inflammation): •

M echanical: •

Strong relationship between pain and

•

Stress state related responses

Strong relationship between

Pain response related to

(fight or flight):

unhel pful thoughts and

•

Heightened pain response to

•

Disproportionate true +ve

emotions

pain and nerve tension!

Allodynia:

sliding (mechanosensitive)

•

Weaker stimulus-response

False +ve or enhanced

movem ent

Weak relationship

(maladaptive) tissue

tissue-based responses when

response to movement

pain states are sympathetically

mechanical stress

and mechanical stress

neurogenic inflammation

•

P rimary hyperalgesia

causes secondary

responses to movement

•

True +ve tissue

hypera Igesia

and mechanical stress

•

•

between pain and

relationship where

mechanical stress

Cognitive emotional:

Secondary hyperalgesia

mechanical forces

•

Autonomic sympathetic output

•

movement or

response to

Affective mechanisms

False +ve tissue-based

maintained •

Development of central sensitization

Weaker relationship between secondary hyperalgesia and mechanical stresses

Ischaemic: •

Strong relationship

(proportionally) •

to mechanical stresses

between sustained mechanical forces and pain

True +ve nerve tissue response

•

False +ve tissue response to mechanical stress for secondary hyperalgesia

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264

MAITLAND'S PERIPHERAL MANI PULATION

•

Secondary hyperalgesia is an accompanying feature to nociception in areas around the tissue damage and along the course of injured nerves, but becomes more a feature in protracted central sensitization mechanisms and maladaptive output mechanisms such as sympathetically maintained pain, unhelpful thoughts and fear avoidance of movement.

Box 10.3 outlines the key features of primary and sec ondary hyperalgesia (i.e. an increased response to a stimu lus which is normally painful). This should help the manipulative therapist to select passive movement techniques appropriately, predict the response to treat ment based on the knowledge of the clinical features and interaction of pain mechanisms, and be aware of how injudiciously applied inputs (mobilization tech niques) can enhance central sensitization (nOCiceptive barrage of already sensitive dorsal horn cells) and therefore reinforce maladaptive outputs which become further barriers to recovery.

Primary hyperalgesia 1

Manipulative physiotherapists, therefore, should be prepared to adapt their skills when dealing with pain that has a strong central mechanism to it (the clin ical consequence of which is likely to be, amongst other features, secondary hyperalgesia). Mobilization/ manipulation techniques should be applied with broader desired effects in mind, i.e. manual techniques should be used not just to stretch a joint or reduce tissue-related pain but to: 1. help the patient to regain trust in movement after a painful episode or because the patient thinks that, if it hurts to move, it is doing more harm 2.

maintain movement when passive movement is less painful than active movement, thereby helping to retain an ideal functional movement environment

3. recondition sensitized musculoskeletal tissue with the aim of gradually exposing the patient to (often) long-forgotten, pain-free, normal movement

Secondary hyperalgesia2

Hyperal gesia at the site of injury or inflammatory

Allogeneic chemicals are released into normal tissue,

response

reducing the threshold of firing of nociceptors ; central

A true positive response pain comes from the tissues at the site of the primary hyperalgesia The response is always proportional to the stimulus (the more the structures are stressed the more painful they become ; the more they have been damaged the more the primary hyperalgesia) The severity and irritability of the disorder are proportional to the tissue rea ctivity and the pathological activity The pain response to movement is fairly consistent (pain is reproduced consistently in proportion to the stress o n the hyperalgesic structures) Symptoms i n crease proportionally with activity and reduce with rest

sensitization occurs due to plasticity of dorsal horn receptor cells and higher centre proprioceptors become sensitized to pain (allodynia) ; maladaptive output also occurs (sympathetic outflow, a b normal movement, unhelpful thoughts about pain) False positives - pain is felt in tissues that are not damaged, have not been injured or are still se nsitized long after the injury has healed The relationship between stimulus and response is weak (a movement evokes a much greater response than would be expected in view of the exte nt of damage or time since onset of the episode or inju ry) Severity and irrita bility in such cases ca n be classified as seco nda ry, i.e. the degree of severity and irritability is

Night pain and morning stiffness/soreness may indicate

more in proportion to the secondary hyperalgesia

inflammatory responses

mechanisms than to primary hyperalgesia. This

NSAlDs should help

classification of severity and irritability is related more

Symptoms which increase proportionally to sustained positions or loading may indicate nociception generated by ischaemic mechanisms Palpation findi ngs are consistent with local tissue changes and signs of injury or disadvantage (cardi nal signs of

to the degree of sensitivity experienced by the patient than to the degree of tissue damage/inflammation NSAIDs are less likely to help this neurogenic inflammation Symptoms often increase in proportion to cognitive a nd emotional or social and psychological stress situations

inflammation, trophic, soft tissue and bony cha n ges con

Functional movements exhibit sensitivity and are dispro

sistent with the stage of the disorder's n atural history)

portionately restricted in relation to the extent of, or the

Peripheral neu romusculoskeletal disorders

The movement diagram will correspond to the severity,

time since, the original injury. Functional loss of

irritability, degree of movement impairment and the

movement is inconsistent and variab le from day to day

degree of palpation findings

or week to week

With the movement diagram pain will increase proportional

Rubbing the painful area, heat applied to it or occupying

to movement, and if present together pain and resistance

the mind with something else may temporarily make the

will increase correspondingly with movement

symptoms more acceptable

The history of the present (and past) episodes will fit with

Palpation findings do not often reveal tissue changes in

movement restrictions and the palpation findings. The

proportion to the response encountered. Palpation

onset, progression and stage of the disorder will reflect

findings are constantly changing and labile (some days

the movement impairments found on examination

painful to touch, other days less painful and other days

Tissue-specific treatments will be effective including

painful again). There is little evidence of cardinal signs of

mobilization and manipulation Grade I and II techniques performed in a pain-free manner will work by producing hypoalgesic effects Grade I I I and IV techniques where pain is proportional to the amount of resistance, including the 'bite' of pain, wil l be effective as stretching techniques. As the movement is stretched and the range of movement increases, the pain related to the stiffness will reduce correspondingly

inflammation and soft tissue changes corresponding to the degree of sensitization to movement The movement diagram for painful passive movements is inconsistent with the palpation findings. The proportional increase in pain does not relate to movement. There is little or no relationship between the sensitized pain and any resistance encountered with movement The history does not correspond to the degree of movement restriction and symptom response to movement. Symptoms and movement restrictions are out of proportion to the extent of the injury or the stage of the disorder (maladaptive) Local treatment has very little lasting effect Grade I and I I techniques on t h eir own will not produce effective hypoalgesia Grade I I I and IV techniques may only serve to enhance nociceptive barrages to the already sensitized dorsal horn cells and higher centres if the patient still strongly links

poin to horm. Stretching, although increasing the range of movement, will not effect pain relief in proportion to the range gained

1 Primarily consider tissue-based approaches but recognize the social and psychological factors which may lead to chronicity. 2

Consider both tissue- and environ mental-based approaches to the application of mobil ization I manipulation techniques.

4. increase ranges of movement to enhance the patient's ability to improve general fitness and proprioception with the aim of maximizing the potential of exercise in regaining function after chronic disuse 5.

deal with mechanical musculoskeletal factors which may be resulting in enhanced sympathetic output and therefore maintaining the central sensitizing process.

Shacldock (1999a, 1999b) has argued for the evidence based use of manual techniques in patients who have developed central pain mechanisms as part of their musculoskeletal disorder. Shacklock's articles are

highly recommended reading for all manipulative physiotherapists who deal with patients who are suf fering from chronic pain. Shacklock (1999b) argues that, through neuroplas ticity, not only may hyperalgesia be conditioned or learned but it may also be unlearned and that learning occurs through afferent inputs which are both tissue based (nociception, proprioception) and environmen tally based (social, psychological). This, Shacklock considers, makes manual therapy particularly import ant in the treatment of pain and disability, i.e.: •

at spinal cord level manual therapy can be responsible for diffuse noxious inhibitory control including that of secondary hyperalgesia

265

266

MAITLAND'S PERIPHERAL MANIPULATION

[ manual therapy can work in altering pain through the sympathetic nervous system's ability to change afferent input changes in the brain's representation of body areas can be evoked by manipulation sensory information in response to passive movement is processed differently from active movement, showing that the two types of movement may exert different gating effects on the brain changes in motor output are a consequence of alteration in central pain mechanisms.

•

•

•

•

Shacklock (1999a), therefore, suggests that cognitive and behavioural components specific to the individual patient's problem can still be addressed through man ual therapy approaches by: helping the patient to overcome fear avoidance or loss in trust of movement 2. helping to weaken the link in the patient's mind that pain means harm 3. desensitizing or reconditioning movement to evoke 1.

stimulus reinterpretation 4. helping the patient to control responses to pain or demonstrating how to do so by, for example, progressing mobilization techniques from small to larger movements as the patient learns to control the quality and quantity of functional mobility, or by showing that more movement is possible if the patient can learn to relax tense muscles during a particularly painful movement (active or passive).

RECOGNIZA B LE SYNDROM ES t RECOGNIZABLE PAT HO LOG IES Recognizable syndromes The typical upper limb and lower limb syndromes encountered by manipulative physiotherapists are detailed in Corrigan and Maitland ( 1983) and are out lined earlier in this chapter. Each corresponding chap ter will review the typical clinical syndromes for each region. It is valuable for the manipulative physiother apist to gain experience in recognizing pain patterns or clinical profiles as many disorders respond to particu lar mobilization techniques as part of the overall man agement of such conditions. I

A

I

•

B

H

Pattern recognition is a valuable clinical reasoning strategy (Chapter 1) which will guide the novice as well as the expert in clinical decision making. An example (from Chapter 11) of clinical profiling and accompany ing clinical thinking is presented in Box 11 .14.

Hypermobility I instability this text hypermobility is used to infer an increased range of a joint (or joints) compared with the average range of movement in a given direction for that joint (or joints) in the general population. The joint may be hyper mobile in one direction whereas other movements of that joint may be of average range or even hypomobile. The hypermobility may be general in that it affects all or most joints in all or most directions. The essential part of the definition is tl1at there is full muscular control of the hypermobile range. To depict a hypermobile range on the baseline of the movement diagram, or on the same baseline as used for depicting grades of move ment on a normal joint, the line AB extends beyond point B. This is because B is defined as the 'end of the normal average range of movement'. The end of range for the hypermobile movement is suitably identified as H (Fig. 10.5). If trauma (or disease) results in loss of a ligament's ability to restrict the range of a movement that it nor mally restricts, that movement will become excessive (unstable). The important implication of these circum stances is that there will not be any muscular control of this new excessive range of movement. Without this muscular control, the joint is unstable. This kind of instability is hypermobility, but hypermobility is not necessarily this kind of instability (a cat is an animal, but an animal is not necessarily a cat). There is another form of hypermobility and another form of instability, both of which are associated with pain: In

•

The hypermobility is seen with the subluxing patella. In tlUs situation the patella has a hypermobile range of lateral displacement. When the patellofemoral articulation becomes symptomatic the 'apprehen sion test' becomes positive, i.e. if the patella is pas sively moved laterally while the tibiofemoral joint is in a relaxed extension position, a point will be reached in the range when the patient suddenly Figure 1 0. 5 hypermobil ity.

Beginning

End of normal

End of

of range

average range

hypermobile range

of movement

of movement

of movement

Movement d i ag ra m showing

Peripheral neuromusculoskeletal disorders

267

] reflexly contracts the quadriceps muscles to prevent further patellar movement. This occurs at the point when the patella, if moved any further laterally, will sublux. •

The other kind of functional instability is a pain response phenomenon, commonly seen in a painful tibiofemoral disorder. Usually, full knee extension (passively or actively) is limited by pain. This being so, when the patient walks and reaches that part of the gait that requires controlled knee extension, the patient is unable to control the position and the knee wobbles until the knee extension phase is no longer required. This kind of instability is some times referred to as 'stable instability' or 'pain alerted instability' because when the knee extension becomes painless the instability seen on walking disappears.

Treatment of such disorders i s also described in Chapter 8. Qualifying 'arthritis' is this way can help the manipu lative physiotherapist to identify which patient's dis orders can be helped by mobilization/manipulation treatment techniques and which disorders will need other approaches to their management. Such situa tions can be identified by detailed history taking and the response to treatment.

Subclinical arthritis This is an extremely difficult subject to discuss without disruption and laying oneself open to criticism. Nevertheless, it is extremely important to have some understanding of: • •

Joint locking

•

•

what it is, and how it presents with patients how it relates to arthritides what medical test results would indicate its presence what medical treatment can be used to indicate its presence what interpretations can be put on it in relation to treatment and prognosis.

This inability to move a joint normally is caused by such events as 'loose bodies' within a joint or a torn meniscus. The onset of a meniscus injury is usually one of an unguarded twisting movement; however, loose bodies may 'come and go' (usually with movement) without the patient being aware of the particular move ment(s) which cause the locking. The role of the physio therapist is to try to free the joint from the obstruction to movement by passive movement techniques. Once freed, exercise for joint support and joint-care educa tion are essential.

Because there is a recognizable pattern of both the patient's symptoms on subjective questioning, and the physical signs on the objective examination, and because the varying responses to passive movements are clear and predictable in terms of (a) the value of physical treatment and (b) the indications for specific medical treatment, the subject should be tackled.

Fractures and non-uniting fractures

Definition of title 'subclinical arthritis'

The manipulative physiotherapy application to such disorders is discussed in detail in Chapter 8 .

Arthritis Simply means that there is an inflammatory

Arthritis (qualified) 'The statement that one has to live with arthrosis seems to be a true statement. However, the pain they relate to within the same pathology is not a symptom the patient has to live with, since correlation between arthrosis and pain is non-existent' (Van Wingerden 1995). An active arthritic disease disorder that is causing pain cannot be relieved of the pain by techniques such as those described in this text. However, both post traumatic arthritis and degenerative osteoarthritis can be helped by skilled manipulative physiotherapy. Additionally, longstanding osteoarthritis which is only minimally (or moderately) uncomfortable rather than painful, but is causing activity limitations, can be helped to gain further range and thus a better lifestyle.

•

process within a synovial joint, and as the 'arthritis' is here tied to the word subclinical, the inflammation will not necessarily show itself in terms of being 'red, hot and swollen'. The word is also not saying that it is osteoarthritis or any other diagnosable arthritis dis order, such as, for example, rheumatoid arthritis. The word 'arthritis' should not be used as a syno nym for osteoarthritis. If it is used to describe to the patient what the problem is, it is also essential to explain that this is not osteoarthritis and that the patient will not be confined to a wheelchair in the future. Some people have a fear of being crippled by osteoarthritis and this fear must be allayed. This use of the word subclinical is meant to empha size that a diagnosis of 'arthritis' cannot be given on a basis of positive blood tests, of radiological changes in a joint or any other medical tests. However, it can be determined by the history of the patient's symptoms,

268

MAITLAND'S PERIPHERAL MANIPU LATION

the behaviour of the symptoms as the patient describes them, and the behaviour of the symptoms on differen tial physical examination, especially if there are any after-effects following such examination.

Presentation The symptoms felt by the patient are con stant though they will vary in intensity. Too much activity and too much rest lead to increased pain. The pain is always at the site of (often better described as being 'within') the joint. If there is any referral of symptoms, they can spread proxima �y or distally . . from the joint and they will decrease m mtensity as they spread away from the joint areas. On passive movement of the joint in any direction . there will be a 'pain-through-range' response. This pain response is heightened if the passive movement is performed while the joint surfaces are held com pressed together. These patients avoid use of the joint affected and prefer to support it in a mid-range position, yet they also choose to move it about in many directions gently and comfortingly in between periods of rest. After more prolonged periods of rest, such as during the night, patients find it more difficult to institute mov� ment as the joint feels to have stiffened; however, this stiffness soon disappears following a little movement. There is yet another aspect of pain present with this disorder. Following either examination movements, or activities that cause discomfort, there is a latent and lingering exacerbation of symptoms. This 'after-effect' may be present with other disorders but it is always present in 'subclinical arthritis'. The exacerbation lasts for a longer period with the more active disorder than with inactive arthritis. The pain of this disorder differs from that found with a more mechanical type of inflammatory disorder. The latter pain can be relieved in particular positions of rest and the position of comfort can be maintained for much longer periods without the feeling of its needing to be moved. In a likewise manner, when it does feel the need for movement, the initial stiff feeling goes much more quickly: it will probably require only three movements before it is freed. These subtle differences are important to be able to distinguish. Perhaps the experience of treating these patients is the only wa'! to be able to distinguish one from the other on the baSIS of pain alone. Experience teaches so much.

The faster the movement is performed, the greater will be the pain. Conversely, it may be possible to move through 50% of the range without discomfort, pro vided the movement is performed: • •

Symptoms

M ovements As stated above, movements in all direc tions of the affected synovial joint will be uncomfort able. It will be a 'through-range-pain' response to the movement, irrespective of whether the movement is a physiological or a passive accessory movement.

•

extremely slowly passively (not actively because this involves a degree of joint compression) in a manner that avoids any moderately firm contact of the contiguous joint surfaces.

This is in contrast to the more mechanical (this is an unfortunate term if it is taken literally) variety of arth ritis (see Symptoms above), where a moderate degree of speed or joint surface contact is not exceSSively painful. Comparing a small passive movement of the affected joint, first with the joint surfaces in their usual normal relationship, and then with compression of the joint surfaces, there are marked differences in the pain response: the slow uncompressed movement is far less painful than that felt when compression is added. Examination of movements of a joint that may be thought to have a subclinical arthritic involvement should initially be performed slowly. This avoids exacer bation that occurs from over-zealous testing. Having tested some of the movements it is possible to have an idea of the likely reaction to the examination. Armed with this information, the following test procedure of a movement will provide definite information as to how primary the inflammatory component of the disorder is. Circumstances can exist where a patient feels pain or discomfort in rhythm with oscillatory movements performed by a therapist. This is not uncommon when these movements are performed at or near the end of a range. With a subclinical arthritic disorder, oscillatory movement within range (grade II-) may be felt as a movement within the joint. However, important though this is, it is not as important as the fact that an ache within the joint will develop and it will increase in intensity as the oscillations are continued. This build-up of ache is a consistent finding with this dis order. To continue building up the ache is harmful and should therefore be avoided. However, more informa tion of importance is gained if a minimal ache is first provoked with a known number of oscillations. The movement is stopped, and time taken for the ache to subside is noted. When it has subsided, the same num ber of oscillations is repeated and the ache compared, as well as comparing the time taken for it to subside again. A favourable finding is the case if the ache is less with the second set of oscillations, or if it subsides more quickly. One point which may make it easier to understand and recognize this particular disorder is that the

Peripheral neuromusculoskeletal disorders

inflammation is primary and not secondary. In this way it is different from the inflammation (the -itis of arthritis) that occurs following a sprain or other simi lar incident. This is probably the reason why it does not recover to a pain-free stage as readily as does trau matic inflammation. Treatment response This aspect is discussed in Chapter 8 but is mentioned here to show the disorder's distinctive nature. When the disorder is in a very low grade inflammatory stage, oscillatory movements of large amplitude are used and are taken into a very small degree · of discomfort. Initially, the movements should not provoke any ache that increases in intensity or does not dissipate quickly when the movement is stopped. In the less low grade stages, movements must not provoke discomfort, or even awareness (to the patient) of a feeling of movement taking place within the joint. There must be no development of ache within the joint. Characteristically, there will be a very pleasant feeling of warmth and comfort following the correct treatment. Though this may only last from half an hour up to 2 hours at first, the feeling is one that the patient has not had previously and is not produced by any other form of physiotherapy.

management programme including medical screening and management, advice and self-management strat egies, hydrotherapy and genera! exercise programmes. Occupational therapists, social services and employ ment services will also be involved. In short, input from the whole rehabilitation team is essential.

Total joint replacement Total joint replacements are a common surgical inter vention in many degenerative, inflammatory types of osteoarthritis and in some post-traumatic situations. Although many protocols describe maintenance and improvement of joint mobility as one of the treatment objectives, they are not explicit in the use of active, assisted active (or assisted passive) or passive move ments (Moncur 1996, Atkinson et a! 1999, Trudelle Jackson et a! 2002, Thomas 2003) . Gentle passive mobilizations may complement the postoperative treatment. However, they may need an approach of 'wise action' (Jones 1997; see also Chapter 4), with the following considerations: • •

Traumatically induced arthritis

•

Such disorders may arise as a result of meniscectomy or intra-articular fractures. Arthritic changes take place within the joint prematurely due to the predisposing injury.

•

Degenerative arthritis Degenerative joint disease can develop purely as a result of wear and tear and age-related changes within the joint. However, there is another type of degenera tive arthritis that affects joints locally through what is thought to be local enzyme or autoimmune responses. This type of degenerative arthritis is progressive but, like wear and tear and traumatically induced arthritis, symptoms can be eased and ranges of move ment increased with passive movement treatment techniques.

Osteoarthritis This is the form of disease that is active and systemic and is characterized by exacerbation and remission affecting many joints. Pain and joint stiffness can be influenced with passive movement treatment tech niques during the quiet phases of the disease but patients with such disorders need a total rheumatology

•

Employ mainly accessory movements. Localization of forces should be as close as possible to the joint line. Application of forces should take place as much as possible parallel to the line through the joint surfaces. Long leverage or techniques which may move the bone around the prosthesis should be avoided (e.g. longitudinal caudad movement localized at the distal part of the tibia in knee treatment, distal part of femur in hip movement, distal part of humerus in shoulder movement). Progression of treatment is possible as described in Chapters 7 and 8.

If active movements achieve the goals of treatment, passive movements become superfluous. However, in an early phase after the operation in which the focus lies on active movement within pain-free limits, gentle passive movements may support the active movement of the patient (e.g. many patients with a joint replace ment of the hip may have difficulties with active flexion of the knee in supine lying. Gentle AP move ment, applied to the joint, may 'centralize' the hip better which then allows the patient to actively flex further into the range). In later stages, when tissue healing is nearly com plete and joint mobility seems more restricted than would be expected in this phase, passive movements may become the first treatment of choice to enhance mobility.

269

270

MAITLAND'S PERIPHERAL MANIPULATION

PROG NOS IS (DISORDERS W H IC H AR E EASY / D I FFICULT TO H EL P) The importance of making a prognosis in manipula tive physiotherapy is discussed in Chapter 8. Essentially, the manipulative physiotherapist should be able to relate certain characteristics of the presenta tion of a disorder to the potential effectiveness of mobilization/manipulation techniques. Box 10.4 com pares and contrasts those features which may make the disorder relatively easy to help (responders) and those features which may make the disorder more dif ficult to help (non-responders).

DI F F ER E NTIAL DIAG NOSIS A patient may have pain which is felt in the shoulder whereas in fact its source may lie in the cervical spine or its neuromeningeal elements. With pain in the right shoulder, the cause may even be in the gall bladder (visceral origin). The role of the physiotherapist is to determine the source of the patient's symptoms. This should include the possibility that pain is referred from the spine, from other peripheral joints, from viscera or to viscera. Examples of this are: •

A patient who feels pain in the vicinity of the insertion of deltoid which is referred from the

Disorders easy to h e l p (responders)

Disorders d i ffi cu l t to h e l p (non-responders)

A strong relationship of the patient's symptoms and

A weak relationship between the symptoms and

movement A recog nizable / typical syndrome, recog nizable / typical pathology Predominantly primary hyperalgesia and tissue-based pain mechanisms (nociception, peripheral neuro genic pain) Helpful thoughts and behaviours ('I can still do some things', 'I have found ways to get relief) Familiar symptoms which the patient recognizes as tissue based ('It feels like a b ruise') No or minimal barriers to recovery or predictors of chronicity ('yellow flags') The seve rity, i r ritability and nature of the patient's symp toms correspond to the history of injury or strain to the structures of the movement system The patient has had a p reviously favourable sampling experience of ma nipulative physiotherapy There are easily identifiable signs of impairment and activity limitatio ns which have a strong relationship to movement Patients are touch tolerant (gain relief by touch, rubbing or massage) An internal locus of control ('I just need to know how to help myself) ; locus of control is consistent The patient has realistic expectations fo r recovery which correspond to the stages in the natural history of the disorder Patie nts will resume appropriate activity and exe rcise at relevant stages in recovery

movements in the patient's mind Atypical, u n clear patte rns, syndromes or pathology Predominantly seco ndary hype ralgesia from central sensitization rather than tissue-based symptom responses Maladaptive thoughts and behaviour ('I don't think I'll ever get better', I dare not move because it always hu rts me') and other 'yellow flags' U n familiar symptoms which the patie nt has difficulty describing in sensory terms Multicomponent / complex regio nal pain syndromes Severity ir ritability and nature do not fit with the history or stage in the natural history of the disorder P revious u nfavourable sampling experiences or knowledge of manipulative therapy (' I've had manipulation before and it just makes it hurt more', ' My mate had manipulation on his shoulder and he said it was much worse afte rwards') Evidence of movement impairment but with little correspondence to the degree of activity limitation Patients are touch intolerant ('I don't like anyone touching my knee') A n external locus of control ('You a re the physiotherapist, you sort me out') or an inconsistent locus of control; patient sometimes wants help and sometimes doesn't U nrealistic expectatio ns for recovery ('I wish I would wake up and all the pain would be gone') Ongoing pain states with little change in symptoms over a long period of time

Peripheral neuromusculoskeletal disorders

271 ]

•

•

•

shoulder joint in the absence of pain in the shoulder joint. Referred pain from the hip can be felt in the knee without there being any complaint of pain in the hip. Visceral pain can be referred into areas of the musculoskeletal system. Left arm pain associated with cardiac disease is quite common.

There are other examples where referral of pain works in the opposite direction, i.e. pain can be referred to an area which the patient describes as being one of the viscera. The referral mechanism in this case is usually related to the vertebral column, such as the experience of abdominal pain referred from the lower thoracic spine. Likewise, pain can be referred into the testicular area from the hip. The manipulative physiotherapist can gain valuable information from: •

•

•

the subjective examination (localization, description of symptoms, behaviour of symptoms with movement of the part where the symptoms are present, the onset of symptoms) the physical examination (movement impairment in the region of the pain, differentiation testing of the neuromusculoskeletal structures) the response to treatment (effectiveness of local treatment).

This information will help the phYSiotherapist to decide whether or not the symptoms have their origin in the neuromusculoskeletal system and if so, what is the neuromusculoskeletal source of the symptoms (local or referred). If the symptoms are originating out side the neuromusculoskeletal system, diagnosis and management may well fall outside the physiothera pist's scope of practice and the appropriate practi tioner should then be contacted. One very useful text entitled Differential Diagnosis in Physical Therapy (Goodman & Snyder 1995) is recom mended reading and a recommended reference book. to help phYSiotherapists recognize and identify condi tions referred to physiotherapy which could be mim icking neuromusculoskeletal disorders. These conditions can be reviewed in relation to body systems and the possible sources of pain in the various body regions (e.g. shoulder pain, hip pain, groin pain). Interestingly, Goodman and Snyder (1995) put great significance on history taking and the relevant ques tions which should be asked if systemic disease is sus pected. It is not the intention of this text to detail all these questions and their interpretation but to make

the clinician aware of what their knowledge base should include and refer to the appropriate texts. Box 10.5 shows the main differences between the presentation of systemic and musculoskeletal joint pain; Figure 10.6 shows the common sites of visceral referred pain. Through thorough questioning and assessment of the relationship of symptoms to movement of the neu romusculoskeletal system, the skilled clinician will be able to identify the presence of disorders of the move ment system. However, if no relationship exists the cli nician should be aware of the possibility of symptoms being referred from systemic disease into muscu loskeletal areas such as the shoulder, hip and groin: •

Cardiovascular pain from cardiac disease referred into the chest and left shoulder (look for symptoms with exertion), arterial insufficiency presenting as hip pain (look for signs of claudication). -

Systemic •

Awa kens at night

•

Deep aching, t h robbing

•

Reduced by pressure

•

Constant or waves / spasm

•

Associated signs a nd sym ptoms: - jaundice migratory a rth ralgias skin rash fatigue weight loss low-grade fever musc u l a r wea kness cycl ic, prog ressive symptoms history of i nfection (hepatitis, streptococcosis, mononucleosis, measles)

Musculoskeletal •

Decreases with rest

•

Sharp

•

Ceases when stressful action is stopped

•

Associated signs and symptoms: usua l ly none - trigger poi nts may be accompanied by nausea, sweating

Reproduced by kind permission from Good man Et Snyder

( 1 995).

272

MAITLAND'S PERIPHERAL MANI PULATION

Perforated

Liver

duodenal ulcer Heart

Biliary colic

Penetrating duodenal ulcer

Cholecystitis,

Renal colic

pancreatitis,

Cholecystitis Pancreatitis,

duodenal ulcer

renal colic

Appendicitis

Rectal lesions

Colon pain

Fig u re 1 0.6

•

Common sites of referred pain. Reproduced by kind permission from Goodman 8: Snyder ( 1 995).

Pulmonary

-

pain in the right or left shoulder from

and general fatigue associated with endocrine and

pleurisy or Pancoast tumours (look for cough spu tum, shortness of breath, weight loss). •

Gastrointestinal/biliary

- the gall bladder referring

metabolic disease. •

may mimic musculoskeletal disorders in terms of

nausea and appetite changes), appendicitis refer

movement restrictions but patients also suffer from

ring pain into the groin area (look for fever and

general malaise and cannot reduce the pain them

altered bowel habits).

•

selves whatever they try to do. This is also the case renal disease referring pain

in metastases in the shoulder from breast and lung

into the loin and even the right shoulder (look for

tumours and metastases in the pelvis and back from

changes in urinary function), ureteral colic causing

prostate tumours. Lymphatic swellings, espeCially

pain to be referred into the hip.

in the neck, axilla and groin, should be considered

Renal and genitourinary

-

with some of the leukaemia/lymphoma patholo

Hepatic - liver abscesses can refer pain into the right

gies, as should the bone pain associated with multi

shoulder. A sense of fullness, jaundice, anorexia,

ple myeloma.

nausea and vomiting may accompany the pain and discomfort. •

- the primary tumours, especially in

bone, of the shoulder and knee (femur, tibia/fibula)

pain into the right shoulder (look for associated

•

Oncological

•

Immunological - here the typical progressive history

Endocrine and metabolic - the cramps and aching, tired

and symptomology of exacerbation and remission

limbs and trophic changes, temperature intolerance

of rheumatic disease springs to mind.

Peripheral neuromusculoskeletal disorders

References Atkinson, K, Coutts, F. & Hassenkamp, A-M. 1999. Physiotherapy in Orthopaedics - A Problem Solving Approach. Edinburgh: Churchill Livingstone Butler, D. 2000. The Sensitive Nervous System. Adelaide: NOr Group Corrigan, B. & Maitland, G. D. 1983. Practical Orthopaedic Medicine. London: Butterworths Elvey, R. & Hall, T. 1999. Nerve trunk pain. Physical diagnosis and treatment. Manual Therapy, 4, 63-73 Fry, H. J. H. 1986. Overuse syndromes in musicians: prevention and management. Lancet, ii, 728-731 Gifford, L. S. 1997. Pain. In Rehabilitation of Movement: Theoretical Basis of Clinical Practice, ed. J . Pitt-Brooke. London: W. B. Saunders Goodman, C. & Snyder, T. 1995. Differential Diagnosis in Physical Therapy, 2nd edn. Philadelphia: W. B. Saunders Greening, J. & Lynn, B. 1998. Minor peripheral nerve injuries - an underestimated source of pain? Manual Therapy, 3, 1 87-194 Harding, V. 1997. AppLication of the cognitive-behavioural approach. In Rehabilitation ofMovement: Theoretical Basis of Clinical Practice, ed. J . Pitt-Brooke. London: W. B. Saunders Hunter, G. 1994. Specific soft tissue mobilization in the treatment of soft tissue lesions. Physiotherapy, 80, 1 5-21 Jones, M. A. 1997. Clinical reasoning: the foundation of clinical practice. Part 1. Australian JOllrnal of Physiotherapy, 43, 1 67-170 Lewis, J., Green, A. & Dekel, D. 200 1 . The aetiology of

Maitland, G . D . 1992. Neuro/musculoskeletal Examination and Recording Guide, 5th edn. Adelaide: Lauderdale Press Moncur, C. 1996. Physical therapy management of the patient with osteoarthritis. In Physical Therapy in Arthritis, ed. J. M. Walker & A. Helewa. Philadelphia: W. B. Saunders Sahrmann, S. A. 200 1 . Diagnosis and Treatment of Movement Impairment Syndromes. St Louis: Mosby Shacklock, M . 1999a. The clinical application of central pain mechanisms in manual therapy. Australian Journal of Physiotherapy, 45, 215-221 Shacklock, M. 1999b. Central pain mechanisms: a new horizon in manual therapy. Australian Journal of Physiotherapy, 45, 83-92 Slater, H. & Wright, A. 1995. An investigation of the physiological effects of the sympathetic slump on peripheral nervous system function in the upper limb. In Moving in on Pain, ed. M. Shacklock, pp. 1 74-184. Sydney: Butterworth-Heinemann Thomas, K. 2003. Clinical pathway for hip and knee arthroplasty. Physiotherapy, 89, 603-609 Trudelle-Jackson, E., Emerson, R. & Smith, S. 2002. Outcomes of total hip arthroplasty: a study of patients one year postsurgery. Journal of Orthopaedic and Sports Physical Therapy, 32, 260-267 Van Wingerden, B. A. M. 1995. Connective Tissue in Rehabilitation. Vaduz: Scirpo Verlag Watson, J . 1986. Pain and nociception - mechanisms and modulation. In Modern Manual Therapy of the Vertebral Column, ed. G. Grieve. Edinburgh: Churchill Livingstone Wright, A. & Sluka, K 200 1 . Non-pharmacological

subacromial impingement syndrome. Physiotherapy, 87,

treatments for musculoskeletal pain. Clinical Journal of

458-469

Pain, 17, 33-46

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275

Chapter

11

The shoulder and shoulder girdle complex

THIS CHAPTER INCLUDES: • • •

•

•

Key words for this chapter Glossary of terms for this cha pter A review of the pain-generating structures of the shoulder / shoulder girdle Subjective exa m ination of the shoulder/shoulder girdle An integrated approach to the physical exam i nation of the shoulder/shoulder girdle

KEY WORDS Glenohumeral, acromiohumeral,

GLOSSARY OF TERMS Adhesive capsul itis - a disorder of the glenohu meral joint of u n known aetiology which is characterized by painful and gradua l ly progressive restriction of active and passive glenohu meral joint motion (Cleland Et Dura l l 2002). Such d isorders tend to run a long and protracted course and eventually become self lim iting. Brief appraisa l - a selection of active movement tests of a joint or region of the spine which should reproduce symptoms or produce comparable signs or selected active

•

•

Exam i nation and treatment techniques The clinica l profiles of common shoulder / shoulder gird le d isorders: frozen shoulder / a dhesive ca psu litis painful stiff/ pseudo frozen shou lder glenohu meral osteoarthritis shou lder i nstability

•

fractures of the neck of h u merus subacromial impingement acromioclavicular d isorder m i n i m u m i nterm ittent m i nor shoulder pain A case study of a patient with a stiff pai nful shoulder.

acromioclavicular, sternoclavicular, scapulothoracic, costal joints,

brachial plexus, rotator cuff.

movement tests to screen a joint or region of the spine in order to exclude it from i nvolvement in the disorder. Functional demonstration - a demonstration of a fu nctional activity (or injuri ng movement), by the patient, which causes difficu l ty or which reproduces the symptoms reliably. Functionally demonstrated movements can then be differentiated to help locate the source of the symptoms. Furthermore, the fu nctional demonstration can be used as a potential treatment movement and

as a n asterisk to use in reassessment. If necessary tests - the use of, for exa m ple, combined movements, susta i ned / repeated movements or movements at speed when routine active function a l testing has not been sufficient to reproduce symptoms or produce comparable signs. Interfaces - structures such as bony tunnels, fibro-osseous tunnels, m uscles and tendon edges adjacent to or through which nerves pass. Locking position - a functional locking of the shou lder when the

276

M A IT LA N D'S P E R I PH E RA L M A N I PU LATI O N

shoulder is a bd ucted with mainta ined medial rotation ; slightly below the median coronal plane there reaches a point i n the abduction where the shoulder can not be a bd ucted, rotated or moved a nteriorly. Thus i n effect the shoulder is locked. Such a fu nctional 'corner' position is often symptomatic in m i nor shoulder disorders and mobilization i nto a pai nful locking position should be considered if m i nor symptoms or

i m pa i rments of the shoulder a re not resolving. Quadra nt - a functional movement of the shoulder which can be used to detect and treat m i nor or less obvious painfu l restrictions. The quadrant is that position, a pproximately 30· lateral to the fu lly flexed shoulder position, where the person's u pper arm has to move a nteriorly and a utomatica lly rotate to achieve the fu lIy flexed position.

MOVEMENT SYSTEM IMPAIRMENTS OF THE SHOULDER/SHOULDER GIRDLE COMPLEX - STRUCTURES AT FAULT

The clinical presentation of movement disorders of the shoulder/shoulder girdle complex (Fig. 11.1) should be interpreted in the light of knowledge about the structure and movement potential of this region. The innervation and potential generation of symptoms

Subacrom i a l i m p ingement - a variety of conditions (independent or i n combinations) which manifest as a nterior and anterior-Iateral su perior shoulder pain. The conditions occurs due to pathology of one or more structu res of the subacromial space and are characterized by painful loss of shoulder function, especially over head activities (Lewis et al 2001).

(pain, stiffness, discomfort, etc.) in and around the shoulder should also be considered. The clinician should consider the role of the articu lar, neural and muscular structures in this region and how they interrelate to affect shoulder/shoulder gir dle movement when impaired. Consideration should also be given to the influence of other body systems in generating symptoms and influencing movement, including visceral referred

�-- Sternoclavicular joint Acromioclavicular joint

�--

Clavicle

L-�-- Acromiohumeral joint Scapula ---I-+-++P",,"Scapulothoracic ---f--f---i-f-f

Figure 1 1 . 1

The shou lder co m plex.

...y"...-

,+y-t- Glenohumerai joint

The shoulder and shoulder girdle complex

pain (Chapter 10) and vascular impairment (e.g. the subclavian artery in the thoracic outlet).

Articular structures (synovial, non-synovial) Glenohumeraljoint The glenohumeral joint has large amplitudes of both physiological and accessory movement. These occur in a greater number of directions than any other joint in the body (Maitland 1991). When the joint is disordered this will be reflected in the answer the patient gives to Question 1 (What is your main problem?). One would expect that the symptoms which the patient is experi encing from a disordered glenohumeral joint will be accompanied by a variety of functional limitations of the shoulder, such as taking off a pullover, reaching above head height and putting the hand up the back. The most commonly diagnosed disorders of the glenohumeral joint are: frozen shoulder or adhesive cap sulitis, which is characterized by painful and gradually progressive restriction of active and passive gleno humeral joint motion (Cleland & Durall 2002) and osteoarthritis, which according to Bland (1983) is char acterized by pain, deformity, limitation of motion and slowly progressive disability. Other disorders which affect the glenohumeral joint are fractures of the humerus, painful stiffness usually as a consequence of an injury or strain to the joint structures and minimal intermittent pain and instability, which was defined by Maitland (1986) as an excessive range of abnormal movement for which there is no protective muscular control. -

The glenohumeral joint receives its articular branches from the axillary, musculocutaneous, suprascapular and subscapular nerves (C4-C7). The clinical rele vance of this knowledge helps the physiotherapist to recognize the potential for the glenohumeral joint to become symptomatic when disordered, to recognize potential associated areas of symptoms and to recog nize that the shoulder can be a site of referred symp toms from other sources. During the subjective examination, while trying to establish whether the patient is experiencing pain coming from the glenohumeral joint, it is often useful to grasp around the head of the humerus so that the fingers on one side of the glenohumeral joint can press into the space between the humerus and the glenoid cavity towards the thumb, which can press in on the opposite side of the joint. At the same time the physio therapist can ask the question, 'Is the pain in (meaning deep within) here?' To emphaSize the 'within' aspect of the question, the fingers and thumb gently rock the head of the humerus backwards and forwards. It may be necessary to support the acromioclavicular area with the other hand (Fig. 11.2). The emphaSiS with which the patient is able to say 'yes' or 'no' to the ques tion has very real value. Pain from the glenohumeral joint can refer both upwards, even as far as the base of the neck (Fig. 11.3a), or downwards, even as far as the forearm and occasionally into the hand. The referred arm pain is commonly less intense in the distal area (Fig. 11.3b). There are two other common areas of referred pain from the glenohumeral joint, usually associated with Figure 1 1 .2 Sites of pai n within the glenohumeral joint.

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Figure 11.3 S i tes of pai n : (a) referred into the neck; (b) referred into the arm.

X\\ � '

(a)

chronic disorders: one is a patch of pain near the insertion of the deltoid muscle (Fig. ll.4a) and the other is a band of pain around the arm at that level (Fig. ll.4b). The physiotherapist should always consider that a patient may have different kinds of shoulder pain and different yet closely associated sites (i.e. the different pains may be constant or movement related; they may be sharp or dull, vague or localized). The physiotherapist must also appreciate that the patient's shoulder disorder may present with different behaviours of pain and different provoking factors for

the pain. By this it is meant that the symptoms may be constant and unvarying or constant but exacerbated by certain movements or activities and require a calcul able period of time to settle. The patient may only have symptoms following vigorous activity and lying on the shoulder at night or it may be a sharp pain which is only felt with sudden unguarded movement. The list goes on but it is clear that there is a relationship between these scenarios and the clinical groupings proposed in Chapter 8. If the glenohumeral capsule and its supporting lig aments are impaired and painful the degree of painful

The shoulder a nd shoulder g ird le complex

Figure 11.4 Sites o f pain : (a) cOmmon patch of pai n ; (b) a band around.

�\\�/

�\�/ movements may well correspond to the capsular pat tern of painful restriction proposed by Cyriax and Cyriax (1983), i.e. activities involving lateral rotation of the shoulder will be more painful than activities involving abduction of the shoulder, which will be more painful than activities involving medial rotation of the shoulder. The degree of pain and restriction should correspond proportionally to the degree of injury or pathological activity and the stage in the nat ural history of the disorder. Correspondingly, if the capsular structures are impaired, the patient or physio therapist will often, with care, be able to position the

shoulder either in a pain-free/discomfort-free position or a position which gives as much relief as is possible in view of the degree of inflammation. If the glenohumeral joint articular cartilage has full thickness defects exposing the C fibres in the subchon dral bone, shoulder movements will be accompanied by pain, stiffness and sometimes crepitation through range. Commonly, patients will complain of a deep ache within the joint while lying on the shoulder at night. In other words, excessive loading and compres sive forces on the articular cartilage/subchondral bone will exacerbate the patient's symptoms.

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Glenohumeral joint disorders resulting in impair ment of movement often follow recognizable courses from onset to resolution. Typically the true frozen shoulder will begin spontaneously and follow a pro tracted course of severe pain, pain and stiffness, and stiffness alone. Osteoarthritic glenohumeral joints will present with gradually developing symptoms which are aggravated episodically by unusual or heavy activ ity. Fractures of the humerus will have a traumatic/ injurious onset. Glenohumeral joints which become painful and stiff will have their origins in injurious mechanisms or overuse strain which often emerge only after careful questioning of the patient. Instability of the glenohumeral joint will similarly develop as a result of injury (recurrent dislocation), predisposing factors (tight glenohumeral posterior capsule) or activ ities (baseball pitching). The physiotherapist assessing a patient with shoul der pain should be aware of other conditions which may be responsible for such symptoms, especially if there appears to be little or inconsistent relationship between the patient's shoulder pain and movement of the shoulder. If this is the case then the physiotherapist should be aware that ischaemia of cardiac muscle can present as pain in the left shoulder. Symptoms of car diac origin are likely to be exacerbated by physical exertion rather than movement and may be accompan ied by shortness of breath and cyanosis. Visceral organs such as the gall bladder may refer pain into the shoulder and are likely to be accompanied, after eating certain foods, by indigestion and flatulence. Circulatory disturbance as occurs with subclavian artery compression is likely to be accompanied by symp toms of circulatory compromise in the upper limb. Metabolic and oncological (Pancoast tumours) disease should also be considered as potential generators of symptoms in the shoulder / shoulder girdle regions (Chapter 10).

Acromiohumeral complex The acromiohumeral 'joint ' is synonymous with sub acromiaL impingement syndrome, rotator cuff pathoLogy and subacromiaL bursitis, all of which can present with pain at the point of the shoulder under the acromion (anterior, lateral, posterior) and most commonly with painful arcs of movement. The joint space includes the subacromial bursa and the supraspinatus tendon, and as a joint, it moves whenever the glenohumeral joint moves. Therefore any glenohumeral joint technique will apply equally to the acromiohumeral joint (except glenohumeral compression techniques). Disorders of this complex are usually due to a reduced subacromial space (averaging 9-10mm) and

are often multifactorial (Lewis et al 2001) with such factors as anatomical variations in the anatomy of the acromion process, disturbance in the union of acromial centres of ossification, rotator cuff overuse or degener ation, failure of the rotator cuff to stabilize the head of the humerus, calcification of the supraspinatus ten don, loss of capsular restraint, restriction of the gleno humeral capsule, functional scapular instability and postural alignment faults, all potentially contributing to the development of subacromial impingement. Acromiohumeral disorders, therefore, will be aggra vated by functional situations which reduce the sub acromial space, such as working with the arms at head height, the cocking position used in throwing (Schieb 1990) or overhead activities where posture is particu larly poor. Weakness often accompanies subacromial pain as a result of the rotator cuff muscles being dam aged, inflamed, degenerate or pain inhibited. The onset of acromiohumeral disorder will relate to the mechanisms which initiate the impairment of the structures within and related to the subacromial space. For example, the patient will relate trauma to the rota tor cuff with a specific injuring movement or activity such as a fall backwards onto an outstretched arm or a particularly vigorous throw of a cricket ball. Anatom ical variations and postural faults may result in a gradual or spontaneous onset of symptoms as the body's ability to compensate eventually starts to fail. Recovery is often slow due to the critical vascular zone in this region and complete rupture of the rotator cuff muscles may well require surgery when conservative means do not result in the resolution of the patient's impairments and activity limitations. Recurrences are dependent on the success of the physiotherapist in dealing with contributing factors such as postural align ment faults, muscle imbalance or restriction of move ment at associated joints such as the glenohumeral and acromiohumeral joints and the cervicothoracic spine. All examination and treatment techniques which are described for the glenohumeral joint also apply to the acromiohumeral articulation. This should include the quadrant and locking positions which must be clear and pain free if the acromiohumeral joint is not to be considered as a source of the patient's symptoms.

Acromioclavicularjoint The acromioclavicular joint functions to allow the acromion and therefore the entire scapula to glide for wards and backwards and to rotate on the clavicle (Peat 1986). The clavicle itself moves upwards, down wards, backwards and forwards or in combinations of these. The upward and downward movement of the clavicle is accompanied by posterior and anterior

The shou l der and shoulder girdle complex

rolling. Movement at the acromioclavicular joint, there fore, occurs during nearly all movements of the arm. Squeezing the spine of the scapula and the clavicle together is one movement which is often symptomatic when the acromioclavicular joint is disordered. Other passive movements anteroposteriorly, pos teroanteriorly, longitudinally and rotationally about the long axis of the clavicle, if impaired, may influence movement of the shoulder in any arm position. These accessory movements may produce symptoms if they are performed with the joint surfaces compressed. They may also produce a different, but relevant, clin ical response if they are performed directly on the joint line or on the acromion rather than the clavicle. The manipulative physiotherapist should also consider the use of glenohumeral joint flexion (and other gleno humeral movements) as a technique to be used in the treatment of acromioclavicular joint disorders. The acromioclavicular joint receives its articular branches from the suprascapular and lateral pectoral nerves which originate mainly from the C4 segmental level. This joint is prone to degenerative changes, sublux ation and involvement in fractures of the clavicle. Damage to the acromioclavicular joint may also encroach into the subacromial space and may contribute to the development of acromiohumeral disorders. Symptoms generated from the acromioclavicular joint will present as pain and stiffness, locally, over the joint line or deep within the joint depending on whether the intra- or periarticular part of the joint is disordered (Fig. 11.5).

pain

Fig ure 1 1 .5

�\\�/

Acromioclavicular and sternoclavicular pain.

Pain i s often generated when the joint is put under strain such as lifting and carrying activities under load, or while lying on the shoulder at night. Painful horizontal adduction (flexion), horizontal extension and end-of-range painful arcs of movement are also common, especially in flexion or during the hand-behind-back movement. Onset and progression of acromioclavicular symp toms depend on the mechanisms involved. These may include traumatic subluxation, or gradual stiffening and increasing ache due to degenerative changes. Spontaneous disorders of this joint have thickened soft tissue over the superior joint line and in the acromio clavicular space irrunediately medial to the articula tion. Acromioplasty is a common procedure when degeneration of the joint does not respond to conser vative management.

Sternoclavicularjoint The sternoclavicular joint enables movements which resemble those of a ball and socket joint rather than a plane joint (Peat 1986). Consequently, roll, spin and slide of the clavicle in relation to its intra-articular disc and sternal articular surface takes place during move ment of the arm. The available passive movements of the joint which contribute to its ideal functioning are longitudinal, posteroanterior, anteroposterior and rota tory movements with the arm in any functional pos ition. All these movements can also be assessed and treated with the joint surfaces compressed together. The sternoclavicular joint is often one of the first joints affected in ankyLosing spondylitis and will be com promised when the clavicle is fractured, when the ster num has been fractured or incised as in open heart surgery, and when significant structural or postural deformities are present, Scoliosis being one such deform ity. This joint, however, when stiff or stiff and painful (Fig. 11.5) is often a contributing factor or cause of the source of movement impairment in other parts of the shoulder complex, rather than the patient's main source of symptoms. Therefore all components of the shoulder complex need to be examined when a stern oclavicular disorder is present and vice versa, i.e. the sternoclavicular joint should be examined as a poten tial contributing factor to any disorder of any of the other parts of the shoulder complex. The sternoclavicular joint receives its articular nerve supply from the supraclavicular and subclavian nerves which stem primarily from the C3 segmental level. Progressive exacerbations of pain, stiffness and accompanying inflammation in this joint, along with exacerbations and remissions of back and hip pain,

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may b e early clues indicating evidence o f ankylosing spondylitis. Otherwise, unless injured, impairment of the sternoclavicular joint manifests along with the development of other shoulder symptoms. One excep tion to this is the joint's tendency to become hyper mobile and unstable (e.g. in competitive swimmers). The hypermobility is not usually a problem in itself unless the joint becomes symptomatic. Even so, pain relieving passive mobilization techniques can be just as effective whether the joint is hypermobile (unstable) or not.

Scapulathoracic articulation The scapula has the freedom to move around the thorax to enhance the potential range of movement available at the shoulder/shoulder girdle. Passively the scapula can be elevated, depressed, protracted, retracted, rotated and tilted as well as moved in any combination of the above with the arm in any position. The scapulothoracic articulation is involved and therefore its movement can be restricted if there has been bony injury to the scapula, injury and shortening of serratus anterior, rhomboids, trapezius and other scapular muscles, and deformity or injury of corres ponding ribs. Scapulothoracic mobility restrictions often occur due to adaptive shortening as a consequence of the long protracted immobility caused by adhesive cap sulitis. On the other hand, impairment of dynamic functional stability of the scapula during arm move ments can be a major cause of the development of

painful movement-related conditions of the gleno humeral, acromiohumeral and clavicular joints and the cervicothoracic spine.

Costovertebral, costotransverse, chondrosternal and costochondral joints Pain and stiffness originating in the upper ribs, espe cially the first rib, can have an influence on the ideal mobility of the shoulder/shoulder girdle region. The first rib is attached to the clavicle at its medial end by the costoclavicular ligaments. The ribs can be moved passively either at their vertebral end (via the rib angle) or at their chondrosternal end. The first rib can also be moved longitudinally via its superior surface (Maitland et al2001). Involvement of the first rib may present as pain in the area of the supraclavicular fossa with radiation of aching down the medial aspect of the upper arm and forearm reaching as far as the little finger (Fig. 11.6). Full elevation of the arm is likely to be limited by pain and stiffness in these areas. Via the attachments of the rib to T1 and the attachment of the scaleni muscles from the first rib to the cervical transverse processes, neck movements may also be limited by pain and stiff ness in the area of the first rib. The close proximity of the brachial plexus and the subclavian artery to the thoracic outlet region may give rise to the clinical presentation of compromise or irritation of these structures, i.e. signs of neural mechanosensitivity or signs of a vascular nature in the upper limb may be present.

Figure 1 1 .6 syndrome. Pain from first rib syndrome

.J

\ / \ [ ,/

....

Pain from fi rst rib

The shoulder and shoulder g ird le complex

Cervicothoracic spine

The consequence of pain and stiffness due to injury, strain, or postural adaptation is likely to be a first rib which is high and tight when palpated underneath the upper fibres of the trapezius (Fig. 11.7). The first rib will also be painful and stiff when moved passively at its vertebral end, its chondrosternal end or longitudi nally via its superior surface. The physiotherapist should also be aware that the common anomaly of cervical rib can also present in a similar way and will need to be confirmed radiograph ically, especially when vascular and or neurological symptoms are predominant.

Figure 1 1 .7

Palpation of the first rib u nder the trapezius.

(a)

Figure 1 1 .8

Involvement of the cervicothoracic spine interverte bral motion segments should be considered in all dis orders of the shoulder. Actual or potential movement impairment in these regions of the spine can con tribute mechanically to the ranges of movement avail able in the shoulder, as well as physiologically to pain perceived in the shoulder but referred from the cervi cothoracic spine structures. Disorder of the cervicothor acic spine often results in movement restriction of the shoulder due to the presence of neurophysiological reflex arc. Mechanical irritation of the cervical or thor acic sympathetic ganglia may enhance sensitivity of nerves, resulting in further aching and heaviness in the shoulder and arm (Butler 2000). Pain felt posteriorly in the upper arm (Fig. 11.Sa) is more commonly cervicothoracic in origin than gleno humeral; pain felt in the area medial to the scapula is also more likely to be cervical or thoracic in origin (Fig. 11.Sb). Similarly pain felt in the supraspinous fossa, in the absence of any glenohumeral pain, is more likely to be of cervical origin (Fig. 11.Sc). When pain, paraesthesia or dysaesthesia are of a non-segmental or stocking distribution, there is the pos sibility of a causal relationship from the thoracic spine at approximately the junction of the superior and mid dle thirds of the thoracic spine (Fig. 11.9). The physiotherapist may well discover that symp toms generated from outside the shoulder complex present with inconsistencies when there is an attempt to relate the symptom behaviour and history to the

(b)

Sites of pai n : (a) posterior a rm pai n ; (b) pain medial to scapula; (c) supraspinous fossa pain.

(e)

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MAITLA N D ' S PERI P H ERAL M A N I P U LATI O N

Figure 1 1 .9 Sites of pain : stocking distribution of pain or pa raesthesia .

\..J \

\

;

f

\ f/

recognizable patterns usually evident when the move ment system structures of the shoulder region are impaired. For example, the patient's shoulder pain may come on during prolonged sitting rather than when the arm is moving and the symptoms may have arisen in line with neck pain and stiffness rather than after any injury or strain to the shoulder.

Elbow The elbow joint should be briefly appraised as a poten tial cause of the source of strain of structures in the shoulder/shoulder girdle region (Chapter 12).

Neural structures Evidence suggests that the cervical dura, the cervical nerve roots, the brachial plexus and the peripheral nerves around the shoulder respond and adapt to movement of the head, neck and upper limb (Breig 1978, Elvey 1988). Greening and Lynn (1998) have also presented evidence suggesting that chronic constric tion of nerve connective tissue produces mechanosen sitivity of the nerve resulting in diffuse dysaesthetic limb symptoms. Painful restrictions of shoulder movement, there fore, could have their origins in these neural mechano sensitive mechanisms (stretch, compression, ischaemia, friction).

suspected if pain has no localizing value. This is the case when mechanosensitivity of the cervical dura presents as diffuse non-segmental arm pain (Butler 2000) which may well be present and aggravated by arm movement. Other mechanical factors such as lengthening of the canal in slumped sitting positions will enhance dural mechanosensitivity. Such factors are often recognized by the patient as triggers which increase the symptoms.

Nerve root pain Butler (2000) has presented evidence which suggests that nerve root irritation in the cervical spine results in 'signature zones' for pain, paraesthesia and other signs of impaired nerve conduction. These signature zones (Fig. 11.10), along with their nature of onset and their relationship to mechanical irritation of the nerve roots, can be useful guidelines to identifying shoulder pain and restricted movement due to nerve· root lesions. Clinical evidence has shown that shoulder movements will be influenced by, or influence, nerve root pain. Take, for example, the tendency of patients with C5 nerve root lesions to seek relief by placing the arm above the head, or those patients with C8 nerve root lesions whose arm symptoms are aggravated if the shoulder girdle is allowed to depress.

Brachial plexus lesions and peripheral nerve injury Dural pain More specifically, Cyriax and Cyriax (1983) said that involvement of the nervous system should be

It is important to be aware of the relationship between the shoulder and the shoulder girdle and the brachial plexus and peripheral nerves. Knowledge about the

The shoulder and shoulder girdle complex

Neurodynamic testing (Butler 2000), nerve palpa tion and neurological testing for altered nerve conduc tion will serve to identify components of shoulder movement disorders which are due to mechanosensi tivity of the nervous system structures.

Neurom uscula r structures

C6 C7

L1 L2 L3

L4

L5

Anterior Posterior Figure 1 1 .1 0 The nerve root 'signature zones'. Reproduced by kind permission from NOI Group Publications, Adelaide.

cutaneous supply of the individual peripheral nerves (e.g. supraclavicular, suprascapular, axillary, musculo cutaneous, median, radial and ulnar nerves) may also help in the interpretation of pain patterns around the shoulder and upper limb (Fig. 11.11).

Interfaces There is clinical value in knowing the sites around the shoulder where the dura, the nerve roots and the per ipheral nerves are vulnerable to mechanical or physio logical compromise. These sites are, more often than not, the sites where pathology has developed or minor nerve injury is likely to occur. They include the inter vertebral foramen, the spinal canal, the scaleni muscles, the first rib / cervical ribs, the coracoid process, the clavicle, the suprascapular notch and the head of the humerus.

Rotator cuff muscle impairment has already been mentioned as an important factor in the development of subacromial impingement. Adaptive shortening of the scapular muscles has also been considered as a fac tor in the presence of stiffness of the scapula in relation to the thorax. In 1986 Maitland described the import ance of dealing with muscle imbalance in patients with low back pain and in 1991 highlighted the role of stretching of contracted or fibrosed muscle tissue in the management of movement-related neuromuscu loskeletal disorders. Muscle tissue around the shoulder can be respon sible for symptom production as is highlighted by the trigger point and referred pain charts related to spe cific muscles (Fig. 11.12). Disorders of muscle causing painful shoulder movement will often present as abnormalities in quality rather than quantity of move ment. There will also be a discrepancy in the active range of movement and the range available when the shoulder is moved paSSively. Weakness will also be a common symptom. The physiotherapist must ques tion the patient and examine them to such a degree that it is clear that the weakness is due to pain inhib ition, disuse atrophy or neurological deficit. Analysis of the dynamic functional stability of the shoulder is beyond the scope of this text. Sahrmann (2001) is the companion text which highlights the clinical value of identifying and dealing with muscle imbalance-related movement impairments around the shoulder.

The in terrelationship of shoulder movement related disorders It is rare that only one movement system component is responSible for a patient's shoulder pain. Clinical sci ence reveals that there is a close relationship between the articular, muscular and neural structures around the shoulder. The relationship between joint and muscle Guanche et al (1995), using a feline model, found that stimulation of the anterior and inferior articular branches to the shoulder joint elicited EMG activity in biceps, sub scapulariS and supraspinatus muscles. Likewise, stimu lation of the posterior articular nerve elicited EMG

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MAITLA N D'S P E R I P H E RAL M A N I P U LATI O N

(a)

----S - upraclavicular, C.3,4-----+.k----- Upper lateral cutaneous of arm, t,;.�I.ti ----+ \-\------lntercostobrachial,T.2-----t--oM

Medial cutaneous of forearm, C.B,T.1 /+---- Medial cutaneous of arm, C.B,T.1-----, Lower lateral cutaneous of arm, C.5,6

//ffh'+f-+--- Lateral cutaneous of forearm, C.5,6 ---f-

r-f----- Palmar branch of median N-- - - Palmar branch of ulnar /�-.,.!f-*+--- Superficial branch of radial, C.7,B ----r,-"

.'b-- --- Ulnar, C.B,T.1 -----r'-,.1�� Median, C.6,7,B ------+,-/f-

(b)

,....<:"\... -----Supraclavicular, C.3,4-----_:'==l---Upper lateral cutaneous of arm, C.5,6---+��t---- Posterior cutaneous of arm, C.5,6

+t�"

---

Yr-+---l-- ntercostobrachial,T.2 \-L-,-\,-+---Medial cutaneous of arm, C.B, T.1 -----.!iIt":\

:..,-�+-- Posterior cutaneous of forearm, C.5,6,7,B -----\

1\--- Lateral cutaneous of forearm, C.5,6 ---+

T'<--T""tt----Ulnar, C.B,T.1

-+

_____

f'r--+,-::+<:--:Superficial branch of radial, C.6,7,B-----'I---'r-

Median, C.6,7,B -----I�....-J. Figure

11.11

The cutaneous nerves of the right upper limb, their areas of distribution and segmental origins, viewed from:

(a) anterior aspect; (b) posterior aspect. Reproduced from Williams, P. L. and Warwick, R. permission from Churchill Livingstone, London.

1973. Gray's Anatomy, 35th

edn ., by kind

The shoulder and shoulder girdle complex

(a)

Posterior deltoid

Lower trapezius

Multifidus T4,5

(c)

Subscapularis

JI---- Infraspinatus

Figure

activity in the acromiodeltoid muscles. When transec tion of the articular branches was performed there was an absence of EMG activity in the relevant muscles, thus suggesting that the sensory function of the joint capsule is closely related to the functioning of the muscles around the shoulder. The relationship between joint and nerve From a mechanical point of view stiffness in the joints of the shoulder complex could naturally restrict the mechan ical properties of the nerves which pass close to these joints, consequently making them mechanosensitive. From a neurophysiological perspective, there is

11.12

Some shoulder region trigger points.

evidence (Butler 2000) that injured nerves can generate antidromic impulses. As the shoulder joints possess articular nerves, these nerve endings could be the site of neurogenic inflammation and clinical pain. This may well be the mechanism of prespondylosis suggested by Gunn (1978) who observed that patients with long histories of neck pain and nerve root irritation seemed to develop secondary changes resulting in painful stiff shoulder joints. The relationsh ip between muscle and nerve Sunderland (1978) reviewed the adaptive protective mechanisms which the peripheral nervous system adopts to enable

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it to maintain an ideal functional environment under the stresses and strains of everyday life. Sunderland suggests that one of the major protective mechanisms for nerves, especially around the shoulder, is the pos tural muscle tone which relieves the peripheral ner vous system of the effects of gravity. On the other hand, this muscle tone is often not ideal (some muscles become short and tight) due to postural alignment faults. Such faults can develop, for example, in the scaleni during keyboard activities. Therefore the fre quently encountered interface between muscle and nerve can result in the development of peripheral neuro genic pain mechanisms.

spines, resulting in an overall improvement in the range of shoulder lateral rotation. Schneider postulated that the mechanisms responsible for this observation were likely to be neurophysiological, either by an influence on somatic referred pain initiating muscle spasm or by descending pain modulation. The subjective examination of the shoulder/ shoulder girdle complex is summarized in Box 11.1. The physical examinations of specific shoulder joints and movements are summarized as follows: • • • •

The relationship between joint and joint Schneider (1989) selected 14 patients with a gross restriction of shoulder lateral rotation and mobilized their cervical

The a rra ngement of the subjective exa m i nation is basically the same for all joints and is therefore only set out i n deta i l for the g lenohumeral joint. 'Kind' of disorder Start with fi rst mandatory question (Q1 ) • Establish why the patient has been referred for or sought treatment: (a) pain, stiffness, giving way, i n stability, wea kness, loss of function, etc. (b) postsurg ical, trauma, M UA, plaster, fracture, dislocation, etc. •

History Recent (previous) ; bruising, swelling, etc.

•

Area • Is the d isorder one of pain, stiffness, instabil ity, weakness? • Record on the body chart: 1. area and depth of symptoms indicati ng main areas and stating type of symptoms 2. paraesthesia and anaesthesia • Check associated areas, i.e. (a) of vertebra l column (b) of joints 'above and below' the lesion (c) other relevant joints • Complete planning sheet Part One, A (see Box 1 .2) Behaviour of symptoms . 1. When a re they present or when do they vary? (constant, i ntermittent - frequency)

• • •

shoulder/shoulder girdle complex (Box 11.2) glenohumeral joint (Box 11.3) acromiohumeral joint (Box 11.4) acromioclavicular joint (Box 11.5) sternoclavicular joint (Box 11.6) scapulothoracic movement (Box 11.7) costal joints and intercostal movement (Box 11.8).

2. What provokes, what relieves? 3. Any pain at nig ht? Need to get up because of it? Able to lie on it? (Is the night pain for mechan ica l reasons or inflammatory?) 4. On first rising c.f. end of day 5. Functional lim itations (dom i nance of pa in, stiffness, weakness, etc.) Special questions 1. Genera l health, relevant weight loss (medical history) 2. What tablets a re being taken for this and other conditions? (steroids, pain-ki l lers, a nti-i nflammatory d rugs) History 1. Of th is attack 2. Previous history 3. Socioeconomic history as a pplicable 4. Are the symptoms worsening or im proving? 5. Any previous treatment? Effect? 6. Any contraind ications?

Highlight main findings with asterisks Plan n i ng the physical exa mination 'Plan n i ng the Physical Examination' is included as part of the total examination procedure as a teaching medium to encourage clea r, methodical and pu rposeful thinking. It is the step taken, after the subjective exami nation, to formulate the requirements of the physical exa mination. Reproduced by kind permission from Maitland

(1992).

The shoulder and shou lder g irdle complex

Observation "Functional demonstration Itests • Theirdemonstration of theirfunctional movements affected by their disorder • Differentiation of their demonstrated fu nctional movement(s) Brief appra isal Active movements (move to pain or move to limit) F (spontaneous then sagittal) • Ab (spontaneous then coronal) • HF, HE • Beh ind back (wrist m id-line) • F and Ab in medial and lateral rotation •

Isometric tests Cuff

•

Arm-by-side t, ; , +-+-+ ca ud and ceph, -- (ga pping G / H joint) Arm abducted, +-+-+ caud, t ; Arm in FlO ; , +-+-+ caud (a nd ceph) 2. A/C joint: squeeze, ;, 1. +-+-+ ca ud and ceph, Rotn (repeat with compression) 3. SIC joint: as appl icable +-+-+ ceph and ca ud, ;, t, Rotn, distraction and compression (repeat first 5 with compression) 4. Canal's slump tests 5. Differentiation tests 6. U LNT Prone Hand-beh ind-back, E, Ad, :J • Forehead resting in pal ms, G I H, ; ; and """1 r •

, +-+-+

caud, cervica l

Side lying scap / thoracic: as appl icable EI, De, Protr, Retr, Rotn as applicable add compression

•

Other structures in 'plan' Thoracic outlet • Entrapment neuropathy • ULNT •

Passive movements As ind icated by site of pain and stiffness Supine 1. G / H joint F, Ab, :J , C:' HF, H E or 0 and locking position

Remember that what is sometimes referred to as an 'accessory joi nt', between the head of the h umerus and the acromion process, forms part of the exa mination of the g lenohumeral joint. Observation • Watch for patient's willing ness to move the arm when undressing " Fu nctional demonstration Itests Their demonstration of theirfunctional movements affected by their disorder

•

Pa l pation + When 'compa ra ble signs' i l l-defi ned, reassess 'injuring movement'

•

Check case records etc. Highlight main findings with asterisks I nstructions to patient Reproduced by kind permission from Maitland

•

(1992).

Differentiation of their demonstrated functional movement(s)

Brief appraisal Note abnormal ities of appea rance, tenderness, temperature and fasciculation (palpation may be performed here)

•

Active movements Active quick tests (+ cervica l)

289

290

M A ITLA N D ' S P E R I PH E RAL M A N I PU LATI O N

Routinely (with a l l joi nts, always modified t o suit 'kind of d isorder') F, Ab, (note drift and counter it) beh ind back, H F Note ra nge, pain, repeated, and behaviour (note scapular rhythm) As applicable

Speed of test movements Specific movements which aggravate The inj u ring movement Movements under load

Thoracic outlet tests M uscle power F and Ab in fu l l medial and latera l rotation

Isometric tests • •

Rotator cuff Other m uscles in 'plan'

Accessory movements As applicable

M ay be assessed at first session or as treatment prog resses: 1. By thumb pressures or a rm leverage ; , t, +-0-+ , caud and ceph, ...... laterally (a) in d ifferent positions in the ra nge (b) with add ition of compression and lor distraction 2. M id-range Ab /Ad, Rotn and F I E osci l lations (a) with g lenohu meral compression (b) with acromiohumera l com pression 3. 1 st rib Note ra nge, pain, resistance, spasm and behaviour Pa lpation •

Other structures i n 'plan' • • •

Cervical spine Joints 'above and below' Thoracic outlet

•

• •

Passive movements

•

Physiological movements Routinely 1. If pa in severe: ; , +-0-+ caud, ...... lateral (in neutral

•

pain-free position) 2. F, :J , C: Ab, H F, HE, components of hand-beh ind' back and Q (if active tests positive). or 3. Q and locki ng position (if active tests negative) Note ra nge, pain, resistance, spasm and behaviour

Temperature Releva nt tenderness (ca psule, tendons, bursae, muscles) Swel ling, wasting Position Altered sensation When 'com parable sig ns' ill-defi ned, reassess 'injuring movement'

Check case records etc.

Highlight main findings with asterisks Instructions to patient 1. Warning of possible exacerbation 2. Request to report details

As applicable 1. Ca nal's slump test

3. I nstruction to 'joint care' if requi red

2. Differentiation tests

Reproduced by kind permission from Maitland

Box 1 1 .4

Physical exa mination of the acromiohumeral joint

The routine exa m i nation of this joint must include exa m i nation of the acrom ioclavicular joint and the g l enohu meral joint. Observation

Other structures in 'plan' •

"Functional demonstration /tests

•

Their demonstration of their fu nctional movements affected by their disorder Differentiation of their demonstrated functional movement(s)

Brief appraisal Active movements (move to pain or move to limit) Isometric tests

Thoracic outlet

Passive movements (supine) •

•

(1992).

Test movements 1 -3 below should:

(a) reproduce the symptoms when the hu merus is

compressed agai nst the interior su rface of the acromion process, compared with (b) being pain less when the head of the humerus is distracted caudad from the acromion process. 1. Osci llatory Ab (from 20' to 50') 2. Osci llatory F I E, in slight Ab (from 0' to 30') 3. Osci llatory Rotn, in slight Ab (30' a rc in mid-range)

The shoulder and shoulder g irdle com plex

Differentiation tests (supine) Differentiating A/H joint:

(c) ....... caud on acromion or clavicu lar hea d : - reproduce pa in w h e n A I H su rfaces com pressed (A/ C movement n i l) - are pa in less when A / H surfaces distracted while A / C movement is produced.

•

1. from rotator cuff

It is A / H if: (a) isometric 30· Ab reproduces symptoms (b) there is no pain with oscillatory Ab at 30· if AI H joint is distracted caudad 2. from G/Hjoint - oscil latory Ab (from 20· to 40·): It is A I H if: (a) painful when A I H surfaces compressed and moved (b) painless when A / H distracted caudad and moved (c) pain less when G / H compressed a nd A/H distracted during movement. 3. from A/Cjoint It is A / H if: (a) HF, -ve (b) ; clavicu lar head -ve

Box 1 1 .5

As applicable

1. Cana l's slump tests 2. Differentiation tests

3. ULNT Pa l pation As previously + When 'comparable signs' il l-defined, reassess • 'inj uring movement' •

Check case records etc. Highlight main findings with asterisks

Instructions to patient Reproduced by kind permission from Maitland

Physical examination of the acromioclavicular joint

When examining the acromioclavicu lar joint (AI C), the G / H, A / H and 5 1Th movements m ust be examined.

• •

•

*Functiona I demonstration Itests Their demonstration of their functional movements affected by their d isorder • Differentiation of their demonstrated fu nctional movement(s)

•

•

Brief appraisal Active movements (move to pain or move to limit) Routinely 1. G / HF, Ab, behind back, HF and H E

2. Scapular elevation, depression, protraction, retraction

and rotation Note range, pa in, repeated (note scapular rhythm) As applicable •

Speed of tests movements Specific movements which aggravate

The i njuring movement M ovements u nder load

Isometric tests Rotator cuff • Other m uscles in 'plan'

Observation

•

(1992).

Other structures in 'plan' Thoracic outlet Passive movements Physiological movements Routinely

G / H F, Ab, :J , C:' HF and HE or Q and locking position 2 . Scapular elevation, depression, protraction, retraction and rotation Note range, pain, resistance, spasm and behaviou r 1.

Accessory movements Routinely 1. By thumb pressure

(a) over acrom ion (b) over clavicle

t , ; ....... ceph and ca ud ,

29 1

292

M A ITLA N D ' S P E R I PH E RAL M A N I PU LATI O N

2.

3.

4. 5. 6.

7.

(c) on t h e joint l i n e (d) repeat with joint compressed Squeeze clavicle and scapula Rotation at S I C and A / C joi nts (a) transverse axis (b) vertical axis (by scapular pro/ retraction) As for G / H joint Canal's slump tests Diffe rentiation tests ULNT

Box 1 1 .6

Pa l pation + When 'comparable signs' ill-defined, reassess 'injuring movement'

•

Check case records etc. Highlight main findings with asterisks

Instructions to patient Reproduced by kind permission from Maitland

Physical examination of the stemQclaviCul. joint

When exa m i ning the sternoclavicular (S /C) joint the A / C j o i n t (including relevant G / H A / H and S/Th movements) must a lso be exa m ined. Observation "Functional demonstration / tests Their demonstration of their functional movements affected by their disorder • Differentiation of their demonstrated fu nctional movement(s)

•

Brief a ppraisal Active movements (move to pain or move to limit)

Accessory movements Routinely

By thumb pressures on clavicle � , ; , ....... , ca ud and ceph, rotation, distraction and compression Note range, pain, resistance, spasm and behaviour

•

As applicable • •

Add com pression (medial and caud) to above U LNT

Pa l pation + When 'comparable sig ns' il l-defined, reassess 'injuring movement'

•

Routinely 1. G / H F, H / F and H E

Check case records etc.

2. Sca pular elevation, depression, protraction, retraction

Highlight main findings with asterisks

and rotation Note ra nge, pain and repeated Isometric tests Other structures in 'plan' Thoracic outlet

•

Passive movements Physiological movements Routinely 1.

(1 992).

Supine: G / H, H F, HE and F

2. Side lyi n g : scapular elevation, depression, protraction,

retraction and rotation Note ra nge, pain, resistance, spasm and behaviour

I nstructions to patient Reproduced by kind permission from Maitland

(1992).

The shoulder and shou lder gird le complex

Box 1 1 .7

Physical exami nation of scapulothoracic movement

-----

r-

When examining scapu lothoracic disorders the g leno humeral (G / H) joint m ust a lso be examined.

Passive movements

Observation

Routinely

"Fu nctiona I demonstration / tests • Their demonstration of their fu nctional movements affected by their disorder • Differentiation of their demonstrated functional movemel1t(s) Brief appraisal Active movements (move to pain or move to limit) Routinely

1 . G / HF, Ab, behind back, HF 2 . Scapular elevation, depression, protraction and

retraction Note range, pain and scapular rhythm

• • • •

Speed of tests movements Specific movements which aggravate The injuring movement Movements u nder load M uscle power

Isometric tests Rotator cuff • Other muscles in 'plan' •

Other structu res in 'plan' • Thoracic outlet • Entrapment neuropathy

Box 1 1 .8

1 . G / H movements 2. Side lying : scapular elevation, depression, protraction,

retraction and rotation (add com pression as applicable) Note ra nge, pain, resistance, spasm and behaviou r A s applicable

1 . Cana l's slump tests 2. Differentiation tests

3. U LNT Accessory movements Routinely

1 . Intercostal movements 2. Lifting scapula off thorax

Note ra nge, pain, resistance, spasm and behaviour

As applicable •

Physiological movements

Palpation + When 'comparable sig ns' i l l-defi ned, reassess 'inj u ring movement'

•

Check case records etc. Highlight main findings with asterisks

I nstructions to patient Reproduced by kind permission from Maitland

(1992).

Physical exam ination of costal joi nts and intercostal movement

Thoracic intervertebral joi nts should form part of the exa mi nation. Observation "Functional demonstration / tests • Their demonstration of their functional movements affected by their disorder • Differentiation of their demonstrated fu nctional movement(s) Brief appraisal Active movements (move to pain or move to limit) Routinely

1 . Inspiration a nd expiration, to maxim u m, qu ickly 2. Trunk F, E, LF, Rotn in F and E

3. Fu l l scapulohu mera l F through F and Ab

4. Side lyi n g : a rm through Ab to fu l l flexion position 5. U LNT and Cerv /Th slump

Note ran ge, pa in and behaviou r As applicable •

The injuring or aggravati ng movements

Isometric tests Other structu res in 'plan' Passive movements Physiological movements Routinely •

As for ' routine active movements' a bove, with overpressure and loca l izing

293

M A ITLA N D'S P E R I P H E RA L M A N I P U LATI O N

294

Accessory movements •

;, f,

-+

-- ,

adding ceph and ca ud and other

varying ang les Note range, pa in, resistance, spasm and behaviou r Pa l pation • For intercostal and thoracic interspinous spacing, prominence and thickening

PHYS I CA L EXAM I NAT I ON : SHOULDER/SHOULDER G I RDLE COMPLEX

•

Check case records etc. Highlight main findings with asterisks

Instructions to patient Reproduced by kind permission from Maitland

I n standing •

• •

•

• •

Observation of: - alignment/alignment faults: from the side, posterior and anterior - asymmetry: adaptive and protective deformity - impairment signs: wasting - structural impairment: scoliosis, torticollis, clavicle, humerus, scapula Present pain Functional demonstration/ active functional movements and differentiation including functional stability and alignment Isometric testing of rotator cuff muscles and biceps, including differentiation of structures causing acromiohumeral pain; palpation of the insertions of the rotator cuff If necessary tests: shoulder Brief appraisal: elbow

(All of the above can also be performed in sitting.)

In sitting •

•

•

•

Cervical spine brief appraisal/screening tests including the lower cervical quadrant and cervical movements under compression (Maitland et al 2001) Thoracic spine brief appraisal including deep breathing for costal joints and cervicothoracic differentiation in cases of pain around the medial border of the scapula (Maitland et al 2001) Slump test if the cervicothoracic dura is suspected of generating symptoms (Butler 2000) Brief appraisal of glenohumeral capsular stability (anterior laxity, posterior laxity and sulcus sign) (Westerhuis 1999)

(1992).

In supine lyi ng •

The following is a checklist for an integrated approach to the physical examination of the shoulder/shoulder girdle complex.

+ When 'com parable sig ns' i l l -defined, reassess 'injuring movement'

•

•

• •

•

•

•

•

•

•

•

•

• •

Palpation for signs of impairment uoint lines, peripheral nerves, muscle origins, tendons, contractile element and insertion) Glenohumeral instability tests (Gerber & Ganz 1984) (anterior, posterior and inferior capsular instability) Shoulder passive physiological movements (flexion to elevation, abduction to elevation, horizontal flexion and extension, medial and lateral rotation) Quadrant and/ or locking position Glenohumeral accessory movements in the neutral arm-by-side position or in any relevant physiological position Differentiation between the glenohumeral and acromiohumeral joints in abduction and at the limit of available elevation Acromioclavicular and sternoclavicular accessory movements in the neutral arm-by-side position and in relevant physiological positions Cervical passive physiological intervertebral movements (PPIVMs) (Maitland et a1 2001) Cervical anteroposterior intervertebral movements (L .1) (Maitland et al 2001) Passive movement of the first rib from above or from under the medial end of the clavicle (Maitland et a1 2001) Passive movements of the sternochondral and costochondral articulation Muscle length testing of the scaleni, levator scapulae, sternomastoid, upper fibres of the trapezius, pectoralis minor/ major, latissimus dorsi and serratus anterior (Kendall et a1 1993) Upper limb neural provocative tests (ULNPT) (Butler 2001) SLR Passive brief appraisal tests for elbow (Chapter 12), and wrist and hand (Chapter 13).

In side lying •

Scapulothoracic movements

The shoulder and shoulder girdle complex

•

•

Rlb movements via the axilla, with the arm in abduction to elevation Cervicothoracic PPIVMs (Maitland et a1 2001).

•

Approximately one-third of the head of the humerus should be protruding anteriorly to the acromion.

•

The medial border of the scapula should have a for ward tilt of about 9° (Culham & Peat 1993) (Fig. 11.14).

•

The acromion should be tilted forwards and up with the head of humerus directly underneath it. An exceptional gap between the acromion and the humerus head is known as the sulcus sign and is often associated with inferior capsular instability.

In prone lying •

•

•

•

Cervical and thoracic palpation including rib angles and passive accessory intervertebral movements (PAIVMs) (Maitland et al 2001) Scapula movements in different physiological positions especially elevation and hand-behind back positions Glenohumeral, acromioclavicular and first rib movements with the arm in the quadrant position Checking of the functional stability of the scapula when ideally aligned (Sahrmann 2001).

Observation of alignment/alignment faults from the back •

The neck to shoulder line should be symmetrical. A high tight shoulder is often a sign of protective deformity and a long sloping shoulder line is com monly found with other postural alignment faults.

•

The acromion should appear horizontal and the medial border of the scapula should be a few centimetres from and parallel with the vertebral column. T2 should be opposite the superior angle of the scapula, T3 should be opposite the spine of the scapula and T7 should be opposite the inferior angle of the scapula.

•

The medial border of the scapula should be firmly against the rib cage and 30° to the frontal plane without winging or pseudowinging (winging of the inferior angle only).

•

The lateral border of the scapula should be tilted anteriorly in the transverse plane, giving rise to the scapula planes of shoulder movement.

•

The olecranon should be posterior facing, indicating the ideal resting position of the head of the humerus and scapula. The cubital fossa should face anteriorly or no more than 30° medially. The hands should rest with the palms facing medially. If the hands face pos teriorly this is often a sign that the scapula is abducted (protracted and downward rotated) as in problems of postural alignment and functional stability.

•

Thoracic scoliosis may be evident.

The initial examination and treatment session should be followed by: a full explanation about the findings and options for treatment 2. a warning that symptoms may be felt more over the following day or so because tissues have been moved in a different way or more than they have been for a while 3. a check of any relevant medical screening and case notes 4. the planning of treatment at subsequent sessions. 1.

PHYSI CAL EXAM I NAT I ON AND PASSIVE MOB I LI Z AT I ON TREATMENT TECHNI QUES FOR THE SHOULDER/SHOULDER GIRDLE COMPLEX

The ultimate aim of dealing with musculoskeletal dis orders is to fully restore the patient's pain-free active functional movement. The initial aim of physical examination therefore is to identify the active func tional movements which are not full and pain free. Passive movements tested both through the avail able range and at the limit of the available range and which are found to be impaired by pain, stiffness or protective spasm can then form the basis of treatment techniques, the guidelines for which are described in Chapter 6. This should include mobilization of joints, lengthening of contracted or fibrosed muscle and restoration of ideal neurodynarnics.

In standing Observation of alignment/alignment faults from the side •

The centre of gravity of the patient's body should pass down through the ear, through the shoulder joint and anterior to the thoracic kyphosis (Fig. 11.13).

Observation of alignment/alignment faults from the front •

•

•

The sternum should be central and the rib cage symmetrical. These alignments will be disrupted in cases of scoliosis. The sternoclavicular joint lines and acromio clavicular joint lines should be symmetrical. Overactivity of the paravertebral muscles may be evidence of postural alignment faults.

29 5

MAITLA N D ' S P E R I P H E RA L M A N I P U LATI O N

296

[ (b) Anatomical structures that coincide with the line of reference

(a) Surface landmarks that coincide with the plumb line

Slightly posterior to apex of coronal suture Through lobe of the ear (head is slightly forward) Through bodies of cervical vertebrae

Through external auditory meatus Through odontoid process of axis

Through shoulder joint (provided arms hang in normal alignment in relation to thorax)

Approximately midway through trunk

Through sacral promontory

Approximately through greater trochanter of femur

Slightly posterior to centre of hip joint

Slightly anterior to a midline through knee

Slightly anterior to axis of knee joint

Slightly anterior to lateral malleolus

•

Through bodies of lumbar vertebrae

Through calcaneocuboid joint

The alignment of the head on neck and neck on neck should be symmetrical.

Asymmetry •

•

•

May present as muscle wasting of the scapula or deltoid muscles or as other signs of movement impairment, such as a swollen thickened acromioclavicular joint or a hot, swollen and tender sternoclavicular joint. Asymmetrical protective deformities such as a high and tight neck/shoulder line will need to be corrected or overcorrected so that their relevance to the patient's pain can be judged. Adaptive asymmetrical deformities should also be corrected in order to judge the degree to which restriction has developed.

•

Fig u re 1 1 . 1 3 Ideal plumb alignment, side view. Reproduced from Kendell, F.P., McCreary, E.K. and Provance, P.G. 1 993, with kind permission from Williams Ct Wil kins, Baltimore.

Bony anomalies such as old clavicular fractures may also be observable as asymmetries.

Present pain Before commencing active functional testing of the shoulder, patients should be asked to define the degree to which they are aware of any symptoms at the pre sent time. This acts as a baseline for functional testing and may also serve as a reassessment asterisk, espe cially if constant pain becomes intermittent.

Functional demonstration/active functional movements and differentiation including functional stability and alignment The three things which must always be documented when analysing movement are the available range, the

The shoulder and shou lder g ird le complex

(such as a pillow) to demonstrate the provoking activ ity even if it is in the middle of subjective questioning. Such knowledge can provide considerable informa tion which will guide the path of the whole physical examination. Among the many active functional shoulder move ments which can be tested, the ones that are used for reassessment purposes should always be reassessed in the same sequence to make the assessment more accurate. In standing, active abduction without lateral rotation is the movement most commonly used for assessing progress, but when all movements of the glenohumeral joint are limited it is more useful for the physiotherapist to assess active flexion. This is because, if treatment effects a 5% improvement, it will be more evident on assessing flexion which has a range of 180° than in the smaller range of abduction.

Shoulder flexion •

•

Figure 11.14 Angle of forward tilt of the medial border of the scapula (A) . The mean angle measu red i n healthy women under the age of 40 was 9.0' (n = 34). Reprinted from Culham, E., Peat, M. Functional anatomy of the shoulder complex. Journal of

•

•

Orthapaedic and Sports Physical Therapy 1993; 1 8(1). 342-350,

with permission of the Orthopaedic and Sports Physical Therapy Sections of the American Physical Therapy Association.

symptom response to the movement and the quality of the movement performed. Functional demonstration/tests consist of a move ment (or movements) which the patient recognizes as demonstrating the disorder (e.g. in a golf swing, the back swing reproduces the patient's symptoms). The therapist analyses (1) the position and (2) the move ment involved. This is the first part of the physical examination and often the most important asterisk to reassess. The functional demonstration may, in fact, form part of the subjective assessment when, after the first few questions, the patient has revealed a movement that is limited by pain or other symptoms. The patient should be asked at this point to demonstrate the move ment(s) which provokes the symptom(s). A good example of this could be that a patient refers to a throw ing action. It is useful to hand the patient something

•

•

•

•

The physiotherapist should stand behind the patient to observe the quality and quantity of the shoulder movement. The patient should be asked to lift both arms forwards and above the head either to the onset of pain or to the limit of the available range (to P1 or limit). The spontaneous direction and rhythm of movement should be noted. The patient will spontaneously raise the arm through its most comfortable range to the maximum height it is possible to reach. The position of the scapula should be noted on the initiation of flexion and the scapulohumeral rhythm should be noted during the movement and its return. Note the degree of 'drift' laterally from the sagittal plane during flexion. Note the quality of the movement and how quickly or slowly it is performed. Record the extent of the range available and the symptom response during the movement.

Painless capsular restrictions (e.g. to 40° of flexion) will result in (1) hitching of the whole shoulder girdle, (2) rotation of the scapula laterally around the rib cage and (3) drift laterally from the sagittal plane of the humerus. A painful restriction (to 40° of flexion) on the other hand will result in glenohumeral movement only to 40° and have none of the features of reverse scapulo humeral rhythm. Alternatively, painful arcs of movement which commonly occur with acromiohumeral disorders may result in alteration in the timing of the scapulohumeral rhythm, both with flexion and the return movement.

297

MAITLA N D'S P E R I P H E RA L M A N I P U LAT I O N

298

This may well b e due t o pain inhibition o f the scapula stabilizer muscles, disuse atrophy of these muscles, neurological weakness or postural alignment faults causing imbalance in muscles and their action. When both pain and stiffness restrict the range of flexion (say to 40°) there will be an element of 'hitching', rotation and drift but less so than the painless restriction. The patient is asked to raise the arms forward and above the head again, this time with the therapist's hands resting on the lateral aspects of the patient's elbows to ensure flexion takes place in the sagittal plane. This will have the effect of correcting any lateral drift. The significance of the drift is measured by any change in range and symptom response when the drift is corrected. It may be possible to assess the influence that the cer vical spine is having on the shoulder pain by distracting the cervical spine while asking the patient to lift the arms forwards and above the head. If the range of shoulder flexion changes dramatically there may be a good case for examining the cervical spine in greater detail. Likewise 'squeeze' of the acromioclavicular joint (see Fig. 11.63) or compression of the acromiohumeral joint (see Fig. 11.61) during flexion may help the physiother apist to assess the degree of involvement of these com ponents, especially if the range and pain response are Significantly changed by such differentiating additions.

As with flexion, the acromioclavicular joint can be 'squeezed' or the acromiohumeral joint can be com pressed during the abduction movement or while the arm is in the painful arc position. Significant changes in the range of movement or the symptom response will indicate the degree of involvement of these components. If the shoulder and arm symptoms suggest that peripheral neurogenic mechanisms are present (burn ing lines of pain around the shoulder or 'string pulling' down the arm) and if addition of cervical contralateral side flexion and ipsilateral wrist extension consider ably changes the range and symptom response of shoulder abduction, a closer look at the peripheral neu rogenic structures and their interfaces is warranted.

Hand-behind-back •

•

•

The physiotherapist should stand behind the patient. The patient should be asked to put the hands behind the back as high as it is possible to reach, either to the point of onset of pain or to the available limit (to PI or limit). The physiotherapist should then endeavour to find out whether the patient's inability to reach a full range is due to limited or painful glenohumeral extension, adduction or medial rotation.

Shoulder abduction • •

•

•

The physiotherapist should stand behind the patient. The patient should be asked to raise both arms sideways and above the head, either to the point of onset of pain or to the limit of the available range (to P, or limit). Note should be taken of the spontaneous quality of the movement and any degree of 'drift' forwards of the frontal plane. The range available and the symptom response should be recorded.

As with flexion note should be taken of any reverse scapulohumeral rhythm, any disturbance of the stabil ity of the scapula on initiation of the movement and any alteration of the timing of movement relatively between the scapula and the humerus during abduction and the return movement (as in painful arcs of abduction). The patient is again asked to abduct the arms but this time the physiotherapist gently holds both arms back in the frontal (coronal) plane. This countering of horizontal flexion (horizontal adduction) will limit the patient's range of abduction if the drift is a protective mechanism. The assessment and recording of the change in. the range and symptom response will confirm the sig nificance of the drift.

Horizontal flexion (adduction) •

•

•

The physiotherapist should stand behind the patient. The patient should be asked to raise the arm and reach across to the opposite shoulder as far as possible, either to the point of onset of pain or to the available limit (to PI or limit). The extent of the range available, the symptom response and quality of the movement should be recorded.

The acromioclavicular joint can be 'squeezed' or the acromiohumeral joint compressed during the painful movement as with flexion and abduction. If pain is localized to the posterior area of the gleno humeral joint and the head of humerus seems to sub lux posteriorly during the movement, a posterior capsular instability may be suspected and investigated further.

Lateral rotation • •

The physiotherapist should stand behind the patient. The patient should be asked to keep the elbows into the sides and to bend the elbows to 90°.

The shoulder and shoulder girdle complex

•

The patient should then be asked to take the hands away from the body, while at the same time keeping the elbows against the sides (this instruction should produce shoulder lateral rotation to the onset of pain or to the available limit).

If this movement is accompanied by apprehension and the appearance of the head of the humerus subluxing anteriorly, an anterior capsular instability should be suspected and investigated further.

Overpressure· It is not uncommon for a patient to perform the above movements of the shoulder with an apparent full, pain-free range. In such cases firm overpressure (Chapter 6) should be applied to these movements. If both abduction and flexion appear to be full range, overpressure should be added further towards the midline with the addition of medial then lateral rotation (Fig. 11.15).

Figu re 1 1 . 1 5

Flexion, abduction overpressure.

Overpressure should be added to the hand-behind back movement in the directions of extension, adduc tion and medial rotation (Fig. 11.16). Overpressure to horizontal flexion (adduction) and lateral rotation can be added by stabilizing the trunk and scapula and continuing the movement passively in the required direction (Fig. 11.17). If all these active tests are normal and pain free with overpressure the physiotherapist should then test, passively, the 'quadrant and locking position' with the patient in supine lying. Only if these tests are negative can the physiotherapist say that the glenohumeral joint movements are ideal and that other structures, mechanisms or dimensions should be considered as a source of the shoulder pain.

Isometric testing of the rotator cuff muscle, differentiation and palpation Isometric testing of the rotator cuff muscles can be per formed in standing or, more finely, in supine lying.

Figure 1 1 . 1 6

Hand-behind-back overpressure.

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Figure 1 1 . 1 7 Overpressure i n : (al horizontal adductio n ; (b) lateral rotation.

Testing should commence b y asking the patient to 'meet my resistance' so that the contraction is gradually built up without any movement taking place (Fig. 11.18). Isometric testing, however, should be put in context of other tests as the contraction may be painful, not because of an impaired muscle but because a painful joint or a mechanosensitive nerve is being compressed. The muscle may also appear to be weak (Oxford scale 0-4), not because it is injured or neurologically impaired but because it is being inhibited by painful joint structures. •

Test supraspinatus by resisting the initiation of shoulder abduction (place a hand on the lateral aspect of the lower humerus). Alternatively, test supraspinatus by placing the straight arm into 90° of elevation in the scapular plane and 45° of lateral rotation then isometrically resist further elevation in the scapular plane.

•

Test subscapularis by resisting shoulder medial rota tion (elbow at 90° and into the side; place a hand against the inner aspect of the forearm). Alternatively, test subscapularis by placing the arm into the hand behind-back position with the wrist over L5 then isometrically resist medial rotation.

•

Test infraspinatus and teres minor by resisting shoul der lateral rotation (start as above and place a hand against the outside of the forearm). Alternatively, place the arm into 45° of medial rotation by taking the arm across the body then isometrically resist lat eral rotation.

•

Test biceps by resisting elbow flexion and supin ation (start as above and place a hand on the upper surface of the forearm). Alternatively, isometrically resist glenohumeral flexion in elbow extension and supination.

The shou lder and shou lder girdle complex

Figure 1 1 . 1 8 Isometric testi ng: (a) abduction (supraspinatus) ; (b) lateral rotation (infraspinatus, teres m inor); (c) medial rotation (subscapularis) ; (d) elbow flexion, forearm supination (biceps).

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M AITLAN D ' S P E R I P H ERAL M A N I P U LATI O N

.. Isometric abduction force .. AH distraction force

Figure 1 1 . 1 9

Isometric abduction (supraspinatus) with acromiohumeral distraction.

If pain is provoked in any of these tests the addition of distraction of the acromiohumeral space will implicate the subacromial bursa and other inert subacromial structures if the patient's pain is significantly reduced with the distraction while the isometric contraction is maintained (Fig. 11.19). Figure 11.20 shows the position of the arm required to palpate the relevant points of insertion of the rotator cuff muscles. It should be noted that palpation of the tendon insertion should produce a consistent response and be accompanied by other signs of impairment such as swelling and thickening. If all the tendon insertions are sensitive, together with other sites, it may be that the tissues are exhibiting secondary hyperalgesia, a response provoked by impaired structures adjacent to the shoulder such as the cervicothoracic spine.

EXAMINAT I ON AND TREATMENT TECHN I QUES GLENOHUMERAL JOINT • • • • • •

Locking position (Figs 1 1 .2 1 - 1 1 .24) •

If necessary tests for the shoulder •

The subjective assessment may indicate that other types of movement may need to be examined in order to reveal the provocative activities causing the patient's symptoms. These may include asking the patient to show: 1. the injuring movement 2. shoulder movements performed at speed 3. shoulder movements performed repeatedly 4. sustained shoulder movements.

Locking position and quadrant Locking position Quadrant roll-over Quadrant - gentle movement Quadrant - moving down the 'low side' Quadrant moving down the 'high side'.

•

•

Direction: The locking position is in the shape of a cave related to the 'mound' of the quadrant produced by the line traversed by the point of the elbow. Symbol: Lock. Patient starting position: Supine towards the edge of the plinth on which the lock is to be performed (in this case on the right shouJder). Therapist starting position: Standing by the patient's right side facing the patient's head and lean towards the patient in order to stabilize the trunk.

Localization of forces (position of therapist's hands)

In this way the patient's symptoms may be reproduced when routine active functional testing is negative.

•

Brief appraisal of other structures in the plan

•

Elbow flexion, extension, pronation and supination can be appraised actively at this point.

•

The distal third of the nearside right forearm is placed under the medial border of the patient's scapula. The right thumb lies immediately adjacent to the vertebral column. Flex fingers over the trapezius to stop the shoulder from shrugging.

The shoulder a nd shou lder g ird le complex

303

] (a)

(b)

\

...._.....'

(c)

Infraspinatus ---'or

(d)

Subscapularis tendon

Figure 1 1.20

Palpation of rotator cuff tendons. Reproduced from Kesson, M. 8: Atkins, E. 1 998. Orthopaedic Medicine - A Practical

Approach, by kind permission from Butterworth-Heinemann, Oxford, pp. 1 1 9- 1 20 (Figs 5.6-5.8).

•

Left hand holds patient's flexed elbow and maintains slight medial rotation and extension of the patient's shoulder during the movement of abduction.

Application of forces by therapist (method) •

Abduct the patient's arm from alongside the trunk and endeavour to reach a position of full flexion.

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M A I T L A N D ' S P E R I P H E R A L M A N I P U LATI O N

•

position where it becomes 'locked'. The humerus cannot be moved further towards the patient's head, neither can it be laterally rotated nor moved anterior from the frontal plane. Feel for any resistance or spasm within the fioor, wall and roof of the 'cave' corresponding to the lock position. Note any accompanying pain response and compare with the non-symptomatic side to appreciate minor yet important differences.

Variations in the application of forces •

Fig u re 1 1 .2 1

Glenohumeral joi nt: locking position. Patient lying supine Anterior

Peak

L" { - - - - �' ;;' Mound �

Elbow's

path

_

/ Mound

_ • • • •

Cave

Superior

Uses Median frontal plane

•

Inferior Posterior

Fig u re 1 1 .22 Side-on view of the path of the right elbow as seen from the patient's right side looking horizontal ly towards the patient's left side. The path traverses a l i ne: (a) i nto the 'cave' of the locking position ; (b) over the 'mound' of the quadra nt, (c) passing the 'peak' of the quadrant.

- - -

{

Median frontal plane

Posterior

•

In exan1ination and treahnent when shoulder movement is minimally painful. The cave is painful and stiff. In such cases a scooping grade IV-, IV technique can be a valuable treatment to 'clear out' the cave. An oscillatory abduction, scooping or semicircular movement of the elbow can be used. The dome of the semicircle faces supe riorly and the movement is performed as if to scoop out the position where the humerus should become locked. Such a semicircular movement is depicted with a double headed arrow (Fig. 11.24). In cases of clinical group 4, momentary shoulder pain. The later stages of recovery from an impingement disorder.

Evidence

Figure 1 1 .23 Side-on view of the path of a patient's elbow when movements are restricted and the 'locking position' lost. •

• •

Patient lyi n g supine Anterior

The locking position may need to be adapted if symptoms are reproduced whicl1 correspond to mechanosensitivity of the ulnar nerve. Symptoms along the ulnar nerve distribution are not uncom mon with this test. To confirm the degree of ulnar nerve mechanosensitivity, relevant neurodynamic tests (ULNPT 3) (Butler 2000) may need to be examined.

Maintain the patient's upper arm in a frontal plane just posterior to the median. If the horizontal extension is more than 3-4° the locking position will not be fotmd. As the abduction movement is continued in the correct frontal plane the humerus will reach a

Evidence is available regarding the structures under stress during the lock (Mullen et al 1989), These are: •

the posterior-superior tip of the glenOid fossa in contact with the lateral quarter of the humeral head and the tip of the greater tuberosity (supraspinatus)

Figure 1 1 .24

Glenohumeral joint: locking position scouring.

The shoulder and shou lder g i rdle complex

•

•

•

the anteromedial part of the inferior surface of the acromion in contact with the humerus the coracoacromial ligament is stretched and the supraspinatus and infraspinatus are impinged on the acromial arch the tendon of the long head of the biceps is impinged between the acromial arch and the humerus.

Quadrant (Figs 1 1 .25- 1 1 .30) •

• •

•

Direction: The quadrant is that position, approxi mately 30° lateral to the fully flexed shoulder pos ition, where the patient's upper arm has to move anteriorly from the locking position. The arc of the quadrant is the shape of a small 'mound'. The 'peak' of the quadrant is the highest point of the 'mound' which also has a 'low 'side and a 'high' side. Symbol: Q. Patient starting position: Supine, lying towards the edge of the plinth on which the quadrant is to be performed (in this case the right shoulder). Therapist starting position: Standing by the patient's right side facing the patient's head and leaning towards the patient in order to stabilize the trunk.

High side of quadrant (cephalad) +

Towards head Fi gu re 1 1 .25

Figure 1 1 .2 7

Quadra nt high side.

Fi gu re 1 1 .28

Quadrant peak.

Low side of quadrant - (caudad) �

Away from head

Glenohumeral joint: quadrant position.

Patient lying supine Anterior

\ t I

�

-------

Superior

�-� -----Inferior

Posterior

Fi g ure 1 1 .26

Fig ure 1 1 .29

Quadrant low side.

Small a mplitude movements at right angles to the surface of the 'mound' of the quadrant.

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M A ITLA N D'S P E R I P H E RA L M A N I PU LAT I O N

306

•

•

•

•

Patient supine: test ing by anteroposterior overpressure on the elbow in positions between flexion and the quadrant. Figure 1 1 .30

Variations in the application of forces • •

Localization of forces (position of therapist's hands) •

•

•

•

The distal third of the nearside (right) forearm is placed under the medial border of the patient's scapula. The right thumb lies immediately adjacent to the vertebral column. The fingers are flexed lightly over the patient's trapezius to prevent too much shrugging of the shoulder. The left hand holds the patient's flexed elbow while maintaining slight medial rotation and extension of the shoulder.

•

•

To reach a fully flexed position from the 'lock', the pressure maintaining medial rotation and extension during abduction should be relaxed slightly to allow the arm to be moved anteriorly from the frontal plane (which was posterior to the frontal plane for the locking position). Lateral rotation can then take place as the abduction movement is continued. This anterior and rotary movement takes place in a small arc of the abduction movement. This arc encompasses the 'peak' of the quadrant position.

Roll over the quadrant. Gentle movements around the quadrant (moving down the 'low' side, moving down the 'high' side).

Uses •

•

• •

Application of forces by therapist (method) •

Once past the 'peak', the arm can then drop back behind the median frontal plane again and the abduction movement can be continued until the upper arm reaches the side of the patient's head. To examine the quadrant the therapist first of all finds the peak of the quadrant and in this position applies a reasonable degree of pressure, pushing the patient's elbow towards the floor. The range should be observed and recorded in two ways: (1) the range of movement in the sagittal plane between the humerus and the anterolateral surface of the scapula, and (2) the extent of the prominence of the head of the humerus in the axilla. While the patient's arm is oscillated anteriorly and posteriorly in the quadrant position as a grade IV or IV + the therapist should take note of the site and degree of pain or discomfort produced. The range should then be compared with that present on the non-symptomatic side. As the quadrant position is usually uncomfortable anyway, it is mandatory to compare both sides.

In both examination and treatment for minor limitations of shoulder movement. In examination as an excluding test to rule out the shoulder as a source of arm symptoms. Clinical groups 2, 3a and 4 (Chapter 8). If symptoms of a neurogenic nature, such as pins and needles in the hand, are produced during examination of the quadrant, it may be necessary to adapt the ULNPT 1 and perform it in the quadrant position. This will enable the exploration of neural mechanosensitivity in this position.

Evidence Magarey (1993) included the lock and quadrant as tests to help validate manual examination of the shoul der when compared with arthroscopic diagnosis. Mullen et al (1989) identified the following struc tures as being compromised during the examination of the quadrant on cadavers: 1.

Contact between the humerus and the scapula, compression of the tendon of the long head of the biceps at 120-135° of abduction; the anteromedial

The shoulder and shoulder girdle complex

2.

3. 4. 5.

part of the inferior surface of the acromion is always in contact with the humerus. The posterosuperior tip of the glenoid cavity contacts the humerus at 105-120° and 135° of abduction. The coracoacromial ligament is stretched at 105-135° of abduction. The greater tuberosity (supraspinatus) is always impinged on the coracoacromial arch. The coracoid process and the subscapularis area of the lesser tuberosity impinge at 120-135° of abduction;

Variations in the application of forces - roll over the quadrant •

•

•

•

•

•

•

The patient's arm is held very firmly against the 'peak' of the quadrant with the glenohumeral joint slightly medially rotated, i.e. the patient's hand is slightly higher (closer to the ceiling) than the elbow. If the arm is positioned exactly on the peak of the 'mound' the correct rotation position can be maintained accurately and easily with an anteroposterior pressure against the medial epicondyle of the elbow alone. There will be no tendency at all for the shaft of the humerus (and therefore the forearm) to roll into a position of medial or lateral rotation. If the correct peak position is being achieved, as above, 1-2° of glenohumeral adduction will result in medial rotation occurring immediately. The opposite is also true. If the humerus is abducted from the peak of the mOlmd, the humerus will immediately rotate laterally allowing the patient's hand to lower towards the floor. The therapist, therefore, can 'roll' over tl1e mound of the quadrant from one side of the peak to the other by abducting and adducting and again abducting the glenohumeral joint. To perform this technique particularly strongly, the back and forth arc of movement occupies a maximum of 6-7° while the rotary range occupies 80-90° starting from a slightly medial rotated position on the 'low' side (adducted side) of the quadrant and finishing in an almost fully laterally rotated position on the 'high' side (the abducted side) of the quadrant. Such a technique is difficult but needs to be performed well so that some patients with minor, stubborn shoulder symptoms can be freed of their pain or discomfort. A vigorous 'roll-over' is even more difficult to perform effectively. It is a painful procedure and requires firm control of the resistance in both the

•

abduction and the adduction components and the . rotary component. To tighten the rotation component of the humeral shaft rotation during the roll-over at the peak, abduction and adduction are held back. During the hold back the rotation is overpressed and the rotation made to occur before the positioning of the humerus beyond the peak on the side of the mOlmd has been allowed to take place.

Variations in the application of forces - gentle movements around the quadrant •

•

•

Figure 11 .29 represents the oScillatory movements of this technique diagrammatically. The movement should be small in amplitude, slow, smooth in execution and at all times directed at right angles to the surface of the mound of the quadrant. The therapist should have the skill to be able to change the position of the oscillatory movement from one position of the mound to another position. It is well-known that during active abduction of the arm, a lateral rotation of the shaft of the humerus has to take place at approximately 90° of the abduction if it is to be taken beyond that point. In a related way, to change from one position to another on the mound of the quadrant, the humerus has to be lifted far enough away from the mound in the same line as the oscillatory treatment movement was being performed for the rotary movement of the shaft of the humerus to be loose, uninhibited and painless. This usually requires a movement away from the mound of approximately 30°.

Moving down the 'low' side (the adducting side or i nferior side) of the 'mound' of the 'peak' • Having lifted the humerus the required 30° away from the mound, the shaft of the humerus is rotated medially around a stationary and stable axis (the axis being the line of the shaft of the humerus). • The amount of rotation performed depends on how far the new position for the oscillatory treatment movement is going to be from the last position. The greater the distance apart of the positions, the greater is the required degree of medial rotation. • Having lifted away and having medially rotated the required amount, the shaft of the humerus is low ered towards the floor (Fig. 11 .26). •

Then gently, slowly and smoothly move towards the mound at right angles to its surface at this new position. When the appropriate pain response is felt and resistance is located, an oscillatory movement is performed in this position as a treatment technique.

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[

Summary - maving dawn the 'Iow' side • • • •

Lift away from the mound 30°. Medially rotate the humerus the required amount. Lower the shaft of the humerus towards the floor. Move towards the mound at right angles to its surface.

Moving down the 'high' side (the abducting side, flexing side or superior side) of the 'mound' from the 'peak' (Figs 1 1 .22, 1 1 . 27) • Lift the humerus the required 30° away from the mound. • Allow the shaft of the humerus to rotate laterally around a stationary and stable axis (the axis being the line of the shaft of the humerus). • The amount of rotation is dependent on how far away the new oscillatory treatment movement position is going to be from the previous position. On the high side of the mound of the quadrant the rate of change of lateral rotation is greater than that of the medial rotation on the low side. • The shaft of the humerus is stabilized in relation to its lateral rotation while the humerus is allowed to slowly lower towards the floor. • An adduction movement at right angles to the line of the forearm is directed towards the high side of the mound of the quadrant. Summary - moving down the 'high ' side • •

•

•

Lift away from the mound 30°. Allow the humerus to laterally rotate the required amount. Lower the shaft of the humerus towards the floor. Move towards the mound at right angles to its surface.

•

•

The position of flexion where the main limitation of range or degree of pain is felt is usually utilized in treatment. When the glenohumeral joint has obvious limitation of active range, the quadrant and locking position will not be required as part of treatment. In such cases flexion may well be required in treatment instead, depending on the degree of pain and limitation.

Flexion and quadrant (Figs 1 1 .3 1 , 1 1 .32) • • •

•

Direction: Glenohumeral flexion and quadrant. Symbol: F/Q. Patient starting position: Supine, lying with the arm in an appropriate degree of flexion (for the right arm). Therapist starting position (grade II): Standing at the head of the couch beyond the patient's shoulder, facing the patient's feet.

Localization of forces (position of therapist's hands) •

•

The left hand holds the patient's wrist and hand to prevent it flapping around during treatment; the right hand holds the patient's elbow. The fingers of the right hand spread over the medial aspect of the patient's elbow joint, reaching to the upper arm.

Flexion • •

Direction: Glenohumeral flexion. Patient starting position, therapist starting position, localization offorces, applications offorces: All these components of the examination and treatment technique for glenohumeral flexion are the same as those described for the quadrant position.

Variations in the application of forces •

•

The patient's arm can be flexed from the arm-by-side position through the flexion range to the position in range where pain, resistance or spasm limits the movement. The patient's forearm should be horizontal with the hand facing across the body.

Figure 1 1 .3 1

Glenohumeral flexion a n d q uadrant grade I I .

The shoulder and shoulder girdle complex

•

•

•

•

•

•

•

The thumb of the right hand cups around the patient's forearm just distal to the elbow. The right knee is placed on the couch beyond the patient's shoulder. The right thigh is positioned as a stop for the patient's upper arm to prevent the movement going beyond an established range of flexion. The right inner thigh makes contact along the length of the patient's upper arm. A pillow or blanket should not be used to form the stop as small variations in the range of flexion cannot be controlled properly. The further laterally away from the patient's head the flexion movement is directed, the further away from the patient's head the therapist needs to stand. The therapist's balance is maintained between the standing leg and the lower leg on the couch. The thigh forming the stop can be lowered as the pain recedes and the patient's arm can be moved further into range.

The right knee can also be withdrawn at this stage to prevent unnecessary pressure being exerted against the upper end of the humerus. Failure to withdraw the knee adequately will have the effect of producing excessive anterior movement of the head of the humerus. However, there may be times (e.g. when the glenohumeral joint is very stiff) when the anterior movement needs to be incorporated with the flexion movement. In such instances stretching the head of the humerus longitudinally or anteriorly may help to improve the flexion range further. Furthermore, this effect may be desirable when the addition of the anter ior movement to the flexion reproduces pain when flexion alone does not.

Application of forces by therapist (method): grade /I •

•

•

•

Raise and lower the patient's arm in a straight line through a range of approximately 30°. The patient's arm should not be allowed to swing through a lateral or medial arc, i.e. the patient's wrist should traverse the same amplitude as the elbow, thus avoiding humeral rotation. If flexion is directed towards the quadrant, the movement must be in a line from the opposite hip to the quadrant. The nearer the flexion is directed to the patient's head the more the starting position of the line of direction should be from the patient's hip on the same side. In such cases it may be better for the therapist to use the other leg (left) to form a stop (Fig. 11.31).

•

The stop should be positioned short of resistance, short of pain or into a 'small degree of discomfort in order for the movement to be a grade II.

Variations in the application of forces Grade II •

•

The direction of the quadrant part of the movement can be towards the peak, the high side or the low side of the mound, or even towards the locking position. Very large amplitude movement, when indicated, may need to be started with the patient's arm touching the chest and then taken through and beyond what would be the horizontal plane if the patient were standing. If pain and discomfort are felt at the 90° horizontal (painful arc), a gentle lift of the patient's arm using the little finger and thumb around the epicondyles will avoid or reduce any pain or discomfort as the movement passes the horizontal position.

G rade III •

•

•

•

•

Patients with stiff shoulders may b e treated with the same technique as for a grade II except that the thigh providing the stop is positioned beyond the onset of resistance in order for the technique to become a grade III. When minimal limitation is present, the therapist can stand in the same position but use the treat ment couch as the stop. When grade III + is to be used the therapist should stand to the left of the patient when treating the right shoulder and grasp the patient's right forearm just distal to the wrist (Fig. 11.32a). The arm is then oscillated in the chosen direction through an arc of approximately 30° with the length of the patient's upper arm contacting the couch as the stop. If a greater range of flexion is possible (as in hypermobile joints), the therapist can place the left hand under the patient's right scapula to raise the shoulder while controlling the movement with the right hand holding the patient's right forearm just above the wrist (Fig. 11.32b). The incorporation of medial or lateral rotation can be used, as indicated by assessment and examination, to assist in the improvement of a stiff range or to reproduce pain. This is achieved by varying the relative paths of the patient's forearm and the elbow during the arc of the flexion/ quadrant movement.

G rade IV •

Adopt the same starting position as that described for examination of the quadrant (Fig. 11.25).

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M A ITLAN D'S PER I PH ERAL M A N I P U LATI O N

310

Uses •

•

•

Primarily a treatment technique rather than an examination technique (clinical groups 2, 3a, 3b). Neither flexion nor quadrant is used as a grade I movement but are more valuable as through-range or end-of-range grade II, ill or IV movements, directed towards the painful position or limitation. Valuable as a grade II + or ill- technique to ease off treatment soreness after vigorous treatment into flexion or the quadrant/ locking position.

Abduction (Figs 1 1 .33, 1 1 .34) • • •

Direction: Glenohumeral abduction. Symbol: Ab. Patient starting position: Supine, lying in the middle of the couch.

•

Therapist starting position (for right shoulder): Standing by the patient's right shoulder facing the patient's feet.

Localization of forces (position of therapist's hands) •

• • •

•

•

Figure 1 1 .32 •

•

Glenohumeral flexion and quadrant g rade I I I .

The treatment movement into flexion and the peak, low side or high side of the quadrant should be performed as an oscillatory movement of 5° or less (Fig. 11.25) rather than a sustained stretching. However, at times, the movement is so small and so slow that it resembles a sustained stretch, partic ularly when muscle spasm restricts range. To add in rotation medially or laterally as indicated through examination, the shaft of the humerus can be rotated at the moment when full flexion is reached. In this case the patient's wrist will not traverse the same amplitude as the elbow.

The web of the left thumb and index finger cup over the patient's shoulder medial to the acromion process. The fingers are extended over the scapula. The thumb extends forward over the clavicle. Alternatively, the heel of the hand extends over the acromioclavicular area. The right hand reaches round the patient's forearm to grasp the elbow from the medial side so that the patient's right forearm is supported by the therapist's forearm (variation 1) (Fig. 11.33a). Alternatively, the right hand holds the patient's right forearm by grasping it proximal to the wrist. The index finger extends along the anterior surface of the patient's forearm and the fingers and thumb hold the medial and lateral borders of the patient's forearm respectively (variation 2) (Fig. 11.33b). A tight grasp with the right hand is required with this variation which may hinder relaxation.

Application of forces by therapist (method) Grade I I • The therapist stabilizes the patient's shoulder with the left hand while abducting the patient's arm to the chosen degree of abduction with the right hand, forearm and body. The therapist's thigh in contact with the lateral side of the patient's elbow provides the stop for the movement, this being short of resistance for a grade II. • The movement from adduction to the therapist's thigh pOSitioned to stop abduction is oscillated

- ------

The shoulder and shou lder gird l e com plex

Figu re 1 1 .34 •

•

Glenohu meral abduction grade IV.

This pressure should be constant rather than being increased in such a way as to provide as an equal and opposite counterpressure at the limit of the abduction. Variation ( 1) of the right hand/ arm grasp should be used for this grade of treatment technique.

G rade IV •

•

• •

Figure 1 1 .33

Glenohumeral abduction grade I I . •

through a n amplitude o f 20° o r more depending on the patient's symptoms and signs. Variation (1) or (2) of the localization of forces with the right hand should be used depending on which helps the patient to relax the most. This should occur while the therapist is maintaining a constant stabilizing pressure with the left hand against the acromion.

Grade III •

The therapist should hold more firmly with the left hand to stabilize the shoulder girdle when the abduction is taken into resistance or up to the limit of the range.

•

When firm pressure is required the therapist changes position to stand beyond the patient's elbow, facing the shoulder (Fig. 11.34). A straight line from the patient's shoulder to the centre of the therapist's pelvis should pass slightly lateral to the shaft of the humerus when it is abducted to the desired position. The therapist crouches over the patient's arm. The therapist's left hand is then placed over the acromion process and the right hand is placed under the patient's elbow. The therapist's forearms should be positioned in a coronal plane pointing in opposite directions. The therapist's right arm and body produce small amplitude oscillations (2°) while the left hand maintains constant pressure on the acromion process. The patient's shoulder girdle is allowed to ride up a little to encourage relaxation. Alternatively, the therapist's left hand is placed and pressure applied over the head of the humerus immediately adjacent to the lateral border of the acromion process. This will encourage downward movement of the head of the humerus in the glenoid cavity during abduction of the patient's arm. The right hand is placed under the patient's elbow. This is glenohumeral abduction combined with longitudinal movement caudad.

31 1

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MAITLA N D'S P E R I PH E RA L M A N I P U LATI O N

Uses •

•

•

•

When other mobilization techniques produce only slow progress. Fractures of the neck of the humerus when abduction is very stiff, likewise with adhesive capsulitis. With compression for intra-articular glenohumeral! acromiohumeral disorders, clinical groups 2 and 3. As a gentle neurodynamic mobilization to reduce the mechanosensitivity of the neural structures.

Abduction with compression •

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Direction: Glenohumeral abduction with compression. Symbol: Ab / >---< Patient starting position: Supine, adjacent to the right-hand side of the plinth (for right shoulder). Therapist starting position: Standing, facing across the patient.

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Uses •

Localization of forces (position of therapist's hands) • •

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0-50° - the right hand grasps the patient's elbow. The right groin supports both the patient's elbow and the therapist's right hand. The cupped palm of left hand applies pressure by being placed against the head of the humerus. The fingers of left hand point medially over the patient's acromioclavicular area (see Fig. 8.60a). 50°+ - the therapist's groin applies pressure through the patient's elbow along the shaft of the humerus as well as the therapist's left hand applying pressure medially through the head of the humerus. This will create a force vector to produce glenohumeral compression beyond 50° of abduction (see Fig. 8.60b).

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0-50° - the therapist applies pressure against the head of the humerus with the left hand to compress the glenohumeral joint surfaces together. This pressure should be maintained during the abduction movement which is produced by a pivoting action of the therapist's pelvis on fixed feet. The supported position of the patient's elbow enables the therapist to make the pivot action simultaneously with the therapist's right hand and pelvis and the patient's elbow.

In examination to help differentiate disorders originating from the intra-articular structures of the glenohumeral joint or symptoms originating from compression of acromiohumeral structures. To reproduce pain occurring during glenohumeral compression - for example a patient who com plains of a deep aching within the shoulder joint while lying on it at night. As a treatment technique for osteoarthritis of the glenohumeral joint causing minor discomfort with compression (Chapter 8) - clinical group 3. To reproduce and treat momentary shoulder pain which occurs during loaded activities - clinical group 4.

Lateral rotation (Figs 1 1 .35, 1 1 .36) • •

Application o f forces by therapist (method)

Small or large amplitude movements can be performed in any part of the 0-50° abduction range. 50°+ - as the therapist performs the pelvic pivot action to produce shoulder abduction, pressure should be applied along the shaft of the patient's humerus via the therapist's right groin in conjunction with equal pressure through the therapist's left hand against the head of the humerus. These two directions of pressure are vectors which combine to compress the articular surfaces of the head of the humerus into the glenoid cavity. Small or large amplitude movements can be used. This technique should be performed slowly if control of compression during the movement is to be maintained.

•

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Direction: Glenohumeral lateral rotation. Symbol: C Patient starting position (grade II and ill): Supine, lying to the left of the couch with the (right) arm abducted. Therapist starting position: Standing by the patient's abducted arm facing the patient's feet.

Localization of forces (position of therapist's hands) •

The left hand is cupped laterally around the patient's upper arm near the elbo�; the fingers of the left hand support posteriorly; the thumb is placed anteriorly.

The shoulder and shou lder girdle complex

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•

The fingers of the right hand spread across the patient's wrist and distal forearm anteriorly. The right thumb grasps the back of the patient's wrist.

Application of forces by therapist (method) •

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Fi gu re 1 1 .35

Glenohumeral lateral rotation grades I and I I.

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The oscillatory movement is produced by a to-and-fro movement of the therapist's right hand through approximately 30° around the circle of an arc, the centre of which is the elbow. Movement is taken to the stop provided by the therapist's left forearm. The patient's wrist should be relaxed during the movement to assist relaxation of the patient's shoulder. The therapist's cup-like grasp round the upper arm should be loose, permitting free rotary movement while at the same time providing a stable pivot point.

Variations in the application of forces The rotary movement can be performed with the humerus in adduction by the patient's side, in abduc tion or in any position between these two limits as dic tated by the most painful or limited position. Variations using grade III + , IV- are as follows. Therapist starting position • Standing beyond the patient's right shoulder facing the patient's feet. The patient's arm is abducted so that the point of the elbow overhangs the couch. Localization of forces (position of therapist's hands) •

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Figu re 1 1 .36

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G lenohumeral lateral rotation grades III a n d IV.

The left forearm is positioned as a stop to prevent the patient's right forearm going further into lateral rotation than is required. The right hand grasps the patient's slightly pronated wrist.

•

The left hand supports the patient's abducted arm by placing the fingers and thumb around the anterior and lateral surfaces of the humerus near to the elbow. The right thigh forms the stop at the limit of the range. The right hand grasps the patient's right wrist with the therapist's index finger and middle finger spreading proximally over the patient's pronated wrist anteriorly. The right thumb grasps through the patient's first interosseous space. The remaining fingers of the right hand spread around the ulnar border of the patient's hand to reach its dorsum.

Application of forces by therapist (method) •

The therapist stabilizes around the lower end of the patient's upper arm to form the pivot for rotation.

J1 J

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MAITLAND'S PER I PH ERAL M A N I PU LAT I O N

•

•

The rotation i s produced through a stable grasp of the patient's wrist pivoting around the therapist's grasp of the upper arm. This assists in relaxation and the stop reassures the patient that movement will not be taken beyond the comfortable limit.

Uses •

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Because lateral rotation is not the most effective technique for shoulder pain it is rarely used as a grade I or 11-. Grade II is occasionally used; grades 11+ and ill are most frequently used. As part of a neurodynamic mobilization technique for median, radial and ulnar nerve entrapment around the shoulder. Very strong pressure should be used with great care because of its leverage and torsional stress on the humerus and glenohumeral capsule. Useful as a grade II + and ill with medial rotation to help glenohumeral osteoarthritic joint surface pain. Used with many other techniques to mobilize an adhesed glenohumeral joint capsule. Used to ease acromiohumeral pain after injury (often worth distraction of the subacromial space). In conjunction with medial rotation to treat pain-dominant disorders of the shoulder as an oscillatory medial-to-Iateral rotation of 15-30° (grade II) in a neutral mid pain-free position of the shoulder. A component of neurodynamic mobilization techniques (either direct mobilization of neural structures or mobilization of the interface to the neural structtues). If apprehension to movement or subluxation of the head of the humerus anteriorly is excessive and there is an 'empty' end-feel to the lateral rotation, an anterior glenohumeral instability may be suspected.

Medial rotation (Figs 1 1 .37, 1 1 .38) • •

Direction: Glenohumeral medial rotation. SymboL: :J

Grades I and /I •

Patient starting position: Supine, to the left of the

•

Therapist starting position: Standing by the patient's

couch (for right arm), arm in abduction. right hip facing the patient's head.

Figure 1 1 .3 7

Glenohumeral medial rotation grades I a n d I I .

Figure 1 1 .38

Glenohumeral medial rotation grades III and IV.

Local ization of forces (position of therapist's hands) •

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The fingers of the right hand support under the distal end of the patient's humerus. The right thumb cups anteriorly. The left hand grasps over the back of the patient's hand. The fingers of the left hand spread across the patient's wrist. The thumb of the left hand grasps anteriorly. The anterior surface of the right forearm is contacted by the anterior surface of the patient's forearm to prevent medial rotation exceeding an established range. The therapist's forearm therefore can be positioned accordingly.

The shou lder and shoulder g i rdle complex

31 5

] •

The right thigh can be used as an alternative stop to the movement by standing lateral to the patient's arm and positioning the right thigh accordingly.

Appl ication of forces by therapist (method) • The oscillation is produced by the therapist's relaxed grasp of the patient's hand. • The therapist's wrist extends slightly as the patient's forearm is moved in order to reach the stop provided by the therapist's forearm or thigh. • The therapist's grasp of the patient's upper arm should not be tight but allow freedom of movement. • If the shoulder girdle is not prevented from lifting it provides a visual amount of glenohumeral rotation and permits the patient a certain freedom of movement if indeed the movement is painful.

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Uses •

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Grades III and IV •

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Patient starting position: Supine so that the elbow of the abducted arm is beyond the edge of the couch. Therapist starting position: Standing away from the right side of the patient's head facing the patient's feet, crouch over the patient and abduct the arm to the chosen degree.

Local ization of forces (position of therapist's hands) • The fingers of the left hand support under the patient's elbow from the medial side. • The left thumb cups over the patient's biceps tendon anteriorly. • The left forearm is placed in front of and just medial to the patient's shoulder. • The right hand holds the patient's pronated wrist grasping round its ulnar border. • The right fingers cover the anterior surface of the patient's wrist and adjacent palm. • The right thumb and thenar eminence point caudally, holding over the posterior surface of the patient's wrist. Application of forces by therapist (method) • Small amplitude rotary oscillations of approxi mately 10° are performed by the therapist's right hand in contact with the patient's right wrist at the point in the range which makes the patient's shoulder girdle lift. • The therapist limits the lifting of the patient's right shoulder with the left forearm which moves with

the patient's shoulder and provides only enough counterpressure to prevent it lifting too far. The therapist's left hand prevents the patient's arm drifting into adduction.

•

Oscillatory movement through an arc of approximately 25° from medial to lateral rotation is a valuable technique for treating pain as in clinical group 1 (Chapter 8). Useful in movements ranging from grade I and II with the arm by the side to grade III and IV with the arm in abduction. Useful as one of many techniques to mobilize frozen shoulders but not to be used overenthusiastically as this can increase the potential for capsular instability. With the joint surfaces compressed together, medial rotation is valuable for treating minor symptoms present with compressive loading (Chapter 8). Useful as a grade I or II (with acromiohumeral distraction) to help create an ideal environment for healing after rotator cuff injury or subacromial surgery.

Hand-behind-back (Fig. 1 1 .39) •

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Direction: The hand-behind-back position, which is functionally very important, is dependent on glenohumeral medial rotation, extension and, to some extent, adduction. Symbol: HBB. Patient starting position: Prone, lying turned slightly towards the right with the right arm behind the back. Therapist starting position: Standing behind the patient level with the patient's shoulder.

Localization of forces (position of therapist's hands) For medial rotation The left hand supports the patient's elbow by reaching over and grasping posteriorly around the distal part of the patient's upper arm. • The right hand holds the patient's wrist. The fingers hold across the posterior surface of the patient's wrist and the thumb anterior.

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For extension The left hand stabilizes the posterior surface of the scapula in the region of the inferior angle.

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M A I T LA N D'S P E R I PH ERAL M A N I PU LATI O N

•

inferiorly and the fingers spread across the adjacent surface of the scapula. The right hand grasps around the patient's upper forearm. Again the right hand may need to grasp round the elbow to adduct the patient's arm.

Application of forces by therapist (method) •

For medial rotation, extension and adduction the small oscillatory movement of the glenohumeral joint is produced by the therapist's right hand moving the humerus.

Variations in the application of forces •

The same movements can also be produced by stabilizing the humerus and using the left hand to produce small oscillatory movements via the scapula: - for adduction the movement is produced by the left arm acting through the left thumb against the medial border of the scapula near the inferior angle - for extension the movement is produced by the left arm acting through the heel of the left hand which moves the inferior angle of the scapula in a posteroanterior direction - for medial rotation the movement is produced by the left arm acting through the heel of the left hand which moves the medial border of the scapula in a posteroanterior direction.

Uses •

Figure 1 1 .39 Hand-behind -back position: (a) medial rotation ; (b) extensio n ; (c) adduction.

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The right hand supports under the patient's distal forearm. The right hand may need to hold the lateral epicondyle of the patient's elbow to produce the extension without including any medial rotation.

For adduction The left hand stabilizes the scapula with the left thumb against the medial border of the scapula

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Usually used as a grade IV or IV + stretching technique in the functional position. Although medial rotation, extension and adduction can be used separately, they may also be used in combinations. The choice of combination will be dictated by the presenting signs found on examination or the progress achieved with the individual movements. The most painful or restricted direction is the one usually chosen. Can be useful also as a grade III or Ill-technique. Note: When stretching a shoulder in the hand behind-back position it is quite usual for flexion or abduction of the shoulder to then feel more restricted. This is usually transient and these ranges are restored quickly.

The shou lder and shoulder girdle complex

•

If HBB is painful there may be a need to test ULNPT 2b (radial nerve biased) to establish whether any neural mechanosensitivity is present.

Horizontal adduction (flexion) (Figs 1 1 .40, 1 1 .41 ) •

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Direction: Although the common description for this movement direction is horizontal flexion the shoulder is, in fact, adducted in the flexed position. Symbol: HAd or HF. Patient starting position: Supine, lying in the middle of the couch with the right shoulder and elbow flexed to 90° and midway between medial and lateral rotation. Therapist starting position: grades II and ill standing by the patient's left shoulder; grade IV standing by the patient's right shoulder facing across the patient's body.

Figure 1 1 .40

Horizontal adduction (flexion) grades II and I I I .

Figure 1 1 .41

Horizontal adduction (flexion) grade IV.

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Localization of forces (position of therapist's hands) Grades I I and III •

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The right hand holds the patient's wrist and adjacent forearm. The left arm reaches across the patient with the left hand grasping the lateral border of the patient's scapula. The left thenar eminence and thumb extend into the patient's right axilla overlying the anterior surface of the lateral border of the scapula. The fingers of the left hand extend around the lateral margin of the scapula on its posterior surface.

G rade IV •

Grade IV •

•

The heel of the left hand is placed under the medial border of the patient's right scapula at the level of the spine of the scapula. The right hand holds the patient's wrist and at the same time flexes the elbow to carry the patient's arm across the body into horizontal adduction.

Application of forces by therapist (method)

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Grades II and III •

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The horizontal adduction movement i s performed carefully by the therapist's right arm and hand while the therapist's left arm and hand stabilizes the scapula. The therapist's body is positioned appropriately as a stop to prevent the patient's right hand continuing its movement.

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To perform the horizontal adduction movement the therapist first leans across the patient. The therapist's right axillary wall is then positioned so that it has the patient's right elbow nestled in it. The patient's arm, held midway between medial and lateral rotation, is then horizontally adducted until protraction of the scapula is complete. The left hand position of the therapist is then checked to ensure correct localization of stabilization of the medial border of the scapula. Small amplitude movements are then performed by increasing and reducing the pressure against the patient's elbow and upper arm. Simultaneously, pressure is applied by the therapist's left hand against the vertebral border of the scapula. The horizontal adduction can then be produced by a twofold action: 1. Pressure along the line of the shaft of the humerus (horizontal adduction will occur

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M A ITLA N D ' S PER I PH ERAL M A N I PU LAT I O N

because the heel o f the therapist's left hand will hold the medial border of the scapula against the rib cage while the lateral border moves posteriorly). 2. Pressure against the patient's elbow in a line towards the opposite shoulder. In treatment these two directions can be used sepa rately or in conjunction with each other. The choice depends on which method produces the strongest hor izontal adduction and which method best reproduces the patient's symptoms.

Localization of forces (position of therapist's hands) •

• •

Application offorces by therapist (method) •

Uses •

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Not often used as a treatment technique on its own; usually incorporated in treatment when several directions of shoulder movement are limited. Acromioclavicular joint disorders; tightness of posterior capsular / rotator cuff structures. Resolving coracoacromial impingement disorders when other movements do not effect adequate progression.

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Direction: Glenohumeral extension with the shoulder in an abducted position. Symbol: HE. Patient starting position: Supine, lying with the right acromion process at the edge of the couch with the arm in abduction to a degree dependent on examination findings. Therapist starting position: Standing by the patient's right side facing the patient's head.

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Horizontal extension.

Not often used in treatment; usually as a grade rv. Acromioclavicular pain and stiffness. Stretching of the anterior shoulder structures either to regain lost range or to increase range beyond normal limits for a sporting or functional purpose (e.g. butterfly swimmers). Patients who cannot abduct their arm without bringing it forwards of the frontal plane.

Long itudinal movement caudad (Figs 1 1 .43 - 1 1 .48)

•

Figure 1 1 .42

The patient's elbow is moved towards the floor by the therapist's body and right arm so as to horizontally extend the glenohumeral joint. Pressure is applied in this direction as a small oscillatory movement. The amount of shoulder abduction depends on whether the desired effect of treatment is to reduce pain or to stretch the structures at their limit (Chapter 2).

Uses •

Horizontal extension (Fig. 1 1 .42)

The fingers of the left hand are placed under the patient's right acromion to feel the joint movement and to protect the patient against contact with the edge of the couch. The right hand cups the patient's right elbow. The side of the right thigh stabilizes the patient's right forearm, wrist and hand.

Direction: Longitudinal movement caudad of the glenohumeral joint in line with the patient's body, independent of the starting position of the patient's arm. Symbol: +-+-+ caud. Patient starting position: - For arm-by-side, in abduction, in 90°flexion and in full flexion: supine, lying in the middle of the couch or towards the edge of the couch on the side of the shoulder being examined and treated; the patient's shoulder can then be positioned in any physiological range depending on the desired effect of the technique. - For in abduction prone: prone, lying in the middle of the couch with the arm abducted to the appropriate degree and laterally rotated and resting on the couch; if the joint range is limited the patient may need to lie more onto the left

The shou lder and shou lder girdle complex

Figu re 1 1 .46 prone.

Longitudinal movement caudad: in abduction

Figure 1 1 .47

Longitudinal movement cauda d : in

Figure 1 1 .48

Longitudinal movement ca udad: in fu l l flexion.

Figure 1 1 .43 Longitudinal movement caudad: a rm-by-side (grade I, grasp around the a rm).

90'

flexion.

Figure 1 1 .44 Longitudinal movement ca udad : a rm-by-side (grade I, thumb pressure against the head of the h u merus).

Figu re 1 1 .45

Longitudinal movement cauda d : in abd uction.

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M A ITLA N D'S P E R I P H E RA L M A N I P U LATI O N

side s o that the shoulder will not b e i n an uncomfortable horizontally extended position. •

Therapist starting position: - For arm-by-side (grades I, II, III and Iv, grasp around the arm): kneeling alongside the patient's right elbow or standing alongside the patient's right elbow for stronger movements. - For in abduction, in 90° offlexion: standing by the patient's right shoulder facing across the patient's body. - For arm-by-side (grades I, II, III and IV using

thumb pressure against the head of the humerus), in full flexion, in abduction prone: standing by the patient's right side beyond the patient's head, facing the patient's feet, crouching over the patient's shoulder.

Localization of forces (position of therapist's hands) Arm-by-side (grade I, grasp around the arm) • The right hand holds the patient's wrist with the patient's elbow flexed. The right forearm gently hugs the patient's right • forearm into therapist's body. The fingers of the left hand are placed over the • patient's upper arm anteriorly with the lateral border of the proximal phalanx of the index finger against the anterior surface of the proximal end of the patient's forearm. The thumb of the left hand is placed against the • lateral surface of the patient's elbow. The patient's right upper arm is lifted fractionally • off the couch. Grades II, III and IV are performed with very • similar localization of forces with the variations of amplitude and depth in range being controlled by the therapist's application of forces.

In abduction The right hand abducts the patient's right arm and supports the elbow at right angles. • The fingers of the right hand support the distal end of the patient's upper arm medially and posteriorly. • The thumb of the right hand extends around the patient's elbow holding it against the therapist's side. • The right wrist rests against the anteromedial surface of the patient's forearm. • The heel of the left hand is placed against the head of the humerus immediately adjacent to the acromion process. • The fingers of the left hand spread over the patient's shoulder towards the neck. • The left forearm, directed caudally, lies in a coronal plane as the therapist crouches over the patient's arm for stronger movement.

•

I n abduction prone The pads of both thumbs are placed against the head of the humerus immediately adjacent to the acromion process. The fingers of the right hand spread over the • anterior deltoid area. • The fingers of the left hand spread over the scapula area. Both arms are directed caudally in line with the • longitudinal movement of the head of the humerus. Alternatively, use the cupped hand or the first • interosseous space of both hands adjacent to each other and the acromion process to produce the caudad movement. •

In 90· flexion The right arm supports the patient's right arm, flexed to 90°. • The right hand and forearm support the patient's right wrist and forearm respectively. . The therapist's side used to support the patient's • right upper arm. • The left hand is placed against the head of the humerus, just distal to the acromion process, with the patient's glenohumeral joint positioned midway between medial and lateral rotation. • The fingers of the left hand are directed distally and the thumb extends laterally around the patient's upper arm. •

Arm-by-side (grade I, thumb pressure against the head of the humerus) • The pads of both thumbs are placed against the head of the humerus immediately adjacent to the anterior and lateral borders of the acromion process. In this way the movement of the head of the humerus can be felt in relation to these acromial borders. The fingers of the left hand spread over the scapula • area. The fingers of the right hand spread laterally over • the deltoid area. Grades II, III and IV are performed with the same • localization of forces with the variations of amplitude and depth being controlled by the therapist's application of forces.

In ful l flexion The therapist's left side is used to hold the patient's fully flexed right arm.

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The shoulder and shoulder g i rdle complex

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Both hands together are placed behind the patient's deltoid. The posterior surface of the left index finger is placed against the anterior surface of the right index finger. The lateral surfaces of both index fingers are then placed against the head of the humerus, immediately adjacent to the acromion process. Both thumbs extend round the sides of the patient's arm to point towards each other across the axilla. The grip is then firmly around the upper end of the humerus near the surgical neck.

Application of forces by therapist (method) Arm-by-side (grade I, grasp around the arm) The patient's arm should be fully supported in its neutral pain-free position (with pillows/ towels) if pain is to be avoided with a grade I. • Tiny oscillations are produced by alternating pressure against the patient's forearm through the therapist's index finger. • The patient's upper arm should be held clear of the couch to enable movement to be friction free. • When extremely gentle techniques (1-) are being used, it is essential to withdraw the index finger from the patient's forearm far enough to allow the head of the humerus to return to the superior part of the glenoid cavity. • This return movement can be assisted by maintaining the patient's elbow at slightly more than a right angle. If the position is maintained it will be natural for the head of the humerus to move upwards in the glenOid cavity once the pressure from the left hand is released. A straighter arm enables the therapist's right hand • to assist the longitudinal movement for stronger grade II, III and IV techniques. Likewise, the patient should stand, not kneel, to exert these stronger movements. •

Arm-by-side (grade I, thumb pressure against the head of the humerus) • The oscillatory movement is produced by the therapist's body and arms, not the intrinsic muscles of the thumbs. In this way the therapist can feel the movement between the head of the humerus and the acromion process more readily. • Once again the arm must be fully supported in its neutral pain-free position with pillows/ towels to avoid pain with the tiny oscillatory movements.

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It i s also necessary t o use the middle of the thumb pads rather than their tips for a better feel to the movement and for patient comfort. Grade I movements should be tiny, gentle oscillatory movements whereas grade II, III and IV movements can be performed by altering the amplitude and depth of the oscillations using the body and arms to transmit the movement through thumb pressure.

I n abduction The movement is produced entirely by the pressure of the therapist's left hand against the head of the humerus, feeling the movement of the head of the humerus in relation to the acromion process. The movement can be produced in three different ways for three different reasons: 1. As the therapist exerts pressure against the head of the humerus, moving it towards the patient's feet, the patient's elbow can be carried as far longitudinally as the shoulder girdle. This method can be used when the longitudinal movement is not inhibited by pain response and maximum longitudinal movement is desired. Such a case may be a moderately chronic intra-articular disorder with 'through range pain' responses on examination of active and passive movements (clinical group 3b). 2. During the movement the elbow can be carried further distally than the head of the humerus in cases similar to above except that the quality of the pain (e.g. irritability) indicates that the tech nique should not be painful (clinical group 3a). 3. As the movement is performed the elbow can be held stationary as the longitudinal move ment is applied to the head of the humerus. This effect results in the longitudinal move ment being combined with a degree of further abduction. This may be required where the abduction is very stiff (clinical group 2).

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In abduction prone The oscillatory movement (usually grade ill or IV) in this case is produced by the therapist's body and arms acting through the thumb pads. The move ment must not be produced by the thumb flexors. The gentler the technique the more of the thumb tips can be used but as the technique becomes stronger more of the thumb pads must be used.

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In 90· flexion The oscillatory longitudinal movement is produced by pressure against the head of the humerus with the cupped heel of the left hand.

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M A I T LA N D'S PER I PH E RA L M A N I P U LATI O N

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The therapist's right hand supports the patient's right arm and: 1. carries it with the movement so that the angle of flexion at the shoulder is not altered (clinical group 3b) 2. releases the flexion a few degrees (clinical group 3a), or 3. carries the arm further into flexion as the longitudinal pressure is applied (clinical group 2), for reasons similar to those discussed in the application of forces for longitudinal movement caudad in abduction.

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Posteroanterior movement (Figs 1 1 .49- 1 1 .52) •

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In ful l flexion Before the oscillatory movement is carried out, pressure is applied through the lateral borders of the index fingers against the head of the humerus to take up the slack by raising the shoulder girdle and moving it caudally. • The oscillatory movement (usually grades III and IV) can be performed by alternately increasing and decreasing further pressure to direct the head of the humerus distally in the glenoid cavity. • Once again this longitudinal movement caudad can be accompanied by: 1. moving the patient's arm in parallel with the longitudinal pressure 2. decreasing the flexion a few degrees in conjunction with the longitudinal movement, or 3. increasing the flexion further as the head of the humerus is moved caudally. •

In acromiohumeral problems, stretching of the glenohumeral capsule as a contributing factor towards acromiohumeral impingement (Conroy & Hayes 1998).

Direction: Movement from posterior to anterior of the head of the humerus in relation to the acromion process.

Symbol: ; Patient starting position: - For arm-by-side: supine, lying with the right

elbow flexed and the right forearm resting against a pillow(s) against the trunk with a pillow or blanket under the elbow. This detail of supporting the arm is necessary so that medial rotation, adduction and extension are avoided and so that the shoulder is in its neutral pain-free position in cases of extreme pain.

Uses •

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One of the most valuable glenohumeral accessory movement examination and treatment techniques for all clinical groups (i.e. group 1, arm-by-side; group 2, in full flexion, in abduction prone; group 3, in abduction, in 90° flexion). Capsular stretching in abduction or full flexion. Acromiohumeral decompression in arm-by-side, abduction, 90° flexion and full flexion. Gentle pain-relieving techniques for both very painful glenohumeral and acromiohumeral disorders. Effect on pain inhibition of scapula stabilizer muscles, especially with painful arcs of shoulder movement.

Figure 1 1 .49

Posteroanterior movement: arm-by-side.

Evidence •

Detection of inferior capsular instability (Gerber & Ganz 1984).

Figure 1 1 .50 Posteroanterior movement: a rm-by-side or hand-behi nd-back.

The shou lder and shoulder g i rdle complex

- For hand-behind-back: supine, lying with the patient's wrist placed behind the back to the appropriate position of adduction, extension and medial rotation. - For in abduction: supine, lying in the middle of the couch with the right elbow flexed and the arm abducted to the required degree. - For in abduction prone: prone, lying with the arm abducted and laterally rotated and resting on the couch. If the joint range is limited, the patient

may need t o turn slightly t o the right s o that the shoulder is not extended and uncomfortable. - For in full flexion: supine, lying with the elbow straight and the arm positioned in full flexion. •

Therapist starting position: - For arm-by-side/hand-behind-back: kneeling laterally and superiorly to the patient's shoulder; alternatively, using the arm as a lever, standing by the patient's right forearm facing the patient's head (Fig. 11 .50). - For in abduction/in abduction prone: standing away from the patient's right shoulder facing across the patient's body. - For in full flexion: standing by the patient's right shoulder beyond the patient's head, facing the patient's feet and crouching over.

Localization of forces (position of therapist's hands) Arm-by-side/ hand-behind-back Both thumbs are placed back to back with the tips of the thumb pads in contact with the posterior surface of the head of the humerus, adjacent to the acromion process and pointing towards each other. • The fingers of the left hand spread over the patient's clavicular area. The fingers of the right hand spread over the • deltoid area. • The anterior surface of the left mid-forearm rests on the superior edge of the couch. • The anterior surface of the right mid-forearm rests on the edge of the couch, adjacent to the lateral surface of the patient's right shoulder. • Both elbows are flexed 90° and both shoulders abducted to about 60°.

•

Figure 1 1 .51

Posteroanterior movement: in abduction.

Alternatively: arm-by-side or in abduction In the crouched position the right side of the trunk and the right forearm support the patient's forearm. • The posterior surface of the right hand is placed in the palm of the left hand so that the index fingers overlap. • The lateral borders of the index fingers are placed in contact with the back of the head of the humerus with the thumbs placed anteriorly to form an encompassing grip. •

In abduction prone The pads of both thumbs are placed against the posterior surface of the head of the humerus, immediately adjacent to the acromion process.

•

Figure 1 1 .52

Posteroanterior movement: in abduction prone.

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M AITLAN D ' S P E R I PH E RA L MAN I P U LATI O N

•

•

Both arms are directed i n a posteroanterior direction with the shoulders positioned immediately above the direction of movement. Alternatively, the cupped palm of the hand or the web of the first interosseous spaces of both hands are placed against the head of the humerus posteriorly.

I n fu l l flexion The therapist's left side is used to hold the patient's fully flexed right arm. • Both hands together are placed behind the patient's deltoid. • The posterior surface of the left index finger is placed against the anterior surface of the right index finger. • The lateral surfaces of both index fingers are then placed against the head of the humerus, immediately adjacent to the acromion process. • Both thumbs extend around the sides of the patient's arm to point towards each other across the axilla. • The grip is then firmly around the upper end of the humerus near the surgical neck (see Fig. 11 .48).

•

•

•

Application of forces by therapist (method) Arm-by-side / hand-behind-back • The oscillatory movement is produced by the therapist's arms adducting and abducting a few degrees using the contact of the forearms against the couch. • If the movement is produced by the flexors of the thumbs the movement will be uncomfortable for the patient and the therapist loses all feel of the movement. • For grades I and II it is essential that no pressure is applied directly to the head of the humerus at the begirming of the movement and that with each oscillation the head of the humerus is returned to its relaxed position. • As the pressure will be very light the tips of the thumb pads should be used. • As stronger movements are required (grades III and IV), a larger area of the thumb pads should be used. • The anteriorly directed movement of the head of the humerus can be emphasized further by an anterior pressure against the clavicle using the ring and little fingers of the left hand. Alternatively: arm-by-side or in abduction Using the grip around the humerus the slack in the scapular movement can be taken up by lifting the

•

•

head of the humerus first so that any further move ment will be of the head of humerus in the postero anterior direction. Grade III + movements are performed like a flick, allowing the shoulder girdle to drop a few centimetres before countering it with a posteroanterior pressure returning through the same few centimetres. The direction of the posteroanterior movement should be parallel to the inferior surface of the acromion process. A grade IV + movement can be performed as a sustained oscillatory mobilization at the limit of the range. If performed in abduction this movement can be accompanied by extension or horizontal extension of the arm which will emphaSize the stretch on the glenohumeral joint.

In abduction prone The movement is produced by the therapist's body and arms through the thumbs. • The thumb flexors must not be used as this will become uncomfortable for the patient and the therapist will not be able to appreciate small amounts of glenohumeral movement.

•

In ful l flexion Before the oscillatory movement is carried out, pressure is applied through the lateral borders of the index fingers against the head of the humerus to take up the slack in the shoulder girdle by lifting the shoulder girdle upwards. • The oscillatory movement (usually grade III or IV) is performed by alternately increasing and decreas ing further pressure to direct the head of the humerus in a posteroanterior direction in the glenOid cavity. • The posteroanterior movement can be accompanied by: 1. moving the patient's arm in parallel with the posteroanterior movement 2. decreasing the flexion a few degrees in conjunction with the posteroanterior movement 3. increasing the flexion as the head of the humerus is moved posteroanteriorly.

•

Uses •

One of the most valuable movements in the treatment of extremely painful shoulders (clinical group 1) is the arm-by-side position. The posteroanterior movement can be accompanied by glenohumeral or acromiohumeral distraction if this augments the pain-free oscillatory movement.

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The shoulder and shoulder girdle complex

•

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When pain is less severe or minimal, performing the technique using the arm as leverage is needed, especially when both accessory and physiological movements are needed in treatment (clinical groups 2, 3 and 4). Mobilizing or stretching of the anterior and poster ior parts of the glenohumeral capsule.

•

•

Grades II and III are useful (along with joint compression for chronic minor aching) when intra-articular disorders are present. Any stage of adhesive capsulitis, post-traumatic disorder, impingement or rotator cuff pathology. The grade, speed, rhythm and duration of the technique will be determined by the clinical features and the desired effects.

Anteroposterior movement (Figs 1 1 .53, 1 1 .54) •

Direction: Movement of the head of the humerus in an anterior to posterior direction in relation to the acromion process.

• •

Symbol: t Patient starting position: Supine, lying in the middle of the couch with the arm by the side (hand behind-back), in abduction or in horizontal adduction (flexion).

•

Therapist starting position: - For arm-by-side (hand-behind-back): standing by the patient's right upper arm, faCing across the patient's body. - For in abduction: standing by the patient's right shoulder facing the patient's feet. - For in horizontal adduction lflexion): standing by the patient's right shoulder facing across the patient's body.

Localization of forces (position of therapist's hands) Arm-by-side • The fingers of the right hand support the lower end of the patient's humerus posteriorly from the

Fig ure 1 1 .53

Anteroposterior movement: arm-by-side.

Figure 1 1 .54

Anteroposterior movement: in abduction.

325

J

326

MAITLA N D ' S P E R I P H ERAL M AN I PU LATI O N

•

•

•

medial side (the patient's forearm resting o n the therapist's forearm). This enables the patient's upper arm to be raised by approximately 20° to the coronal plane of the patient's trunk so that the head of the humerus will not impinge against the inferior surface of the acromion process posteriorly and allows better movement of the head of the humerus in the glenoid. The heel of the left hand is cupped anteriorly over the head of the humerus. The fingers extend superiorly and posteriorly over the acromion.

In abduction • The right hand supports the distal end of the patient's humerus posteriorly from the medial side. • The forearm is positioned to support the patient's flexed forearm with the arm in abduction. • The cupped heel of the left hand is placed anteriorly against the head of the humerus. • The fingers extend medially across the adjacent clavicular area. In horizontal flexion (grades I I I and IV) • The localization of forces is identical to those described for horizontal adduction (p. 317) except that the head of the humerus is vertical and the hand under the scapula is placed laterally near the posterior rim of the glenoid fossa.

Uses •

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•

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Lateral movement (Figs 1 1 .55, 1 1 .56) •

• •

In abduction The oscillatory movement is produced by pressure against the head of the humerus with the left hand. • The degree of flexion, extension or horizontal adduction may be altered in order to make the anteroposterior movement most effective, i.e. by searching for the stiffest or most painful movement.

•

In horizontal adduction The anteroposterior movement is produced by pressure directed down the shaft of the humerus.

•

Direction: Lateral movement of the head of the humerus in relation to the acromion and glenoid cavity. Symbol: -+ Patient starting position: Supine, lying in the middle of the couch with the right arm by the side or in 90° of flexion.

•

Therapist starting position: - For arm-by-side: standing by the patient's right side distal to the flexed elbow and facing the patient's head. - For in flexion: standing distal to the patient's right shoulder facing the patient's head.

Application of forces by therapist (method) Arm-by-side • The anteroposterior oscillation is produced by pressure of the cupped heel of the left hand against the head of the humerus via the left arm and body. • The fingers cupped loosely around the acromion process do not apply any pressure but assist in feeling the movement.

Not as useful as the longitudinal movement or posteroanterior movement in treating very painful shoulders. Grades ill and N are more useful when the joint is stiff. Stretching the posterior glenohumeral capsule, or relocating an anteriorly subluxed humeral head. A means of encouraging proprioceptive recovery in unstable shoulders. A means of mobilizing the interface surrounding local nerve tissue. A technique to influence impairment related to coracoacromial impingement especially when performed in horizontal adduction.

Localization of forces (position of therapist's hands) Arm-by-side The right hand is placed as high as possible into the patient's axilla with the distal aspect of the palm in contact with the medial surface of the patient's humerus. • The fingers of the right hand spread posteriorly . around the patient's arm. • The thumb crosses the deltoid anteriorly. • The left hand supports the patient's elbow, the palm of the left hand being placed against the lateral surface of the joint. • The fingers of the left hand support posteriorly. • Crouch over the patient's arm. • The forearms are directed opposite each other in as near a coronal plane as possible. •

In flexion The fingers of the left hand grasp the distal end of the patient's upper arm laterally across the biceps. • The left thumb is placed across the biceps.

•

The shoulder and shou lder gird le complex

•

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•

If a grade III is desired, the pressure must be almost completely released at the end of each oscillation. During grade IV movement some pressure should be maintained throughout the technique while a further increase and decrease of pressure produces the oscillation. Take care not to compromise the ulnar and median nerves in the brachial region.

In flexion •

•

Figure 1 1 .55

Lateral movement: a rm-by-side.

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The mobilization is produced by the therapist's right arm while the left hand either stabilizes the position of the patient's humerus in relation to the scapula or it does the opposite by moving the elbow medially. The choice depends on the degree of pain or stiff ness found on examination of the movement and the intention to relieve pain or stretch the stiffness. The elbow can be moved in conjunction with the lateral pressure in three different ways: 1. by releasing the supporting pressure on the elbow (clinical group 3a) 2. by moving the elbow in parallel with the head of the humerus (clinical group 3b) 3. by moving the elbow medially (clinical group 2). Take care not to compromise the ulnar and median nerves in the brachial region.

Uses •

• •

Figure 1 1 .56

Lateral movement: in flexion.

•

Pain and stiffness in conjunction with other techniques. Capsular tightness. Joint surface pain (as a through-range grade I I o r III-). To increase the range of flexion and abduction at the limit of range (clinical groups 2, 3b) To help regain shoulder abduction after fracture of the neck of the humerus. .

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• •

The patient's glenohumeral joint is flexed to 90° with this grasp, allowing the patient's elbow to relax comfortably in flexion. The right hand is placed against the medial surface of the upper end of the patient's humerus, high in the axilla. The fingers and thumb of the right hand spread anteriorly. Crouch over the patient's arm. The forearms are pointed in opposite directions in the horizontal coronal plane.

•

GLENOHUMERAL I NSTA B I L I TY TESTS

(Gerber Et Ga nz 1 984)

Apprehension test (anterior i nstabil ity) (Fig. 1 1 .57) •

•

Patient starting position: Standing, shoulder laterally rotated in 45°, 90° and 135° of abduction. Therapist starting position: Standing behind the patient.

Application of forces by therapist (method) Arm-by-side •

The mobilization is produced by pressure through the therapist's right hand against the upper end of the patient's humerus.

Localization of forces (position of therapist's hands) •

The right hand grasps the patient's wrist with the thumb posteriorly placed and the fingers anteriorly placed.

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M A ITLA N D ' S P E R I P H E RA L M A N I P U LATI O N

•

The first web space of the left hand i s placed against the posterior and superior surfaces of the head of the humerus immediately adjacent to the acromion process.

Anterior drawer test (anterior capsu lar insufficiency) (Fig. 1 1 .58) •

Patient starting position: Supine, to the right side of

•

Therapist starting position: Standing by the patient's

the couch.

Application of forces by therapist (method) •

•

As the humerus is laterally rotated by the therapist's right hand in each of the abduction positions the web space of the left hand exerts a forward and downward pressure against the head of the humerus. If the shoulder is unstable the patient will exhibit apprehension and prevent further movement.

•

Localization of forces (position of therapist's hands) •

•

Uses •

right side facing the patient's shoulder.

•

At 45° of abduction the integrity of subscapularis and the middle glenohumeral ligament is being tested. In 90° or more of abduction the integrity of the inferior glenohumeral ligament is being tested.

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The therapist's right axilla fixes the patient's right hand, wrist and forearm; using this grasp the patient's shoulder is positioned in 80-120° of abduction, 0-20° of forward flexion and 0-30° of lateral rotation. The left hand holds the patient's scapula. The index and middle fingers maintain pressure against the scapular spine. The thumb exerts counterpressure on the coracoid process. The right hand grasps around the patient's upper arm.

Application of forces by therapist (method) •

Figure 1 1 .57

Apprehension test.

The left hand firmly fixes the scapula while the right hand draws the humerus anteriorly; the therapist notes the degree of anterior displacement and the end-feel to the movement. Accompanying 'clunks' may indicate injury to the labrum.

Figure 1 1 .58

Anterior drawer test.

The shoulder and shou lder g i rdle com plex

Uses •

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Confirmation of anterior instability and anterior capsular insufficiency.

Posterior drawer test (posterior ca psu lar insufficiency) (Fig. 1 1 .59) •

Patient starting position: Supine, towards the right side of the couch.

•

Therapist starting position: Standing by the patient's right side adjacent to the shoulder.

Localization of forces (position of therapist's hands) •

•

The degree of subluxation and the end-feel are noted.

Uses •

Confirmation of posterior glenohumeral instability and capsular insufficiency.

Su lcus sign (i nferior insta b i lity) (Fig. 1 1 .60) •

•

Patient starting position: Sitting upright or standing with the arm relaxed by the side in a neutral position. Therapist starting position: Standing by the side of the patient.

The right hand grasps the patient's forearm proximally. With this grasp and with the elbow flexed to 120° and relaxed, the shoulder can be positioned in 80-120° of abduction and 20-30° of forward flexion. The left hand holds the scapula with the index and middle fingers on the scapular spine and the thumb immediately lateral to the coracoid process such that the ulnar aspect of the thumb remains in contact with the coracoid during the test.

Application of forces by therapist (method) •

•

The therapist's right hand slightly rotates the patient's upper arm medially and flexes it to 60-80°. At the same time the thumb of the left hand subluxes the head of the humerus posteriorly.

Figure 1 1 .59

Posterior drawer test.

Figure 1 1 .60

Su lcus sign.

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M A ITlA N D' S P E R I P H E R A L M A N I P U LATI O N

Localization of forces (position of therapist's hands) •

•

The left hand can stabilize the scapula with the fingers over the spine of the scapula and the thumb against the coracoid process. The right hand grasps round the patient's upper arm laterally near to the elbow.

Application of forces by therapist (method) •

With a relaxed grip the therapist applies a gentle traction or caudal longitudinal movement of the humerus in relation to the scapula, noting the degree of subluxation of the head of the humerus inferiorly.

Uses •

Confirmation of inferior glenohumeral instability and inferior capsular insufficiency.

Diffe rentiation of pain from the acromiohu meral joi nt, rotator cuff or the g lenohumeral joint (i ntra-articu lar) •

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Perform the provocative movement (in this case passively but differentiation can also be attempted with the active movements provoking the patient's pain) such as shoulder abduction, flexion, rotation, hand-behind-back and horizontal adduction. The provocative movement should be performed so as to reproduce the patient's symptoms. Repeat this movement with the head of the humerus firmly compressed against the underside of the acromion process. If the acromiohumeral structures are the source of the pain, an increase in symptoms will be experienced by the patient (Fig. 11.61). Repeat the provocative movement with the head of the humerus distracted away from the acromion process. This will have the effect of reducing compressive forces on the acromiohumeral structures and at the same time further stretching the inferior part of the glenohumeral capsule. If the patient experiences significantly reduced symptoms it is likely that the acromiohumeral joint is the source of the symptoms. If the symptoms are increased the therapist may want to investigate further the possibility of glenohumeral. joint periarticular involvement. Repeat the movement with the glenohumeral joint compressed into the glenoid cavity. If the

�...

Figure 1 1 .61

Acromioh umeral compression.

symptoms produced are unchanged this may well strengthen the hypothesis of acromiohumeral involvement (see Fig. 8.60). If the patient has a painful arc of shoulder abduction and it is unclear whether this is due to acromio humeral impingement or contraction of the rotator cuff muscles, the following differentiation can be attempted: •

•

•

With the patient lying supine place the shoulder in the painful arc position and perform an isometric contraction such that the patient's pain is reproduced. While the isometric contraction is being applied add in a longitudinal caudad movement of the glenohumeral joint, which will have the effect of distracting the head of the humerus away from the acromion. If the patient's pain decreases it is likely that there is an element of pain originating from the non contractile structures of the acromiohumeral joint (e.g. subacromial bursa) but if the pain remains it may be that this is due to the force being transmitted across the contractile structures.

Note that all these differentiation tests on their own are of limited value but they may serve as a guideline and

The shou lder and shoulder girdle complex

331 ]

help to plan which structures to examine further in finer detail. For example, the differentiation may point to a need to palpate for swelling of the subacromial bursa anterior and posterior to the acromion process, particularly if the patient complains of pain locally 'under' the acromion process.

Uses •

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Differentiation of the source of a patient's shoulder pain in examination. In treatment if this is the best means of provoking a patient's symptoms.

Acrom ioh u meral joint - rotation with compression (Fig. 1 1 .62) •

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Direction: Glenohumeral (GH) medial and lateral rotation with the head of the humerus firmly compressed against the acromion process in any relevant physiological position. Symbols: IN acromiohumeral compression DO glenohumeral :J , c: Patient starting position: Supine, near to the right side of the couch. Therapist starting position: Standing by the patient's right side level with the shoulder and facing across the patient's upper body.

Localization of forces (position of therapist's hands) • •

•

•

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The right hand holds the patient's right elbow. The right groin and thigh comfortably support the patient's right elbow and the therapist's right hand. The right upper arm and the right side firmly support the patient's right hand. The left hand is placed over the acromion process with the fingers of the left hand pointing posteriorly. The left elbow is kept away from the trunk so as to enable the caudad pressure to be exerted through the left hand.

Fig u re 1 1 .62 Acromiohumeral rotation medially (and laterally) with compression.

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Uses •

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In order to perform mid-range medial and lateral rotation, the therapist's trunk is tilted to the right for the patient's humeral shaft to be medially rotated. A smooth side flexion of the therapist's trunk to the left then follows to allow the humeral shaft to be laterally rotated. The patient's elbow is kept stationary by the therapist's right hand and groin.

Painful arcs of movement of the shoulder due to subacromial impingement. Where the quadrant and locking position provoke minor symptoms which are provoked further by acromiohumeral compression. Residual minor symptoms after rotator cuff repair or injury where pain is provoked with acromiohumeral compression.

Acrom ioclavicular joint - anteroposterior 'squeeze' (Figs 1 1 .63, 1 1 .64) •

• •

Application offorces by therapist (method)

Compression of the acromiohumeral space is then maintained by the equal and opposite pressure being exerted by the therapist's right hand and groin and the therapist's left hand.

•

Direction: Movement of the spine of the scapula and the clavicle together about the acromioclavicular joint or anterior movement of the clavicle in relation to a stable acromion process. Symbol: 'Squeeze'. Patient starting position: Supine, lying in the middle of the couch with the arm by the side. Therapist starting position: Standing by the patient's right shoulder faCing (1) across the patient's body or (2) the patient's head for the localized technique using the thumbs.

Localization of forces (position of therapist's hands) •

The heel of the left hand is placed under the spine of the scapula near its vertebral end.

332

M A ITLA N D'S P E R I P H ERAL M A N I P U LATI O N

therapist's right hand, countered by the posteroanterior pressure over the medial end of the spine of the scapula with the left hand.

Alternatively: •

Figure 1 1 .63

Acrom ioclavicu lar 'squeeze'.

The movement is produced by the body and arms acting through the therapist's thumbs and not through the flexor muscles of the thumbs. There should be the feeling through the thumbs of movement of the clavicle in relation to the acromion.

Variations in the application of forces •

• •

•

The movement can be repeated with the arm in different physiological positions depending on the reproduction of pain and the functional restriction. With the joint under compression. Using thumb pressure localized to the joint line or the acromion close to the joint line. Inclinations medially, laterally, cephalad and caudad.

Uses •

•

Acromioclavicular pain after injury, subluxation or fracture of the clavicle. Stiffness and pain especially with horizontal adduction and hand-behind-back movements.

Acrom ioclavicular joint - posteroanterior movement (Fig. 1 1 .65) Figure 1 1 .64 movement.

• •

•

Acromioclavicu lar joint: anteroposterior

The fingers of the left hand point laterally. The heel of the right hand is placed over the anterior border of the clavicle near the junction of its middle and lateral one-third. The fingers of the right hand point laterally.

•

• •

•

Alternatively: •

• •

The thumbs are placed tip to tip against the anterior border of the clavicle immediately adjacent to the acromioclavicular joint line. The fingers are spread to provide stability. The shoulders are positioned above both hands to line up the anteroposterior movement.

•

The movement is produced by anteroposterior pressure against the clavicle through the

Symbol: ; Patient starting position: Supine in the middle of the couch with the arm by the side and the hand resting on the abdomen. Therapist starting position: Kneeling by the right side of the patient's head facing the patient's feet.

Localization of forces (position of therapist's hands) •

•

Application offorces by therapist (method)

Direction: Movement of the clavicle in a posteroanterior direction relative to the acromion process.

•

The thumbs, tip to tip, are placed against the posterior border of the lateral end of the clavicle adjacent to the acromioclavicular joint line. As much of the pads of the thumbs as possible should be used. The heels of the right and left hands make contact with the posterior shoulder area and the upper trapezius area, respectively.

The shoulder and shoulder g i rdle complex

Fi g u re 1 1 .65 movement.

•

Acromioclavicular joint: posteroanterior

The fingers of the right and left hands spread over the anterior shoulder and anterior clavicular area, respectively.

Application of forces by therapist (method) •

•

The posteroanterior movement is produced by the therapist's arms acting through the thumbs which should be placed close together so that the line from the therapist's shoulders to the thumbs passes through them. The movement must not be produced by the thumb flexors.

Variations in the application of forces •

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The posteroanterior movement of the acromioclavicular joint can be performed in any appropriate physiological position. One common variation for stiffness is to place the patient in a prone position with the shoulder in the equivalent of the quadrant position and perform the technique, with the therapist faCing the patient's head, using the thumbs. With the acromion being compressed against the clavicle to produce joint compression. With thumb pressure on the joint line or via the acromion. Inclinations medially, laterally, cephalad and caudad.

Fi g u re 1 1 .66 caudad.

Acromioclavicular j o i n t : longitudinal movement

Uses • •

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Acromioclavicular pain. To improve the range of movement of horizontal adduction (flexion) or extension. Stiffness at the end of range of shoulder movements.

Acromioclavicula r joint - longitudinal movement caudad (Fig. 1 1 .66) •

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•

Direction: Longitudinal movement of the clavicle in a caudal direction in relation to the acromion, in the line of the patient's body. Symbol: ...... caud. Patient starting position: Supine in the middle of the couch with the arm by the side and the hand resting on the abdomen. Therapist starting position: Standing by the right side of the patient's head facing the patient's feet.

Localization of forces (position of therapist's hands) •

The tips of both thumbs are placed on the superior surface of the clavicle adjacent to the acromioclavicular joint line.

333

334

M A IT LA N D'S PER I PH E RAL M A N I P U LATI O N

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The fingers spread around the thumbs to provide stability. The fingers of the right hand rest over the shoulder and deltoid area. The fingers of the left hand rest over the anterior clavicular area. The forearms are directed in line with the longitudinal caudad movement of the joint.

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•

Application of forces by therapist (method)

•

The movement is produced by the therapist's arms and body acting through the thumbs. The movement of the clavicle can be felt through the pad of the right thumb in comparison with the stable acromion.

couch with the arm by the side and the hand resting on the abdomen. Therapist starting position: Standing by the patient's right shoulder faCing the patient's head.

Localization of forces (position of therapist's hands) •

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Patient starting position: Supine in the middle of the

• •

The pads of the thumbs near their tips are placed against the inferior surface of the clavicle adjacent to the joint line (see Fig. 11 .64). The fingers are spread to provide stability. The shoulders and forearms are positioned more horizontally in order to direct the movement in a cephalad direction.

Application of forces by therapist (method) Variations in the application of forces •

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The technique can be performed in any appropriate physiological position of the shoulder such as the quadrant position with the patient lying prone. If performed with or at the limit of flexion, the longitudinal caudad movement will inhibit the degree to which the clavicle can rotate. If performed with or at the limit of extension, the longitudinal caudad movement will increase the amount of clavicular rotation taking place. With the acromioclavicular joint under compression. With the thumbs positioned on the joint line or on the acromion close to the joint line. With inclinations medially, laterally, anteroposteriorly or posteroanteriorly.

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Variations in the application of forces •

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Uses •

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Painful acromioclavicular joint (clinical groups 1 and 3a). Painful arc of flexion. Stiffness at the limit of flexion, abduction and horizontal adduction.

Acrom ioclavicular joint - longitudinal movement cephalad •

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Direction: Longitudinal m
The movement is produced by the therapist's arms and body acting through the thumb pads.

•

The movement can be performed in any relevant physiological position of the shoulder. If performed with or at the limit of flexion, the longitudinal cephalad movement will encourage further rotation of the clavicle. If performed with or at the limit of extension, the longitudinal cephalad movement will effectively reduce the rotation force of the clavicle. The movement can be performed with the acromioclavicular joint surfaces compressed together. With thumbs localized to the joint line or acromion. With inclinations medially, laterally, anteroposterior and posteroanterior.

Uses •

Usually only used if other directions are not producing the desired effects.

Sternoclavicu lar joint - longitudinal movement cephalad and ca udad (Figs 1 1 .67, 1 1 .69) •

Direction: Movement of the clavicle in a longitudinal direction cephalad or caudad in the patient's body line and in relation to the sternum.

The shoulder and shou lder girdle complex

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•

The fingers o f both hands fan out over the pectoral area to enhance the stability of the thumbs. The forearms are lowered to ensure a longitudinal cephalad direction.

Caudad •

•

•

Figure 1 1 .67 cepha lad.

Sternoclavicular joint: longitudinal movement

The thumb tips held back to back are placed on the superior surface of the clavicle adjacent to the sternoclavicular joint line. The fingers of both hands fan out over the clavicular area to ensure stability of the thumbs. The forearms are lowered to ensure a longitudinal caudad direction.

Application of forces by therapist (method) •

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•

The oScillatory movement in both longitudinal directions is produced by the therapist's arms and body acting through the thumbs. At no time should the movement be produced by the thumb flexors. Small or large amplitude movements can be used in any position in the range.

Variations in the application of forces •

•

•

Figure 1 1 .68 movement. • •

Sternoclavicular joint: a nteroposterior

Symbols: ....... ceph and caud. Patient starting position: Supine, lying with the arm

•

by the side and the hand resting on the abdomen. •

Therapist starting position: - For cephalad standing by the side of the patient facing the patient's right shoulder. - For caudad standing to the left of the patient's head facing the patient's feet.

The movements can be performed in any physiological position. If performed with or at the limit of flexion and extension, the longitudinal movements will reduce or increase the degree of clavicular rotation taking place in the same way as that described for the acromioclavicular joint. Changing the point of contact of the thumbs to the joint line or the sternum (caudad only) may be necessary to provoke the patient's symptoms more readily. Likewise, inclining the movements medially, laterally, posteriorly or anteriorly, or performing the movements under compression or distraction, may be needed in examination and treatment.

Uses •

Pain and stiffness of the sternoclavicular joint.

Localization of forces (position of therapist's hands) Cephalad •

The thumb tips held back to back are placed on the inferior surface of the medial end of the clavicle near to the joint line.

Sternoclavicu lar joint - anteroposterior and posteroanterior movement (Fig. 1 1 .68) •

Direction: Anteroposterior or posteroanterior movement of the medial end of the clavicle in

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•

•

The thumbs of both hands are hooked under the inferior surface of the clavicle ensuring that the thumb pads are the main point of contact. The shoulders are positioned above the sternoclavicular joint to ensure the correct line of movement.

Application of forces by therapist (method) •

•

•

Figure 1 1 .69 caudad.

Sternoclavicu lar joint: longitudinal movement

The anteroposterior movement is produced by the therapist's arms and body, not the flexor muscles of the thumbs. The left thumb can then feel the movement of the clavicle in relation to the sternum. The posteroanterior movement is produced by a combined action of the therapist's body, arms, fingers and thumbs pulling the clavicle in a posteroanterior direction.

Variations in the application of forces

• •

•

relation to the clavicular notch of the sternum and its fibrocartilaginous disc. Symbols: t , ; Patient starting position: Supine, lying in the middle of the couch with the arm by the side and the hand resting on the abdomen.

•

Therapist starting position: - For anteroposterior standing beyond the left side of the patient's head facing towards the patient's feet. - For posteroanterior standing by the side of the patient facing the patient's head and leaning over the sternoclavicular joint.

•

•

•

The movements can be performed with compression of the sternoclavicular joint via the lateral border of the acromion or distraction via pull of the humerus head laterally. Compression and distraction can also be valuable when performed with tl1e shoulder girdle in elevation and depression. Movements can be performed with or at the lintit of flexion or extension. Where iliumb pressure is used the point of contact can be varied to the joint line or sternum adjacent to the joint. Movements can also be inclined medially, laterally, cephalad and caudad.

Localization of forces (position of therapist's hands) Anteroposterior •

•

•

•

The tips of the thumbs pointing towards each other are placed directly over the sternal end of the clavicle anteriorly and adjacent to the joint line. The fingers of both hands fan out around the thumbs to produce stability. The metacarpophalangeal joints of the thumbs are brought together so that the line of the pressure from the shoulders to the thumb tips will pass through them in an anteroposterior direction. The shoulders are positioned over the thumbs to ensure this direction is achieved.

Posteroanterior •

The fingers of both hands are hooked under the superior surface of the clavicle. The pads of the fingers are the main points of contact.

Uses •

Pain and stiffness of the sternoclavicular joint.

Scapulothoracic movements - protraCtion, retraction, elevation, depression and rotation (Figs 1 1 .70- 1 1 .75) •

• •

•

Directions: Movements of the scapula about the chest wall. Symbols: Protr, Retr, El, De, Rot: :J , c: Patient starting position: Lying on the left side near the forward edge of the couch, head resting on pillows, hips and knees comfortably flexed. Therapist starting position: Standing by the patient's hips facing the patient's head, leaning across the pelvis so that the right ilium is cradled in ilie left axilla. This position ensures stability.

The shoulder and shoulder g i rdle complex

Figu re 1 1 .70

Sca pu lothoracic movement: protraction.

Figure 1 1 .71

Scapu lothoracic movement: retraction.

Localization of forces (position of therapist's hands) •

•

Figu re 1 1 .72

Sca pulothoracic movement: elevation.

Figure 1 1 .73

Scapulothoracic movement: depression.

•

For protraction the fingers of the left hand grasp the medial border of the patient's scapula. The right hand grasps over the spine of the scapula, cupping the heel of the hand anteriorly over the clavicular area. The right forearm firmly supports the patient's right arm flexed at the elbow to prevent any gleno humeral movement during the scapulothoracic mobilization. For retraction the left thumb and thenar eminence are placed very firmly against the lateral border of the scapula.

•

For elevation and depression the left hand is placed over the lower half of the patient's scapula with the fingers pointing towards the head. The left hand cups the lower third of the scapula so that the thenar eminence and the thumb grasp the lateral border and the middle finger grasps the medial border. For rotation the right hand holds over the patient's acromion area from in front. The right arm supports the patient's flexed right arm firmly to avoid any glenohumeral movement during the technique. The left hand grasps the medial and lateral borders of the scapula with the fingers and thumb respectively.

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•

•

Figure 1 1 .74 Scapulothoracic movement: medial rotation of the inferior angle.

and (2) the therapist's thumb against the lateral border of the scapula. The patient's arm should be carried with the scapula to avoid glenohumeral movement. The elevation movement is produced by the therapist's left hand; during depression it is the therapist's right hand cupped over the shoulder girdle which produces the movement. The glenohumeral joint is easily stabilized during this movement. The rotation movement of the scapula is produced by the combined action of the therapist's two hands. The left hand moves the inferior border of the scapula around the thorax while the right hand pivots the scapula from the top. The right hand stabilizes the scapula to prevent protraction. The patient's right arm must be stable on the therapist's left arm and flexed appropriately to avoid any movement of the glenohumeral joint. This is also achieved by the therapist's hips being pivoted from left to right.

Variations in the application of forces •

•

Compression of the scapula against the rib cage may be added during any of these movements. Likewise, distraction of the scapula away from the rib cage to reveal the anterior surface of the scapula may be useful in stretching the attached soft tissues. The distraction has to be performed slowly to allow the patient time to relax.

Uses •

Figure 1 1 .7 5 Scapulothoracic movement: lateral rotation of the inferior angle.

•

•

Application of forces by therapist (method) •

•

The protraction movement follows the curve of the rib cage and is produced by the fingers of the therapist's hands against the medial border of the scapula. As the scapula moves around the chest wall the therapist's body is lowered to lower the level of support of the patient's right arm and therefore avoid any glenohumeral movement. The retraction movement is produced by pressure from ( 1 ) the therapist's grasp of the upper scapula

• •

Usually used as grade III or IV. To reinforce proprioceptive position sense of the scapula in order to enhance the effectiveness of functional scapula stabilization. Stiffness after long periods of immobility as in stage 3 of frozen shoulder. Restoration of scapula mobility after fracture. In conjunction with rib mobilization to improve overall mobility of the shoulder complex.

Anteroposterior costal joi nts and intercosta l movements (Fig. 1 1 .76) •

Direction: Anteroposterior movement of the costal joints, i.e. chondrosternal margins or costochondral margins and intercostal movements.

The shoulder and shou lder g i rdle complex

•

•

If the movement is to be directed in an upward direction with the contact against the lower border of the rib, the therapist must stand by the patient's right side at waist level. In both these positions the thumbs may be directed along the shaft of the rib.

Uses •

•

Figure 1 1 .76 Anteroposterior costal movement.

•

Symbol: L .J Patient starting position: Supine, lying over to the

•

Therapist starting position: Standing by the patient's

•

•

•

Pain and restriction being produced locally at the costal joints or with intercostal movement. After rib fracture or open heart surgery if the joints become stiff and symptomatic. As a contributing factor to persistent restriction of the shoulder. Tietze syndrome (costochondritis) (Goodman & Snyder 1995).

right side of the couch. right shoulder facing across the trunk, shoulders positioned directly above the hands. The arms can be directed in a cephalad or caudad direction so that the movement will stretch the restriction or reproduce the symptoms.

Localization of forces (position of therapist's hands) •

•

• •

•

,

•

The pads of both thumbs are placed side by side across the joint to be mobilized. As much of the thumb pads as possible are used to make the contact more comfortable. The bases of the thumbs are kept close together. The thumbs are more stable in this position than when directed along the shaft of the rib. The thumbs may be placed along the line of the rib if symptoms are attributed to abnormal movement between adjacent ribs. Fingers spread in a fan to provide stability.

Application of forces by therapist (method) •

The anteroposterior movement must be produced by the therapist's trunk and arm movements rather than the thumb flexors.

Muscle length testing around the shoulder Scaleni With the patient in supine lying on the couch and the therapist standing at the patient's head facing the patient's feet, the therapist fixes the right first rib with the heel of the right hand placed against the superior surface of the first rib. The therapist's left hand placed under the occiput then side-flexes the patient's head and neck to the left. This will test the length and pain response of the middle scaleni. The further addition of left rotation will test the anterior scaleni; right rotation will test the posterior scaleni.

Upper fibres of trapezius With the patient lying supine on the couch and the therapist standing at the patient's head facing the patient's feet, the therapist maintains the patient's right shoulder girdle in depression with the right hand while flexing and side-flexing the patient's head and neck to the left by supporting under the occiput with the left hand. Comparison should be made with the opposite side and with the response while the patient's arm is in a position of neural mechanosensitivity.

Levator scapulae Variations in the application of forces •

•

The mobilization may be directed towards the patient's feet by applying pressure against the upper border of the rib. The therapist then stands alongside the patient's head.

With the patient lying supine near to the head of the couch and the therapist standing at the patient's head faCing the patient's feet, the therapist places the heel of the right hand over the acromion process and the palm of the left hand under the occiput to support the head and neck. With the left hand maintaining the neck in a

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neutral position the right hand depresses the scapula via the acromion, thereby stretching levator scapulae.

into elevation the therapist can test the length of latis simus dorsi.

Pectoralis minor

Serratus an terior (Fig. 1 1 .78)

With the patient lying supine on the couch and the therapist standing at the patient's head facing the patient's feet, the therapist places the heel of the right hand over the coracoid process of the scapula and the heel of the left hand over the anterior surface of the third to fifth ribs. By separating the heels of both hands the therapist applies stretch to the pectoralis minor.

The same position as for latissimus dorsi length testing is adopted with the exception that in the final position the therapist pushes the lateral border of the scapula medially with the heel of the right hand while main taining the patient's arm in elevation with the left hand. CLI N I CAL PRO F I LES : SHOULDER AND SHOULDER G I RDLE

With the patient lying supine near to the head end of the couch, with the back flat on the couch and the ther apist standing by the right side, the therapist places the right hand under the scapula and stabilizes it in its ideal functional position. The therapist then grasps the patient's elbow with the left hand and proceeds to ele vate the patient's arm alongside the patient's ear in its natural tendency to laterally rotate. During this move ment the therapist should ensure that the scapula does not move and that the patient does not lose the flat position of the back against the couch. By stabilizing the scapula and stretching the patient's arm further

The majority of patients with shoulder disorders who are referred to physiotherapy experience stiffness and pain with shoulder movement. Spontaneous or gradual onset disorders will usu ally have several components to them. For example, it is surprising how often a patient with a diagnosis of 'supraspinatus tendonitis' is also found to have an acromiohumeral joint component. Even when the diagnosis of supraspinatus tendonitis can be made, testing of the quadrant and locking position usually reproduces the patient's symptoms. Likewise, patients who fall on their arm and injure their shoulder will have their recovery enhanced if components within the spine are identified and treated accordingly.

Figure 1 1 .7 7

Figure 1 1 .78

Latissimus dorsi (Fig. 1 1 .77)

Testing the length o f latissimus dorsi.

Testing the length of serratus anterior.

The shoulder a n d shoulder g i rdle complex

Corrigan and Maitland (1983) have classified shoul der lesions as follows: •

•

• • • •

Tendon lesions: a. rotator cuff tendons - tendonitis, incomplete and complete rupture and calcification b. biceps tendon - tendonitis, tenosynovitis, subluxation and rupture Bursitis: a. subacromial bursitis related to chronic or acute calcific bursitis b. subacromial bursitis alone Capsulitis Instability of the shoulder joint The shoulder-hand syndrome Entrapment neuropathies.

Shoulder disorders can also be classified in terms of their presenting movement impairment (Rigg 2002). Common clinical patterns of presentation of shoulder disorders are evident to physiotherapists working clinically with such patients. Quite often the response to treatment, including mobilization, can be predicted based on the pattern of movement impairment. These impairments appear to fall broadly into five common classifications: •

painful loss of active elevation only (passive range full) - usually easily reversible

Box 1 1 .9

•

•

•

•

painful loss o f elevation both actively and passively - usually more difficult to reverse; conservative treatment alone may be insufficient to relieve symptoms painful loss of elevation and rotation movements reversible over time painful arc of movement during full elevation reversible over time major loss in all directions of movement - usually more difficult to reverse; conservative treatment alone may be insufficient to relieve symptoms.

The clinical profiles detailed in this text draw together the various classifications of shoulder disorders and refer to patterns of presentation which are seen most commonly by physiotherapists on a day-to-day basis. Emphasis is placed here on the role of mobilization and manipulation but it is recognized that many other man agement approaches may well be relevant instead of or alongside manipulative physiotherapy. Clinical profiles are presented for the following shoulder disorders: • •

• •

frozen shoulder (adhesive capsulitis) (Box 11.9) painful stiff shoulder (pseudo or secondary frozen shoulder) (Box 1 1 . 1 0) glenohumeral osteoarthritis (Box 11.11) shoulder instability (structural! functional) (Box 11.12)

C�nlcal profi le: frozen shoulder (adhesive ca psul itis)

--------�

Exami nation

Cli n ical evidence / 'brick wall' thinking

Kind of disorder

True shoulder pain and stiffness; difficulty with many activities of daily livin g ; usually unable to lift the a rm u p without pa in and/or stiffness

Body chart features

Patient describes pain deep in the shoulder when the therapist g rasps the joint and rocks it back and forth. Often referred pain or aching is felt at the insertion of deltoid or l i ke a cuff around the upper a rm. The forearm may a lso ache

Activity lim itations / 24-hour behaviour of symptoms

A strong relationsh ip between pain, spasm, stiffness and movement is present. All shoulder movements are restricted. A capsu lar pattern of restriction often emerges (Cyriax Et Cyriax 1 983), i.e. lateral rotation is more restricted than abd uction which is more restricted than medial rotation. Pai n is often a problem at night when lying on the shoulder. Stiffness and pain may be more noticeable in the morning d u ring the intense inflammatory stage

Present/ past history

U n known aetiology. Onset is usually sponta neous and rapidly worsen ing. Three stages a re described lasting between 1 8 and 24 months - stage 1 : very painfu l ; stage 2 : pai nfu l and stiff; stage 3 : stiffness alone. Recovery is often sponta neous but patients progressing through the stages of the natu ra l history ca n be helped by conservative means and manipu lation under anaesthetic (Reichm ister Et Friedman 1 999)

Special q uestions

There may be a history of angina or ca rdiac d isease or other visceral disorders as predisposing factors

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[

Source / mech a n isms of symptom production

Chemica l / i nfla m matory, ischaemic and mechanica l nociception from the g lenohu meral joint ca psule and related soft tissues

Cause of the sou rce

U n known aetiology but medical conditions or scapulothoracic impairment may contribute

Contributing factors

Age related. It is unusual for people u nder 40 to have a frozen shou lder

Observations

Protective deformities, wasting of deltoid and scapular m uscles, reverse scapulohumeral rhythm

Function a l demonstration of active movements

Lateral rotation, abduction and medial rotation restricted by pain and / or stiffness proportional ly. Hand-behind-back, reach ing to the head and d ressing particularly l im ited

If necessary tests

Lower cervical quad rant or cervical compression test may reveal referral of pain from cervical components into the shoulder

Other structures in plan

The other joi nts of the shoulder complex (acromioclavicu lar, sternoclavicu lar, sca pulothoracic) and the cervicothoracic spine should a lways be exa m ined in deta i l

Isometric/ m uscle length tests

Often u n revealing due t o pain i n hibition and restriction o f t h e glenohumeral joint

Neu rological exa m i nation

Not u su a l ly necessary u nless signs of neura l entrapment are present

Neurodynamic testing

Usually inconclusive due to joint restriction

Pa l pation findings

Pa l pable th icken ing of the joint ca psu le i n the early stages. Trigger point tenderness in the glenohumeral and sca p u la m uscles due to reflex arc activity

Passive movement, accessory / physiological combined movements

Both glenohu meral accessory and physiological movements w i l l be painfu l and stiff proportional ly, depending on the stage of the disorder

Mobil ization / manipu lation techn iq ues preferred

Sta g e 1 (cl inica l g roup 1 ) : Pain is either at rest or early onset and early limiting ; mobilization shou l d be based on the g uideli nes for clinical group 1 (Ch. 8), i.e. the desired effect of rel ievi ng nociceptive mechanical pain using accessory movement g rades I and II with the a rm in a fu l ly supported and neutral pain-free position. At this stage i nitia lly only the symptom response to treatment should be reassessed rather than the movement. There shou l d be a lessening of symptoms with treatment after two or three sessions when the chosen accessory movement can be prog ressed in terms of its ampl itude (larger) and it being taken i nto a sma l l degree of d iscomfort

Stage 2 (cl i n ical group 3a, 3b): In this stage accessory movements with the arm in its neutral pai n-free position should sti l l be used. If pain and resista nce are present it may be necessary to progress i nto resistance if techn iques short of R, are not being effective. As pa i n subsides and the ra nge of, say, flexion i ncreases to 100-120·, slow movements into the quadrant (111-, slow, smooth, first of all i nto a control led a mount of pain and then into pain and resistance) may be necessary to effect further change i n symptoms. Progression ca n be carried further by using g rade IV to IV+ sma l l a m plitude movements into the resistance with respect to pain. The quadrant and accessory movements at the l i m it of th e range can be used for this purpose. Large a m plitude g rade 1 1 1 - movements in the direction of the quadra n t can be used to ease off any treatment soreness. A stage may be reached where strong physiological and accessory stretch ing at the l i m it of, say, flexion does not produce any more improvement in the range, even with a home exercise programme. In such cases it may be relevant to attem pt to break the ad hesions within the joint by considering the g u idel ines proposed for manip ulation of the conscious patient (Ch. 8). For the shoulder specifica lly this should be carried out using stretching movements towards the quadrant position or flexion depending on which is more stiff and painful. The patient's chest, shou lder and tru n k shou l d be firmly stabilized and the strength of the stretching movement shou l d be g radually i n creased while the pressure being appl ied and the pain response are taken i nto account. When the tearing occurs the movement can be continued to reach ful l ra nge or it can be limited depending on t h e patient's p a i n response. Rotation should never

The shou lder a n d shoulder g i rd l e com pl ex

be used because of the leverage transmitted to the joint and the humerus. The feel a n d sound of t h e tea r c a n be as fol lows: *a sharp 'snap' sound - most desirable; needs little fol low-up exercise *a tearing of blotting paper sou nd - w i l l requ i re exercise *a wet blotting paper ri pple - effective exercise is vita l otherwise the manipu lation w i l l have been i neffective The manipu lation shou ld always be followed up by an effective active fu nctional exercise programme to mai ntain ra nge and restore normal fu nction. This shou l d be attempted over several sessions gauged by the patient's response to strong stretch ing and the time for pain and discomfort to subside. It is important to stress that national guidelines on informed consent should be followed before attempting such a manoeuvre

Stage 3 (cl inica l g roup 2) : If stiffness only is l i m iting fu nction then g rade IV+ physiolog ica l and accessory movements at the l i mit of the stiff ra nge ca n be used. Grade I I I movements should be interspersed to lessen the degree of treatment soreness. Once the movements a re functional and the patient is not i n hibited by a certai n degree of l i m itation, it may be that such an outcome is acceptable to both therapist and patient. If the shoulder is g rossly restricted mobi l ization w i l l have a l i m ited va l u e (even M UA) and i n such cases the patient will regain a degree of fu nctional recovery with the passage of time Other ma nagement strategies

NSAIDs; one corticosteroid injectio n ; MUA; deal with other movement impairments (cervical thoracic, scapulothoracic), explain the natural history of the condition to the patient

Prog nosis / natura l history

Usua lly recovers over time; self-li m iting ; fol low stages of d isorder to be classed as a true frozen shoulder

Evidence base

Cleland and Dura l l C (2002) conclude in their systematic review that 'most of the a rticles reviewed suggest that physica l therapy a lone, or as part of a combi nation of modal ities, is beneficial for patients with adhesive ca psul itis, but the extent of the benefit is not clear'

Box 1 1 . 1 0

Clin ical profile: painful stiff shoulder (pseudo o r secondary frozen shoulder)

Exam ination

Cl i n ica l evi dence / ' brick wa l l ' thinking

Kind of disorder

Pa i n and stiffness resembling the second stage of the true frozen shou lder

Body chart features

The sa me as for frozen shoulder and often diag nosed as such. Pain is often a nterior to the shoulder joint and the main complaint is the aching around the deltoid i nsertion or the band of pain around the u pper a rm

Activity l i m itations/ 24-hour behaviour of symptoms

Lim ited in specific activities such as lying on the a rm at night or with reaching movements d uring the day; patient w i l l be able to position the shoulder i n a pa in-free position. Pa i n and stiffness with movements similar t o the capsu l a r pattern of t h e froze n shoulder. I n m a n y cases hand-behi nd-back may be p a i n free and flexion and abd uction are stiff a n d painful or vice versa

Present/ past history

The present history w i l l suggest either an inj u ry or a predisposin g stra i n such as overuse or new use. There will be no stage 1 as with frozen shoulder and the pa i n a n d stiffness will resolve within weeks of com mencing treatment rather than months

Special q uestions

Check that there is no evidence of cardiac, respiratory or visceral d isease which may be mim icki ng muscu loskeletal disorder

Source/ mecha n isms of symptom production

Predominantly mechanical nociception due to mechanical stra i n or spra i n of the glenohumera l joint capsu l e

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Cause o f t h e source

Often overuse, new use, misuse, a buse

Contributing factors

Stiff cervical and thoracic spine; shoulder/shoulder g i rdle functional stability impairments including postural align ment and m uscle i m ba l ance

Observations

Protective or adaptive postures and m uscle wasting may have developed if the symptoms have been longstanding

Functional demonstration of active movements

The patient will easily be able to demonstrate a shou lder movement which is painful and stiff such as flexion, hand-behind-back or latera l rotation. There will be a strong relationsh ip between the movement and the pain and stiffness

If necessary tests

Usua lly not req u i red

Other structu res in plan

It is a lways worth checking the cervicothoracic spine, neural mobil ity and muscle length strength changes as these components a re often a reason why recovery does not prog ress as expected

Isometric/ m uscle length tests

Isometric testing usually negative u n less acromiohumera l impi ngement has developed. Testing the length and strength of the serratus a nterior, pectora lis minor and the lower trapezius may well revea l m uscle imbalances

Neurolog ica l exa mination

Usually not necessary u n less neurodynamic factors are in evidence

Neurodynamic testing

Not usually a factor u n less mechanical sensitivity of the neura l structu res has developed with d isuse / misuse

Pal pation findings

Joint pal pation, especially a nterior, may reveal tenderness and thickening of the capsular structures

Passive movement, a ccessory / physiologica l combi ned movements

The findings w i l l depend on the stage of the natural history but if the shoulder capsu le is the source of the patient's pain and stiffness, such joint signs will be readily found on accessory and physiolog ical movement exa m i nation

Mobilization / m a n i pu lation techn iq ues preferred

Usually such shoulder d isorders fa l l into clin ica l g roups 3a and 3b and the guidelines for treating patients who fal l into these clinical groups should be fol l owed (Ch. 8). Techniques such as posteroanterior glenohumera l movement, medial rotation, hand-behind-back position, horizontal adduction, longitudinal caudad of the g lenoh u mera l joint at the limit of flexion and quadrant mobilization are often most va luable

Other m a nagement strategies

I mprovement of postural a l i g n ment and cervicothoracic mobil ity is essential if recurrences a re to be made less l i kely. Likewise, functional stab i l ity of the shoulder region will need to be addressed. Mobilization may com plement other pa in-rel ieving strategies and functional rehabil itation program mes

Prognosis/ natural h istory

The rate of recovery w i l l be m uch q u icker than that of frozen shou lder. The d isorder usua l ly recovers in l i ne with the g radual restoration of ranges of movement back to their ideal degree

Evidence base

Refer to Chapter 8 for g u ideli nes on how to manage periarticu lar disorders

Box 1 1 . 1 1

Clinical profi le: glenohumeral osteoarthritis

Examination

Clinical evidence / brick wall' thinking

Kind of d isorder

An aching-type pai n within the joint at rest or with shoulder movement. The patient will complain of morn ing stiffness which is eased by movement and a deep ache within the shoulder when lying on it at night. Associated symptoms such as crepitus or locking may be p resent. The joint feels 'dry'

Body chart features

Deep constant va riable ache within the shoulder joint; referred aching into the upper arm often referri ng into the forearm

'

The shoulder and shoulder g ird l e com p l ex

Activity limitations/ 24-hour behaviour of symptoms

Activities mainly restricted due to pain and stiffness i n the m.orn ing or after a period of disuse. Pain and stiffness through the ra nge of shoulder movements which is worse after a period of immobil ity and easier with throug h-range movements of the a rm. All movements feel l i ke this but symptoms increase when the a rm is loaded such as d u ring l ifting. Symptoms a re va riable depending on the time of day and the amount of activity carried out. Symptoms are often weather- or stress-dependent. Symptoms w i l l increase if the joint su rfaces a re fi rmly compressed together

Present/ past history

Usually episodic, with episodes or 'flare-ups' related to new or unusually heavy activity. Symptoms settle with time but episodes may result i n prog ressive worsening of pa i n and stiffness. Work or activity-related or i nj u ry-related degenerative changes may be evident as contributing factors. Osteoarthritis may be systemic and part of a general osteoarthritis disease process

Special q uestions

Check X-rays for stage of pathological progression and medical history for factors which could l i mit the recovery and rehabil itation process, especi a l ly i n older people

Source / mechanisms of symptom production

Pa i n originating from the subchondral bone exposed by fu l l thickness articu lar carti lage defects. Chronic, centra l ly sensitized pain due to ongoing nature of nociceptive symptoms affected by mood and distress from ongoing symptoms

Cause of the sou rce

Age-related repair

Contributing factors

Stiff joints above and below; pred isposing i njury; systemic d isease processes; immobil ity; lack of use

Observations

Bony and synovial th ickening evident i n advanced cases. Wasting of shou lder/shoulder gi rd l e muscu lature due to painfu l ly i n h ibited disuse. Adaptive, pa i n - rel ieving postures of the a rm , shou lder and neck

Functional demonstration of active movements

Pa infu l arm movements throughout the active range with end-of-range stiffness due to joint changes

If necessary tests

Symptoms increased when the active movements are performed under compression

Other structures in plan

Cervical and thoracic spine, posture, sca p u la fu nctional stability, adaptive m uscle length and neurodyna mic changes

Isometric/ muscle length tests

The degree of pain with isometric testing depends u pon the i nvolvement of the rotator cuff in the degenerative processes or the degree to which they a re i n h ibited by pain

Neurological exa mination

Usually not necessary

Neurodynamic testing

Usually not necessary

Palpation fi ndings

Thickening of the joint synoviu m and soft tissue and bony (th ickening) changes cond ucive with old pathology or new-on-old pathology will be present

Passive movement, accessory / physiological combined movements

Pain and stiffness w i l l be felt by the patient through the ra nge being tested passively, be it an accessory or a physiological movement. The friction-free feel of passive movement will be lost when the movement is carried out with the joint surfaces compressed together

Mobil ization / manipu lation techniques preferred

Pa in from an osteoarthritic shoulder is best treated with accessory movements a lone. The posteroanterior movement of the glenohu meral joint is often most successfu l using as large an a m p l itude of movement as possible (grade I I / I I I). Grade I movements may be needed i nitia lly after an acute exacerbation and the aim should be to reach a g rade 1 1 1 - or 1 1 1 + movement throughout the entire ra nge without pain. Physiological g rade II movements such as flexion / quadrant abduction or rotation may a lso be effective. M i nor symptoms from osteoarthritis may also respond to passive mobilization with the addition of intermittent joint compression

Other management strategies

NSAIDs and pain-rel ievi ng medication and modal ities a re usually necessary. Consider injections and joint replacement in severe cases. Home exercise prog ram m e and pa in coping strategies a re also essential

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Prog nosis ! natural h istory

As d iscussed in Cha pter 1 0, osteoa rthritis ca n be classified as a mecha nica l, degenerative, trau matic and systemic d isease. In the mechanical type, if pain is due to mechanical d isorder within the joint and if passive mob i l ization ca n a l l eviate the mechanical factor, the patient's symptoms shou l d resolve according ly. The tra u matic and degenerative types will a lways have i m pairment but with a ppropriate management and advice patients can remain symptom free for long periods. The d isease type relates to the general systemic type of osteoarthritis which usua l ly fol lows a prog ressive natural history. In such instances mobi l ization ca n be a means of al leviating symptoms but total rheumatolog ica l management of this type of osteoa rthritis is essential

Evidence base

Refer to Cha pter 8 for the evidence for the use of passive movement and articu lar cartilage repa i r

Exami nation

Clin ical evidence / 'brick wal l' thinking

Kind of d isorder

History of recurrent spontaneous or tra u matic d islocation of the head of the humerus, more commonly anteriorly or inferiorly. Apprehension, feel i ng that the shoulder will come out of p lace with certai n activities or movements. Vague feeling of someth ing not being q uite right with the shoulder, accompan ied often by sharp, 'locking' pain. Associated symptoms include a feeling of weakness or 'dead arm' and the sensation of clunking (from the damaged labrum)

Body chart features

Vague symptoms i n the shoulder and arm which move a round, sharp loca l pain felt within the joint on unguarded movements. Often associated neura l symptoms i n the a rm i n the absence of a ny sign ifica nt neck pain

Activity l i m itations! 24-hour behaviour of symptoms

Shou lder ra nge of movement is often fu l l or excessive. Patient seems to have problems with the qual ity of movement when perform ing activities rather than having movement restrictions. Pa in, weakness or a pprehension may be more evident at the extremes of ra nge or with unguarded movements such as throwin g a ba l l or when l ifti ng heavy loads. Symptoms are often worse when the patient is fatigued and the arm is tired. Anterior instabil ity often corresponds to activities which involve shoulder lateral rotation in abd uction and horizonta l extension (throwing); posterior instabi lity is often noticed with activities such as press-u ps; i nferior instabi l ity may be noticed d uring activities which involve traction being exerted to the a rm (e.g. carrying heavy cases). U nstable shou lders do not l i ke the creep loadi n g exerted on them by susta i ned positions such as sleeping in side lying or resting on the elbows or carrying bags

Present! past h istory

Often a long history of recurrent i njury or episodes of shoulder pa i n : each episode is more easily provoked, is more intense and lasts longer. Treatment often only helps partial ly. The patient feels that they are never fu l ly recovered

Special q u estions

It may be worth knowing the results of an M R I scan or asking for one to be carried out if i nstabil ity is suspected. Knowing that the patient has genera l ized hypermobility predisposin g to i nstabil ity may be of va l u e

Sou rce ! mechan isms of symptom production

Trau m a d a m a g e t o the glenohu mera l liga ments, the g lenoid labrum and i m pa i rment of actively restraining rotator cuff mechanism. Some periphera l neurogenic pain may also be part of the patient's symptoms

Cause of the sou rce

I nj u ry to the passive restraints at the shoulder, pain inh ibition of the active restraint

The shoulder and shoulder g ird l e com p l ex

•

•

Contributing factors

Repeated stressfu l i nj u ry or loading of the shoulder ligaments and capsule as in throwing sports or contact sport. Stiffness of adjacent joi nts. Fai l u re of the dyna mic fu nctional a l ignment and stabil ization mecha n isms a round the shoulder and shoulder g ird le

Observations

Align ment fa ults of the shoulder, shoulder gi rdle and the cervicothoracic spine; a nterior, inferior subl uxation of the head of the h u merus; m uscle wasti ng of deltoid and the scapula m uscles; raised shou lder where neurogenic pa i n results in protective mechanisms

Functional demonstration of active movements

Active movements often fu l l ra nge or even excessive, a pprehension may be the factor which l i m its movement. For a nterior instability lateral rotation i n a bd uction is excessive ; for posterior i nstabil ity horizonta l adduction w i l l be excessive; for inferior instabil ity there will be evidence of a su lcus sign especia l ly in medial rotation. The m isti ming of the scapulohumera l rhythm (especia l ly on return from susta ined positions) may wel l be the most objective movement i mpairment

I f necessa ry tests

The apprehension test will be positive for a nterior i nstabil ity

Other structures in plan

Especially neurodynam ics and the effect of the relocation test on neurodynamic mechanosensitivity. Stiffness i n the thoracic/ cervical spine, acromioclavicular/sternoclavicu lar joints and elbow. Muscle length tests especia l ly pectora lis minor. Dynamic sca p u la and h u meral sta b i l ization d u ring active movement

Isometric/ muscle length tests

Essential to determ ine the degree of involvement of the rotator cuff

Neurological exam i nation

Usua lly necessary d u e to the interface effects on the neura l structu res arou nd the shoulder

Neurodynamic testing

Usua lly necessary as mechanica l sensitivity of the peripheral nerves a round the shoulder may be a result of anterior instabil ity i n particu lar. Minor nerve entrapment symptoms should resolve as the instabil ity resolves

Pa lpation fi ndi ngs

Deformity may be present due to the abnormal resti ng position of the head of h u merus

Passive movement, accessory / physiological combined movements

Specific instabil ity testi ng will be positive depending on the d i rection of the i nstabil ity (Ch. 1 1 ). Accessory movement may be excessive and result in a pprehension and correspond to the directions of specific instability. The quadrant w i l l have no peak and w i l l often reproduce the c l u n k as the damaged g lenoid labrum is compromised. When the shoulder is medially rotated actively in 90· of abduction there w i l l be relatively more h u meral movement than scapula movement

Mobil ization / manipu lation techn iques preferred

Mobil ization of stiffness in the spine and clavicu lar joi nts. Accessory or physiological shoulder movements (grade I I) to e n hance proprioceptive mecha n isms prior to fu nctional stabi l ity training. Neurodynamic mobil ization to encourage a n ideal fu nctional environment for neura l tissues

Other ma nagement strategies

Restoration of ideal fu nctional m uscle balance; closed cha i n neurom uscu lar proprioceptive retra i n i n g ; taping to enha nce ideal proprioceptive feed back; dyna mic fu nctional stabilization (especia l ly the rotator cuff) ; may need surgical intervention if recurrences persist

Prognosis / natural history

Recovery depends on the abi l ity of the patient and thera pist to gain dyna mic control of the instability

Evidence base

Magarey and Jones ( 1 992)

fractures of the humerus (neck and shaft) (Box 11.13) subacromial impingement syndromes (non-acute) (Box 11.14)

•

•

acromioclavicular joint disorder (Box 11.15) minimum intermittent minor shoulder pain (Box 11.16).

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Box 1 1 . 1 3

Clinical profi le: fractures of the humerus (neck and shaft)

Exam i nation

C l i nical evidence/ 'brick wall' thinking

Kind of disorder

Pa i n fol lowing a fa l l and fracture of the shaft or neck of the h umerus; loss of movement d u e to immobil ization or pain

Body cha rt featu res

Such i nj u ries will stra i n or sprain structures of the glenohumeral joint; therefore the pain pattern will be simi lar to a ny glenoh u m era l joint i njury with the addition of pain originating from soft tissue injury and bruising. Look for signs of radial nerve damage with fractures of the shaft of the h u merus

Activity l i m itations/ 24-hour behaviour of symptoms

Movement l i mited by i m mobi l ization or severe pain. I m pacted fractures of the neck of the humerus w i l l move sooner and easier than unstable fractures. Constant pain and night pain d uring the period after inj u ry when the inflam matory process is active

Present/ past history

Trau matic sudden onset usu a l ly due to contact sports or fal ls d uring sporting or leisure activities i n the young and usually d u e to fa lls in the elderly. In the elderly the more i m portant aspects of the history might be related to how many other fa lls the patient has had and for what reason. The fracture w i l l heal a long the l ines of recog nized healing times for bone u n less there are medical or other contributing factors which may result i n delayed, mal- or non-union. Falls d i rectly onto the shoulder will often result i n mainly local i m pa i rments but if the fal l is on an outstretched arm it is l i kely that other components such as neck strain may be present and contribute to the speed of recovery

Special q uestions

A fu l l medica l , and social screening of elderly patients is essential to identify potential barriers or risk factors to recovery

Sou rce / mechan isms of symptom production

Fracture site pai n with corresponding symptoms due to associated soft tissue i njury in and a round the shoulder

Cause of the source

Older patients may well have underlyi ng restrictions in neck and spinal mobi l ity

Contributing factors

Care in rehabil itation needed with osteoporosis. General medical and physical condition may well i nfl uence the rate of recovery

Observations

Pri mari ly gravitational bruising and swe l l i ng a long with protective pai n-relieving postures

Functional demonstration of active movements

It w i l l be obvious which shou lder movements are l i mited by pa i n , spasm and later stiffness. Functionally, abd uction is the movement which is most restricted fol lowing fractures of the neck of the h u merus

If necessary tests

Not necessary

Other structures in plan

Check cervica l / thoracic spine and ribs and a ny other structures which may have been i nj u red

Isometric/ muscle length tests

May o n ly be necessary to test i n the later stages of rehabilitation or if rotator cuff i njury is suspected

Neurological exam ination

Only necessary if nerve inj u ry (radial nerve with mid-shaft fractures) is suspected

Neurodynamic testing

Screening relevant o n ly in the later stages of recovery

Pal pation fi ndings

Fracture site pai n may be reproducible on pal pation, otherwise a l l the signs of trauma to the tissues a round the shou lder should be expected

Passive movement, accessory / physiological combined movements

All accessory movements are l ikely to be painful in the early stages and stiff and pai nful later on. Physiological ly, rotation should be avoided i n itially because of the torsional effects on fracture sites. Abduction may well be most lim ited by pain, spasm and stiffness

Mobil ization / manipu lation techniq ues preferred

1. Lateral movement of the head of the humerus using the thu mbs in the axilla. The patient's a rm should be fu l ly supported and the movement performed slowly with a sma l l a m p l itude

The shoulder and shoulder g i rd l e complex

2. Posteroa nterior movement of the head of the h u merus . 3. Long itudinal movement of the head of the h u merus using the thumbs agai nst the head of the h u merus 4. Abduction very slowly and gently with sma l l a m pl itudes at the l i mit of the ra nge to start with. To ensure there is no movement at the fracture site, the humerus m ust be fu lly supported along its l ength and the therapist m ust fi rmly pa l pate the lateral border of the acromion to ensure that the humera l head moves i n the right proportion to the shaft d u ring abduction 5. Other accessory movement performed with the thu mbs or heel of the hand may further affect the ra nge and pa i n response during shoulder movement

Other management strategies

Encourage movement as early as possible; pain management through medication ; orthopaedic management including i nterna l fixation i f a ppropriate; active fu nctional rehabilitation i n both the young and old; in the elderly, identifying the risk factors involved with fa l ls

Prog nosis / natura l history

Fracture heals with i n 8- 1 2 weeks u n less malun ited, rehabil itation w i l l take months. I n the elderly fu l l recovery of ra nge is often less im porta nt than fu nctional rehabilitation

Evidence base

Refer to Chapter 8 for g u idel ines on the use of mobil ization after fracture

Box 1 1 . 1 4

Clinical profile: su bacromial impingement syndromes (non-acute)

Exam ination

Cl i n ica l evidence/ 'brick wa l l ' t h i nking

Kind of disorder

Pa i n at poin t of shoulder when working at shou lder height (su bacromial i m p i ngement). feels weak to lift a rm (pain inhibition / rotator cuff injury)

Body chart features

Expect loca l symptoms and postura l aching in scapular thoracic a reas (contri buting factors such as stiff thoracic spine/sca pu lar stabil ity)

Activity l i mitations/ 24-hour behaviour of symptoms

Pa infu l arc of abduction, pain with weig ht-bea ring through the a rm, impingement. With horizonta l add uction and HBB, symptoms related to certai n activities

Present/ past history

Tra umatic onset, throwing or fa l l on outstretched a rm (rotator cuff tear). I nsidious onset, overuse activities (with postural predisposing factors)

Special questions

Noth ing extra of note, cou l d be some neurological signs if brachial plexus/ neura l involvement, watch for vascular signs with i m pi ngement o f subclavian artery

Source/ mechanisms of symptom production

Primary hypera lgesia from structures of the subacromial space ; secondary hypera lgesia from cervical neurogenic, a utonomic involvement

Cause of the source

Stiffness i n the g lenohumera l joint, thoracic spi n e / ribs, cervical spine. Muscle imbala nce of the cervical spine and scapulothoracic regions

Contributing factors

Predisposing impairment (neck shou lder) new / over / mis/ ab / d is-use

Observations

Align ment faults of the head of the h u merus, acrom ion, scapula, cervica l / thoracic spine

Functional demonstration of active movements

Pa i nful a rc of abduction and / or flexion of the shou lder. Horizontal adduction, H B B painful end of ra nge (when not severe). Qual ity of movement affected

If necessary tests

Movement at speed may give more comparable response. Differentiation reveals i ncreased pain with acromiohu mera l compression test

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Other structures i n plan

Cervical spine, thoracic spine and ribs should be exam i ned. May need to examine elbow as a cause of the sou rce

Isometric/ m uscle length tests

Rotator cuff testing positive (note : differentiate AH compression and pain inh ibition). Scapular stabi lity dysfu nction, overactive u pper trapezius, tight pectora lis minor

Neurological exa m i nation

Usually not necessary u n less neurological signs evident

Neu rodynamic testing

U pper l i m b neura l provocation tests often positive, especia lly if cervical spine involved

Pa lpation findings

Rotator cuff i nsertions sore to touch if i nj u red, a reas of secondary hyperalgesia if spine and n e u ra l i nvolvement. The recovery i n abduction power can be dramatic due to the reduction in pain i n hibition of the rotator cuff. If the tendon is ruptured this will not occur

Passive movement

Shoulder q uadrant/ lock reproduce symptoms, longitudinal ca udad of humerus stiff, cervical spine, thoracic spine and ribs

Accessory / physiological com bi ned movements

Accessory movements stiff and pai nfu l especially posteroa nterior movement of the head of the h u merus (grade I to pain less 1 1 1 + in treatment)

Mobil ization / m a n i pu lation tech n iq ues preferred

Shoulder quadrant lock, longitud inal ca udad humeru s i n abduction. Shoulder abd uction / rotation with AH compression, neura l mobi l ization. Cervica l / thoracic/ rib mobil ization, thoracic manipu lation

Other management strategies

Correct a l ignment fa u lts, ti ming of scapular stabilization, ergonomic eval uation. The overa l l a i m is t o improve the painful arc o f movement and the power o f abd uction

Prognosis/ natural history

Often m u ltiple com ponents, function recovers if fa ults correctable, may need rotator cuff repa i r or subacromial decom pression

Evidence base

Lewis et al (200 1 ) suggest that each category of i m pingement has its own specific treatment and rehabilitation programme and that, at present, there is i nsufficient evidence to determ ine the most appropriate assessment methods or treatment strategies for each category of i m pi ngement

Exa m i nation

Cli n ica l evidence/ 'brick wa l l ' thinking

Kind of disorder

Pain local to the joint on in itiation of movement, at the l i mit of shoulder movement or when lying on the shoulder

Body chart features

Pai n / aching felt loca l ly on top of the joint or deep within it. Referra l of pain is not usual but would be along the line of the clavicle or towards the neck if at a l l

Activity l i m itations/ 24-hour behaviour of symptoms

Pain related t o movement especially horizontal add uction (flexion). fu l l elevation, horizontal extension and hand-behind-back. There may be catches of sharp pain with certai n movements and movements under load if the joint is subluxed ; when the joint is arthritic the patient will experience pa i n in the joint when lying on the shoulder in bed. They w i l l a lso experience a degree of morning stiffness i n the joint

Present/ past h istory

The acromioclavicular joint is often subl uxed d u ring falls on the point of the shoulder as in a l pine skiing or when playing rugby footba l l . The joint ca n be affected by i nj u ries wh ich fracture the clavicle and it ca n become arth ritic due to repeated injury or long periods of h eavy work when the onset is spontaneous, progressive and episodic

Special q u estions

There should be little to cause concern i n such cases or i nju ries

Sou rce / mechan isms of symptom production

Nociception from the joint capsu l e and ligaments and nociception from subchondra l bone i rritation in fu l l thickness a rticu lar ca rtilage defects

The shoulder and shoulder g i rdle complex

Cause of the sou rce

Structural anomal ies of the acromion, stiff glenohumeral joint, sternoclavicu lar joint and first rib

Contributing factors

Align ment fa u lts of the scapula may a l so contribute to the development of pathological changes i n and around the joint

Observations

Local swe l l i ng over the joint is usually evident after inju ry. Subluxation of the joint ca n clearly be seen if present. Make comparisons with the other side as it may be the case that the acromion via the scapula has become m isaligned and depressed rather than the clavicle being elevated. The a l i g n ment of the scapula and h u merus should a lso be checked i n case postural fa ults have developed and a re contributing to the generation of pa i n from an overstra i ned acromioclavicu lar joint

Functional demonstration of active movements

As the clavicle moves with all shoulder movements pain can be felt with any shou lder activity. This is often more so when movement is i n itiated or when the scapula starts to come i nto play and the patient experiences painfu l a rcs of movement. Pain i n the joint is often felt when the joint is stretched, as i n fu l l elevation or horizonta l adduction. An osteoarthritic joint w i l l be more painful when the joint is moved under compression

If necessary tests

Performing the squeeze test d u ri n g functional movements may serve as a differentiation proced u re to confirm involvement of the joi nt. Movements at speed may reproduce the patient's pain more readily in the provoking d i rection

Other structures in plan

Exa mination of the neck and thoracic spine may reveal contributi ng factors

Isometric! muscle length tests

Muscle length testing and assessment of dynamic functional stability of the sca p u la should be considered to enha nce ideal fu nctional recovery

Neurological examination

Usually not necessary

Neurodynamic testing

Usually not necessary

Pa l pation fi ndings

Thicken ing of the soft tissues over the su perior aspect of the joint and in the acromioclavicul a r space just medial to the joint line ca n readily be felt when the joint is d isordered

Passive movement, accessory / physiological combi ned movements

Joint signs w i l l be reprod uced with one or more of the accessory movement tests. These will i nclude a nteroposterior and posteroa nterior movements, longitudinal movements (especially caudad) and rotation movements of the clavicle produced at the l i m i t of flexion or extension of the shoulder. Horizontal add uction (flexion), horizontal extension and the quadrant and locking position may a lso be pai nful as w i l l a ny of these movements performed under compression

Mobil ization / manipu lation techniques preferred

Accessory movement g rade I and II for painful joi nts with the arm fu lly supported and pain free. Accessory movement g rade III and IV for stiffness at the l i m it of the stiff movement. Stretch ing movements into horizonta l add uction, horizonta l extension, hand-behind-back and the quadrant or locking position

Other ma nagement strategies

Functional sca pula stabil ization ; cortisone i njections into the joint; subacromial decom pression or acromioplasty may be required i n cases of severe arthritis; surgical pinning of the acromioclavicu l a r joint may be necessary i n cases of severe dislocation

Prog nosis/ natura l history

I nju ries of the joint usually recover well and often with little or no intervention by a physiotherapist. Arthritic joi nts have periods when they are symptom free but recurrences are often episodic and progressive, requiring medical or orthopaedic i ntervention

Evidence base

Refer to Chapters 8 and 10 for g u ideli nes on the use of mobil ization for painful joint disorders

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Box 1 1 . 1 6 r--

Clinical profi le: minimum intermittent minor shou lder pain

---

Exa m i nation

Clin ical evidence / 'brick wall' thinking

Kind of disorder

Patient com plains of a sharp pain when the arm is moved u n expectedly; momentary pain

Body cha rt featu res

Spot of pain felt over the insertion of deltoid. Local shoulder pa in difficult to describe as it is only felt i ntermittently

Activity l i m itations/ 24-hour behaviour of symptoms

O n ly felt with u n expected movements or d u ring vigorous or heavy activity. Goes off immediately, the pain is fleeting a n d momentary

Presen t /past h i story

Often u n remarkable: may be a history of m i nor i nju ry, an i ncrease in tra i n i ng or a different activity having been carried out recently

Special q u estions

Such patients usually participate i n vigorous sporting or occu pational activities. Therefore there should be l ittle to warrant concern

Sou rce / mecha n isms of symptom production

No clear or obvious sou rce or mechanisms. Reproduction of the pain is the key

Cause of the source

Cou ld be an awkward ly performed activity or movement or a movement performed with poor functional sta bil ity

Contributing factors

Previous i nj u ry or vigorous, stressfu l activity

Observations

M i nor ada ptive changes in posture and a l ig n ment may be present but the patient is unaware they exist

Functional demonstration of active movements

All pain free with overpressure

If necessa ry tests

Repeated, susta i ned or com bi ned movements will be needed to reproduce the pai n ; movements performed at speed m a y a lso reveal symptoms or altered qual ity o f movement

Other structu res in p l a n

M i nor i m pairments of the spine and ribs (from previous inju ry) may have contributed to the development of the minor symptoms in the shoulder

Isometric/ muscle length tests

M uscle imbala nces a round the shoulder gi rd le and a l ig nment fa ults such as timing of the scapulohumeral rhythm w i l l need to be identified and dealt with

Neurological exa mination

Usually not necessary

Neurodynamic testi ng

Usually not necessary or of minor concern

Pa l pation fi ndings

Areas of soreness will only be found with deep pa l pation a round the shoulder. Trigger points i n m uscles around the shoulder girdle may be consequences of adapted movement

Passive movement, accessory / physiolog ica l combined movements

The only passive movements which a re l ikely to reproduce the patient's pain are the quad rant or the locking position

Mobil ization / manipulation tech n iq ues preferred

Quadrant (scooping) g rades IV- to IV+ , at the peak, on the low side or on the high side depending o n where and by how much the pain is reproduced, fol lowed by the stronger technique of rol l i ng over the quadra nt. If pai n is reproduced i n the locking position a grade IV to IV+ scouring movement should be used

Other management strategies

A thorough assessment of stiff joints above and below the shoulder and a complete assessment of dyna mic fu nctional sta bil ity of the shou lder is necessary

Prog nosis/ natural h istory

The pai n w i l l genera l ly resolve when the fu nctional corners have been cleared out and when other barriers to recovery have been add ressed

Evidence base

None

Physical examination o f the composite shoulder is outlined i n Box

11.2.

The shoulder and shou lder g i rd le complex

CASE STU DY 1 1 . 1 S H O U LD E R A N D S H O U LD E R G I R D L E The patient, Mrs P, i s a 53-yea r-old part-time cleaner.

@ Stiff i n the morning when rol l i ng out of bed and when bend ing forwards. Present and past history Cam e on spontaneously and g radually over the last 6 months with a g radually n oticeable l i m itation of activity and movement, no previous symptoms in this a rea. @ Has had it on and off for the last few years since i ncreasing her cleaning hours by 1 00%, occasional stiff neck i n the past. @ Has had it for 10 years or more but ca nnot reca l l having a n inju ry, j ust l ives with it, t h i s hasn't been any worse or better recently.

(j)

Kind of disorder** Left shoulder pain and stiffness especially when putting the left hand behind the back, 'fibromya lgia' and a rth ritis of the spine and hi ps. Body chart features Left antedor shoulder pain of a deep i ntermittent ach ing nature; @ occasional su perficial intermittent tightness across the top of the left scapula. At present the low back is stiff @ only in the mornings and the hips are symptom free. (j), @ and @ seem u n related (Fig. 1 1 .79).

(j)

Activity Iimitations/ 24-hour behaviour of symptoms (j) Increases with hand-behind-back movements, the movement feels l imited and pai nful and settles with i n 5 m i n utes o f stopping the movement. (j) I ncreases with stiffness when reaching above head heig ht, becomes tired with i n 5 min utes but goes off within 1 m i n ute of stopping the movement. (j) Disturbs sleep occasionally when lying on the arm (once or twice per n i g ht) but goes off with slight adjustment of position. @ Noticed at the end of the day or after a heavy shift of clea ning, stil l feels it when going to bed but has gone by the next morni ng.

Special questions Has been on predn isolone for asthma but not for severa l years. Doctor told her she has fibromya lgia with her a rth ritis and these aches and pains a re helped by NSAI Ds as and when req u i red. Also suffers from peripheral vascu l a r disease, type 2 diabetes mel l itus for the last 2 years. She has had a n X-ray of her shou lder and it l ooks normal. The rheumatolog ist i njected the shoulder once without a ny effects. Source/ mechan isms of symptom production More l i kely to be nociception, mainly from (j) the g lenoh umera l , acromiohumera l or acromioclavicular complex, @ the cervicothoracic spine and the @ l u mbar intervertebral joi nts.

Figure 1 1 .79 Mrs P. 4 Stiff deep

intermittent

CD CD CD Separate

Body chart of

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MAITLA N D'S P E R I P H E RA L M A N I P U LATI O N

The cause of the source/ contributing factors

Degree of restriction

Look mainly for static and dynamic a l i g n ment faults of the spine as a cause of the source of the shoulder i m pa irment and the genera l 'arthritic' state.

Observation Left shoulder sloping more than the right, with the left scapula abd ucted relative to the right, loss of posterior deltoid and sca p u la muscle b u l k, poking ch i n / head forward position with dowager's h u m p.

Functional demonstration / active movements •

•

• • •

Shoulder H B B ( 1 ) wrist to i l iac crest: + glenohumera l MR ( 1 ) + + A H compression ( 1 ) ISO +AC squeeze ( 1 ) ISO Shoulder Ab 1 1 0· forward d rift 00 stiff, correct d rift 00 + Shoulder flexion 1 70· stiff + I V overpressure 00 + , @ Shoulder H / Ad, ./ ./ Shoulder LR 40· 00, @

Other structures to test on 0 7 • • •

Lower cervical quadrant E + LLF + LR 1 0·, stiff @ Cervical compression, moderate @ Forward flexion to mid shin @ stiff + cervical flexion @ lsO

Figure 1 1 .80

•

Quadrant appearance (initial examination).

U n i lateral posteroanterior movement on the angle of rib 2, stiff mid ra nge @.

Plan See how mobi l ization of the stiff second rib affects the shoulder pain as a cause of the sou rce and a barrier to the recovery of ideal shoulder movement, then mobil ize shoulder medial rotation eventually clearing the quadrant and locking position in conjunction with correction of postural alignment fa ults and m uscle imbalance correction. Check neurodynam ics later if necessa ry. D l , Rx l

r

On the second rib angle g rade IV i nto a deg ree of @ for 3 mins

HBB qual ity better, range 00 IsQ Shoulder Ab, F, LR ISO Lower Cx O/COMP ././ FF IsO @

Isometric testing - not tested on 0 1 . M uscle length testing - not tested o n D 1 . Neurological exam ination

-

not tested.

Neurodynamics - not tested.

Palpation •

•

Tenderness on pa l pation of the a nterior shoulder adjacent to the acromion process, but otherwise no other sign ificant pa l pation findings. Thickening of soft tissues and promi nence at C7, T l , T2 interspinous and over the a rticu lar pillars on the left.

DS, Rx2

00 ISO, @ felt better less ache EOO, @ ISO

r

On the second rib angle g rade IV+ i nto stiffness and loca l pain, 3 mins

H B B ISO Shou lder Ab, F, LR ISO FF ISO

I n 90· shoulder Ab did GH 4-++ cau d g rade I I I i nto a degree of 00 for 2 m i ns

HBB ra nge increased, wrist to L5 Shoulder Ab, F, LR ISO FF ISO

Passive movement •

•

•

•

•

• •

Glenohumera l accessory movements in neutral ideal range and symptom free. Glenohumera l and acromiohu meral joint com pression pain free. Acromio/sternoclavicu lar joint accessory movements idea l range and pain free. Glenohumeral medial rotation in 90· abduction, 50· of movement l i mited by stiffness and 00. Shoulder q uadrant low side and pea k especially stiff and 00, @ reproduced. Ouadrant a p pearance (Fig. 1 1 .80). Central and u n i l ateral posteroanterior accessory movement of C7, T l , T2, stiff late ra nge especially T2, local deep ache reproduced.

Dl,Rx3

00 easier, @ gone, @ ISO. Main problem now is putting her coat on. I n 90· shou lder Ab did GH 4-++ ca ud grades I I I / IV i nto a degree of 00, interspersed for 5 m i ns

H BB, shoulder Ab, F, LR ISO FF ISO

In 90· of shoulder Ab and 50· of medial rotation :J did ; of the head of h u merus grade III + into a degree of 00 for 3 m i ns

HBB wrist to L2 less stiff 00 ISO Shoulder ABD, F, LR ISO FF ISO

The shoulder and shoulder girdle complex

D 1 2,Rx4 •

•

(j) felt easier for a few days (putting coat on and lying on arm) but returned to normal level of pa i n after, neck felt stiff after Rx4 and sti l l feels a bit stiff. Shoulder movements ISO, lower cervical extension stiff 40· ®.

In prone did r move ment grade i l i on T 1 . T2 into ® for 5 m i ns

In prone did r move ment grade I I I + on T2 into ® for 4 mins

Cervical extension fu l l ra nge (55·) ® with overpressure (IV) H B B wrist to TlO less stiff (j) Shoulder Ab, F, LR ISO FF ISO Cervica l extension ././ HBB, Ab, F, LR ISO

Figure 1 1 .8 1

Quadrant appearance (after treatment five).

Figure 1 1 .82

Quadrant appearance (after treatment six).

Figure 1 1 .83

Quadrant appearance (after treatment seven).

D30, Rx5 (away on holiday over Xmas) •

Shoulder feels looser to move and easier to lie on but remains troublesome with the sa me movements. The neck and shoulder blade are now fi ne, the back is a bit stiffer after all the sitting about over Christmas. Cervical spine ././, shoulder HBB wrist to T10 (j) stiff, shou lder latera l rotation is better 65· (j) but Ab and F are ISO, forward flexion is stiffer, hands to knees reproduces @. (j)

•

In supine lying did shou lder quadrant scooping low side and peak g rade IV- i nto a degree of (j) for 4 mins

HBB better wrist to T7 stiff (j) Ab 1 50· stiff (j), less forward d rift F 1 70· stiff no (j), @

Figure 1 1 .81 ill ustrates the quadrant a ppearance after Rx5. D33, Rx6 and subsequent •

•

treatments

The stretching of the q uadrant had been fol lowed u p by a series o f automobi l izations for t h e shoulder i nto the quadrant position (throug hout the episode of care concurrent program mes of a utomobi l ization, functional stabil ity and muscle bala nce were carried out). Sta rting to feel as though the treatment is being effective, the neck has been fi ne, the shoulder is feeling looser and (j) is less noticeable.

In supine did quadrant low side, locking position and peak scooping g rade IV into discomfort for 5 m i ns Fig u re 1 1 .82 i l l u strates the q uadrant a ppearance after Rx6; Figure 1 1 .83 i l l u strates the q uadrant a p pearance after Rx7. Further treatment did not result in any more improvement q uickly. The quadrant rol l -over technique was used but was too pai nfu l and did not resu lt i n a ny further gain i n range. The patient was happy that her movements had returned and she would conti n ue to exercise and use the a rm norma lly until she felt there was no longer any restriction or until she had forgotten about it.

Refe rences Bland, J . H. 1 983. The reversibility o f osteoarthritis: a review. American Journal of Medicine, 74, 1 6-26 Brieg, A. 1978. Adverse Mechanical Tension in the Central Nervous System, Parts I and II. Stockholm: Almqvist and Wiksell

Butler, D. S. 2000. The Sensitive Nervous System. Adelaide: NOI Group Cleland, J. & Durall, C. 2002. Physical therapy for adhesive capsulitis: a systematic review. Physiotherapy, 88, 450-457

355

356

MAITLA N D ' S P E R I P H E RA L M A N I P U LATI O N

Conroy, D . & Hayes, K 1998. The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome. Journal of Orthopaedic and Sports Physical Therapy, 28, 3-14

Corrigan, B. & Maitland, G. D. 1983. Practical Orthopaedic Medicine. London: Butterworths Culham, E. & Peat, M. 1993. Functional anatomy of the shoulder complex. Journal of Orthopaedic and Sports Physical Therapy, 18, 342-350 Cyriax, J. H. & Cyriax, P J. 1983. Illustrated Manual of Orthopaedic Medicine. London: Butterworths Elvey, R. 1. 1986. Treatment of arm pain associated with abnormal brachial plexus tension. A ustralian Journal of Physiotherapy, 32, 223--225 Gerber, C & Ganz, R. 1984. Clinical assessment of instability of the shoulder with special reference to anterior and posterior drawer tests. British Journal of Bone and Joint Surgery, 66B, 551-556

Goodman, C & Snyder, T. 1995. Differential Diagnosis in Physical Therapy, 2nd edn. Philadelphia: W. B. Saunders Greening, J. & Lynn, B. 1998. Minor peripheral nerve injuries - an underestimated source of pain? Manual Therapy, 3, 187-194

Guanche, C, Knatt, T., Solomonow, M. et al. 1995. The synergistic action of the capsule and the shoulder muscles. American Journal of Sports Medicine, 23, 301-306

Gunn, C C 1 978. Pre-spondylosis and some pain syndromes following denervation supersensitivity. Notes presented as part of the 47th annual meeting of the Royal College of Physicians of Canada Kendall, E P, McCreary, E. K & Provance, P G. 1993. Muscle: Testing and Function, 4th edn. Baltimore: Williams and Wilkins Lewis, J., Green, A. & Dekel, D. 2001 . The aetiology of subacromial impingement syndrome. Physiotherapy, 87, 458-469

Magarey, M. E. 1993. The Shoulder Complex: Differentiation of Different Diagnostic Procedures from Clinical Orthopaedic Physiotherapy and Arthroscopic Examination. PhD Thesis,

University of South Australia

Magarey, M. E. & Jones, M. A. 1992. Clinical diagnOSis and management of minor shoulder instability. Australian Journal of Physiotherapy, 38, 269-280 Maitland, G. D. 1986. Vertebral Manipulation, 5th edn. London: Butterworths Maitland, G. D. 1991 . Peripheral Manipulation, 3rd edn. London: Butterworth-Heinemann Maitland, G. D. 1992. Neuro/musculoskeletal Examination and Recording Guide, 5th edn. Adelaide: Lauderdale Press Maitland, G. D., Hengeveld, E., Banks, K. & English, K, eds. 200 1 . Maitland's Vertebral Manipulation, 6th edn. Oxford: Butterworth-Heinemann Mattingley, G. & Mackarey, P 1996. Optimal methods of shoulder tendon palpation: a cadaver study. Physical Therapy, 76, 1 1 6-124 Mullen, E, Slade, S. & Griggs, C 1989. Bony and capsular determinations of glenohumeral 'locking' and 'quadrant' positions. Australian Journal of Physiotherapy, 35, 202-208

Peat, M. 1986. Functional anatomy of the shoulder complex. Physical Therapy, 66, 1855-1865

Reichrnister, J. P. & Freidman, S. 1. 1999. Long term functional results after manipulation of the frozen shoulder. Maryland Medical Journal, 48, 7-11 Rigg, D. 2002. Classification of shoulder disorders by their movement restrictions. Clinical Audit, Rotherham Primary Care NHS Trust Sahrmann, S. A. 2001. Diagnosis and Treatment of Movement Impairment Syndromes. St Louis: Mosby Schieb, ] . S. 1990. DiagnOSiS and rehabilitation of the shoulder impingement syndrome in the overhand and throwing athlete. Rheumatic Disease Clinics of North America, 16, 971-988

Schneider, G. 1989. Restricted shoulder movement: capsular contracture or cervical referral - a critical study. Australian Journal of Physiotherapy, 35, 97-100 Sunderland, S. 1 978. Nerves and Nerve Injuries, Part 1, 2nd edn. Edinburgh: Churchill Livingstone Westerhuis, P. 1 999. Shoulder Instability. Course notes, level 3. International Maitland Teachers' Association, Switzerland

357

Chapter

12

The elbow complex

THIS CHAPTER INCLUDES: • •

•

Key words for this chapter Glossary of terms for this chapter Presentation of the e l bow complex as a peripheral transitional region

KEY WORDS Transitional region, superior radiou lnar joint, radioa n n u l a r Joint,

GLOSSARY OF TERMS Diurnal events - events which happen during the day as opposed to nocturnal events which happen during the night. Lateral epicon d yla l g ia - a syndrome whereby pain is experienced over or arou nd the lateral epicondyle of the el bow. Such a d isorder is characterized by d ifficulty or loss of functional activities i nvolving gripping because of lateral epicondylar pain. Pai n dimensions - the realization that pain always has cognitive and

•

•

•

•

Subjective exa m ination of the e lbow complex Evidence-based practice related to the elbow I ntegrated physical exam ination of the el bow com p l ex Exa m i nation and treatment techniques

•

•

Common elbow d isorders and syndromes including: - tennis elbow - chronic m i nor joint pai n - latera l epicondylalgia A case study relevant to the elbow

h u merou lnar joint, radiohu meral jOint, radial nerve, ulnar nerve, media n nerve, sympathetic chains,

extensor carpi radialis brevis, common extensor origi n , common flexor origin.

emotional dimensions to its experience as well as sensory di mensions. Pain processing - the means by which pai n comes to be registered as a sensory, cognitive and emotional experience. Such processing is i nfl uenced by the com plex i nteractions within and at a l l levels of the neuromatrix (nociceptive I neurogenic input, central sensitization, su ppression and relayi ng, present and past environmenta l i nfl uences on the whole sam p l i ng experience, maladaptive or ada ptive motor

outputs in the endocrine, i m m une, a utonomic and movement systems). Prehension - the abil ity of the h u m a n hand to function as an organ which can g rasp and m a n i pu late tools and objects with fi ne detail. U p per l i m b neural provocation tests (ULNPn - a term used to acknowledge the effects of movement on the mechanical sensitivity of the neura l structures in the u pper l i m b, in particu lar the radial, u l nar and median nerves.

358

M A I T LA N D'S P E R I PHERAL M A N I PULAT I O N

[ INTRODUCTION The elbow is a region which is far too often examined poorly by manipulative physiotherapists (Maitland

1991). This is due to a lack of attention to detail. There is ample evidence, both clinically and in the available literature, to suggest that symptoms in the area of the elbow have a multifactorial origin. For example, Kamien

(1990) suggests that 'tennis elbow'

can be due to the involvement of any structure around the elbow and that pain may even be referred from dis tant sites such as the wrist, neck and thoracic outlet. With this in mind, symptoms in the area of the elbow demand that the physiotherapist pays particular atten

Humeroulnar (Coranoid olecranon)

tion to the subtleties of the information which the patient is presenting. For example, patients with elbow pain will often have more than one pain in the same area. On fur ther questioning the pains are found to be different in

Figure 12.1

Superior radioulnar Joints of the elbow complex.

description and movement-related behaviour: 'I have a sharp pain in my elbow when 1 grip things, but then it

primarily with pronation/supination movement and

can ache in the same place when 1 twist my arm.' The

the humeroulnar joint is involved primarily with the

therapist must follow up this information with, 'Do you

hinge movement of flexion and extension. The transition

think the sharp pain is the same thing as the ache?' From

is the radiohumeral joint which is involved with both

here a line of questioning may develop which estab

sets of movement and is often the joint that is found to be

lishes that the sharp pain is on the surface and unrelated

most often symptomatic in movement-related joint dis

to the deeper ache. Both pains may then have different

orders of the elbow. Furthermore, incongruence of the

origins and need treating in different ways.

joint surfaces, partly to provide for the carrying angle of

Likewise, the physiotherapist must be prepared to consider all potential sources or causes of the source of

the elbow at the end of extension, will also contribute to the articular compromise of this joint complex.

the patient's symptoms, as well as the possible mech

Both anatomically and physiologically the elbow

anisms and dimensions involved in their production.

region is an extensive juncture of neural information

(Chapter

10). Detailed examination of the elbow and

associated structures will only serve to enhance the potential of manipulative physiotherapy management

from various sources. It is a: •

peripheral nerves and a common site of nerve

of movement-related disorders.

entrapment •

THE ELBOW AS A PERIPHERAL TRANSITIONAL REGION The elbow can be likened to a biomechanical, func tional,

physiological

and

meeting point for articular branches from several

pathological

transitional

region for several reasons.

common site of referred pain from the shoulder or cervical spine

•

site of sympathetic activity due to enhanced

•

site of secondary hyperalgesia accompanying

sympathetic outflow in thoracic spine disorders peripheral nerve entrapment. The radial nerve is vulnerable at the elbow as it

The elbow joint allows relatively less movement

passes over the head of the radius then deep into the

than its multidirectional neighbours, the shoulder and

supinator tunnel; the ulnar nerve is vulnerable at the

the wrist and hand. This compromise of stability of the

elbow as it passes through the hard intermuscular sep

upper limb and the enhancement of the scope of pre

tum and becomes superficial behind the medial epi

hensile function of the hand can make the elbow vul

condyle, and the median nerve becomes vulnerable as

nerable to overstrain and trauma, these factors being

it passes close to the hard edge of the biceps tendon

the most common reasons for movement-related pain

and then passes through pronator teres.

and dysfunction of the elbow.

The elbow is also a vulnerable site in terms of

The joints within the elbow complex are a move

muscle/tendon injury and degeneration. The anchorage

12.1). The super

sites of various muscle groups at the elbow produce

ior radioulnar and radioannular joints are concerned

short, forceful leverage over the elbow in order that

ment compromise in themselves (Fig.

The e l bow compl ex

the muscles can work effectively through long lever

3. specific (easy for the patient to localize in areas of

age at the wrist, the hand and the shoulder.

recognizable neuromusculoskeletal strucrnres). On the other hand remote sources or symptoms influ enced more by pain processing than input mech

SUBJECTIVE EXAMINATION

anisms will be:

Question

1

1.

Knowing what the patient's main problems are can help the physiotherapist to decide what kind of dis order the patient has. If elbow pain is the problem the site, description and depth may be diagnostic in itself. The relationsrup of pain to everyday activities will help to establish whether the problem is movement related or not. If the symptoms are movement related,

�ose

activities causing symptoms may also help to

Identify the source. For example, the patient may com plain of the elbow being stilf causing an inability to bend, straighten or twist it fully (joint dysfunction). Alternatively, the patient may say that when griping a kettle a sharp pain is experienced on the outside of the elbow (forces created about the common extensor origin). The patient may complain of aclting or burn ing around the elbow especially when sitting for long . penods or when lying in bed (referred pain mech anisms or radicular pain). Sometimes the patient may relate the main problem to the onset of symptoms. Trus may reveal an injuring movement or a predisposing activity. For example, the patient may tell of being unable to straighten the elbow since falling on the arm or may indicate that the out side of the elbow is sore after spending 2 hours pruning

inconsistent (symptoms move around

and are

more variable in their diurnal nature)

2. unfamiliar (described in terms of their effects rather than their sensory dimensions, i.e. tiring, wearing, depressing)

3. vague (difficult for the patient to localize, often being outside the body or 'like it doesn't belong to me'). Attention to the non-verbal cues wruch the patient may give also enhances the physiotherapist's hypoth esis about the disorder. The patient may point to a spe cific spot of pain with the tip of a finger or may grasp round the elbow to describe the vice-like pain being experienced. Likewise, the patient may use the whole hand to describe a vague area of symptoms or may sweep the hand down from the upper arm across the elbow into the forearm. In each case these non-verbal cues will be of great value. It is also important to know whether the symptoms are palpable or whether they are deeply sirnated witltin the joint. If they are deep, time should be taken to know precisely wruch of the closely associated joints seems to be implicated. Certain areas of symptoms are quite common to specific local elbow strucrnres and are described in Box

12.1.

roses in the garden.

Behaviour of symptoms (d iurnal and nocturnal patterns)

Areas of symptoms (body chart) A detailed body chart can help the physiotherapist to mterpret the source of the patient's symptoms witltin the movement system strucrnres around the elbow or from struchlres that can refer pain into the elbow, such as the neck, shoulder and nerve roots (radicular pain). The familiarity of the symptoms and their location may help the therapist to decide wruch pain mechanisms are in operation (nociception, peripheral neurogenic pain, sympathetically

maintained

pain,

central! affective

mechanisms or combinations of these).

In hlrn it may be helpful to consider a scale of factors to determine how locally or how remotely the symp toms are being generated. Local sources are more likely to be the origin of the symptoms if the symptoms are:

1.

If the patient's symptoms are being generated from local struchlres, the body will provide valuable infor mation about wruch activities the patient associates with a worsening of symptoms. What eases the symp toms and how quickly may be less clear, purely because the patient has often not really thought about this aspect of the symptom behaviour. If the neuromusculoskeletal strucrnres of the elbow are impaired the patient will quickly associate the symptoms (pain) with such activities as gripping objects tightly or not being able to straighten the elbow fully due to pain and stilfness, or waking up in the morning and finding that it takes several movements of the elbow for it to unstiffen. If pain in the elbow has its source in strucrnres far

consistent (always in the same place and a given

removed from the elbow or is due to mechanisms

stimulus will give a predictable response)

that are less influenced by movement, the patient will

2. familiar (described as being a joint-like ache or a sore ligament)

associate the elbow pain less with obvious functional activities of the region. The patient may associate a

359

360

M A ITLAN D ' S P E R I P H E RA L M A N I PU LATI O N

Elbow symptoms

Local structures

Tip of the lateral epicondyle Medial part of the lateral epicondyle Rad ioh u meral joint line Head of radius Posterior to the lateral epicondyle Band of pain across the e lbow Deep anterior pain

Bone, radial nerve hyperalgesia Common extensor origin Radiohumeral joint, rad ial nerve (anterior) Annu lar l igament. rad ioannu lar joint Olecranon Rad iohu meral, h u meroulnar joints Rad iohumeral, humeroulnar, superior rad ioulnar, median, radial nerves Anterior capsule, coranoid, biceps Vascu lar Common flexor origin U lnar nerve Olecranon

Surface anterior Deep throbbing Medial epicondyle U lnar notch Posterior

worsening of symptoms more with the time of day such as morning, evening or night time, or with other factors such as prolonged sitting or changes in the weather. A detailed knowledge of the behaviour of the patient's elbow symptoms with movement will help the clinician to decide which movements are impaired and which are likely to reproduce the patient's pain when examined. The ease with which the symptoms will be reproduced and therefore the care required to avoid excessive provocation of the symptoms will be established. 1£ the patient can also conSistently per form a functional demonstration activity which repro duces the symptoms, the potential for structural differentiation is enhanced. If a patient experiences lateral elbow pain, for ex ample while clenching the fist with the elbow straight and pronated, the following differentiations may be considered: •

•

Lay the patient in supine and ask them to adopt the position and perform the fist clenching. In this pos ition adopt the localization of forces for the ULNPT 2b and add cervical contralateral lateral flexion and shoulder depression to the functional demonstra tion. If the symptoms increase and decrease with the sensitizing additions (Butler 2000) entrapment of the radial nerve may be postulated. In the same starting position either perform a pos teroanterior movement on the head of the radius or, while maintaining the clenched fist, push the radius cephalad so that the head of the radius is com pressed more against the capitulum. If either of these differentiations changes the symptoms signi ficantly, the radiohumeral joint may be considered for further examination.

•

1£ the only factor which alters the patient's symp toms is the strength of the grip and pain is repro duced on palpation of the common extensor origin rather than the radial nerve or the radiohumeral joint line, the most likely source of impairment will be with the extensor muscle apparatus.

Pain and stiffness produced in the elbow primarily with a flexion/extension movement would suggest further investigation of the raruohumeral and humer oulnar joints in particular. Pain and stiffness with activ ities involving pronation/supination activities suggest that further investigation of the radiohumeral, radioul nar and radioannular joints is warranted. Elbow pain with keyboard use or other relatively fixed postural activities is often associated with either muscle imbalance and alignment faults of the spine and upper limb or chronic constriction of nerve tissue around the elbow or even further afield. Elbow pain with weight-bearing activities through the arm may indicate the need to use compression tests of the elbow joints within examination and treatment to have a better chance of reproducing and affecting the pain experienced with weight-bearing. Where pain is referred into the elbow from other sources a relationship between symptoms and move ment in these other areas and the elbow symptoms should be established.

History (present episode and its progression since onset and past episodes and their natural histories) Present episodes of elbow impairment can begin in several ways. The most obvious is following trauma

The el bow complex

such as fracture of the olecranon or head of radius or

with the Mill's manipulation for treating tennis elbow.

subluxation of the head of radius. Sudden spontaneous

He states that 'the more effective technique is to gap

episodes of elbow pain and dysfunction may follow

the elbow in adduction with a sharp flick of the

unusual or heavy activity or new or unfamiliar use.

forearm'.

Predisposing factors such as past injury may explain

Gunn and Milbrandt (1976) wrote their classic study

why the elbow has become symptomatic in individual

based on 50 patients with tennis elbow whose condition

cases.

had proved resistant to treatment directed to the elbow

Degenerative arthropathies may result in recurrent

and who showed good or satisfactory improvement in

episodes of pain and stiffness which recover over a

86% of cases when the neck was treated (including cer

period of time. Rheumatoid elbows may become

vical mobilization). The suggestion was that the under

swollen, tender and stiff in line with exacerbations and

lying condition may have been a reflex localization

remissions of the systemic disease.

of pain from radiculopathy in the cervical spine. Thus

Whatever the nature of onset, the physiotherapist

a link between arm pain and the cervical spine was

must be aware of the complexities of why a particular

established, a link that is now routinely investigated by

disorder runs its natural course in the way that it does.

manipulative physiotherapists.

The ultimate aim is to restore pain-free ideal quality and quantity of movement.

Gifford

(1986) in his elbow symposium to the

Manipulative Physiotherapists Association of Australia

In many cases of elbow pain and activity limitation

emphasized the detail of physical examination of the

there does not seem to be one clear cause and no recog

elbow which Maitland

nizable pathology. In such cases the natural history is

ing in the way manual therapists dealt with elbow dis

protracted beyond what is expected for natural bio

orders. Gifford is clear that:

(1977) suggested had been lack

logical recovery times or there is recurrence with little evidence of mechanical or stressful triggers. In such situations the physiotherapist should be concerned with identification of the actual and potential barriers to recovery. This will include detailed examination of any part of the movement system which may be holding back maximization of movement potential. In the case of the elbow this may well include examination of the

We [manipulative physiotherapists] are now at a stage of clinical precision where it is frequently possibLe to be abLe to difef re from individual joints in the elbow and make decisions as to whether problems are intra-articular or periarticular in origin ... Priorities of treatment may therefore be based on the results of this.

thoracic spine and ribs which, in the authors' experi ence, commonly generate or add to sensitivity around

Hyland et al (1990) reviewed the clinical benefits and

the elbow - a slightly stiff shoulder may lead to over

adaptations of the extension/adduction test in chronic

straining of the elbow structures; an overactive extensor

tennis elbow. They acknowledged Maitland's

carpi radialis brevis may result in malalignment of the

view that extension/adduction of the elbow is most

wrist and therefore forces of muscle imbalance around

frequently positive in chronic tennis elbow sufferers

the elbow.

(1977)

and that the test is a useful technique for evaluating and treating the articular components of chronic tennis elbow as well as extra-articular soft tissues such as

Special questions

extensor carpi radialis brevis. Hyland et al also pro

As well as routine information about the patient's gen eral health, any relevant weight loss, the medication the patient is taking and any medical imaging proced ures that have been undertaken, there may well be value in checking that the elbow pain is not cardiac, visceral or vascular in nature (Chapter

10).

posed that the addition of wrist flexion and extension can further augment the pain reproduction of the extension/ adduction test. Wright and Vicenzino

(1997) reviewed a number of

studies evaluating a variety of therapeutic interventions used in the management of lateral epicondylalgia. The review of

manipulation,

based on one study by Burton

(1988), suggests that manipulation of the elbow joints is associated with an improvement in clinical presentation

EVIDENCE-BASED PRACTICE WITH REFERENCE

of patients with lateral epicondylalgia over a short

TO MANIPULATIVE PHYSIOTHERAPY

period. However, this study by Burton failed to address

Stoddard

(1971) was one of the first to comment on

that attributable to placebo or natural recovery. Like

manipulation of the elbow joint in the physiother

wise, the authors demonstrated an improvement in both

apy literature. He describes how he is impressed

pain and function following treatment with a lateral

the question as to whether any change was better than

36 1

362

M AITLAN D'S P E R I PHERAL M A N I PULAT I O N

glide mobilization technique o f the elbow a s described by Mulligan (1995). The authors were also able to demonstrate that a lateral glide mobilization of the cervical spine produced an immediate improvement in elbow pressure pain threshold, pain-free grip strength and neural tissue mobility. However, no long term follow-up was undertaken. Vicenzino B (2003) in his Manual Therapy Masterclass on lateral epicondylalgia believes that the mainstay of successful management of this condition is therapeutic exercise. Adjunctive procedures such as manipulative physiotherapy and sports taping techniques show evi dence of producing early pain relief. Such early pain relief in the rehabilitation programme will help to accel erate recovery. This underlines the value of manipula tive physiotherapy as a means to an end in this and many other rehabilitation programmes. Several biomechanical, anatomical and pathological features of lateral epicondylalgia and elbow joint injury are frequently repeated in the literature: •

•

•

musculotendinous emphasis on the role of the exten sor carpi radialis brevis in symptom production (Kamien 1990) the processes of radial nerve entrapment (Albrecht et a11997) the role of the cervical spine in the mechanisms producing lateral elbow pain (Vicenzino 2003).

All this evidence strengthens the case for a multi component, multidimensional approach to the exami nation, treatment and management of many elbow disorders. This should include detailed examination of the joint accessory, physiological and combined move ments, isometric testing (especially of extensor carpi radialis brevis and palpation of its origin) and biasing neural provocation tests to the radial nerve in particu lar. This, coupled with detailed examination of cervi cothoracic intersegmental mobility, will only serve to enhance the diagnostic, treatment and management role of manipulative physiotherapy in elbow disorders.

articular emphasis on the intra-articular and peri articular structures as being vulnerable to compres sive and shearing forces and stretching (Shapiro & Nyland 1994) and the common occurrence of chondral lesions of the head of the radius in exten sion-defective elbows (Quintart et a11998)

lox 1 2.2 Observation •

•

PHYSICAL EXAMINATION: ELBOW REGION

The following is a checklist for an integrated approach to the physical examination of the elbow region, as summarized in Boxes 12.2-12.5 (Maitland 1992).

Physical examination of the composite elbow

*Fu nctional demonstration / tests

Theirdemonstration of theirfunctional movements affected by their d isorder Differentiation of their demonstrated functional movement(s)

Brief appraisal Active m ovements (move to pain or move to limit) F, E (as appl icable, bouncing F and E in fu l l pronation • and su pination) • Sup, Pron (as appl icable, performed in F and E) Isometric tests Other structures in 'plan' Thoracic outlet • Entrapment neuropathy •

I

•

Passive movements As applicable · F, E ; Su p and Pron as IV- to IV+ to I I I ++

Differentiating as required 1. F and E as IV+ at l imit of range (a) F/ Ab, F/ Ad, E/Ab, E/ Ad. Ab and Ad in the first 5° of F and full E (b) ...... (in l ine with h umerus) ceph and caud (i) on rad ius (rad iohumeral) (R/H) joint or su perior radioulnar (R/U) joint add superior R/U compression to d ifferentiate between R/H and superior R/U (ij) on u lna (humeroulnar joint) (c) ...... (in line with rad ius) ceph and caud (i) on rad ius (R/H or su perior R/U joint) add su perior R/U com pression to differentiate between R/H and su perior R/U (ii) on ulna (hu meroulnar joint) 2. Sup and Pron as IV+ at limit of range (a) ; t on head of rad ius (su perior R/U or R/H joint) add com pression of su perior R/U joint to differentiate between rad iohu meral and su perior R/U joint. (b) ; , t on u lna (humerou lnar joint)

The e l bow com p l ex

3.

4. 5. 6. 7.

Other differentiating tests (a) ; , \., ,/, t , \' I on head of radius in different positions of el bow F and E (b) -++, -- on olecranon and coronoid Combined movements Ca nal's slump test Differentiation tests ULNT

Box 1 2.3

II

Pa l pation + When 'comparable sig ns' il l-defined, reassess 'inj u ring movement'

•

Check case records etc. Highlight main findings with asterisks

Instructions to patient Reproduced by kind permission from Maitland

(1992).

Physica l examination of the radiohumeral joint

The routine exa mination of this joint must include examination of other joints forming the el bow. Observation "Functional demonstration/tests • Theirdemonstration of their functional movements affected by their d isorder • Differentiation of their demonstrated fu nctional movement(s) Brief a ppraisa l Active movements (move to pain or move to limit) Routinely • F, E; Sup and Pron in F and E • Note range, pain As applicable • Speed of tests movements • Specific movements which agg ravate • The i njuring movement • Movements u nder load • Thoracic outlet tests • Muscle power

Isometric tests • Muscles in 'plan' including clench ing fist in d ifferent positions of elbow

The routine exam ination of this joint m ust a lso include exa m ination of the superior radioulnar (R/ U) joint as supi nator/ pronator torsion is possible at the hu merou lnar joint. Observation "Functional demonstration /tests • Their demonstration of their functional movements affected by their disorder

Other structures in 'plan' Thoracic outlet • Entra pment neuropathy

•

Passive movements Routinely 1. F, E; Sup and Pron in F and E 2. +-+-+ ceph and ca ud (by wrist deviations) i n d i fferent ang les of el bow from full F to fu l l E, and fu l l supination t o fu l l pronation 3. ;, t i n d ifferent positions of F, E, Sup, Pron, without compression and with compression Note range, pain, resistance, spasm and behaviour As applicable 1 . Ca nal's S l u m p tests 2. Differentiation tests 3. U LNT

Palpation + When 'comparable signs' i l l-defined, reassess 'injuring movement'

•

Check case records etc. Highlight main findings with asterisks

Instructions to patient Reproduced by kind permission from Maitland

•

(1992).

Differentiation of their demonstrated fu nctional movement(s)

Brief appraisal Active movements (move to pain or move to limit) Routinely • F, E; Sup and Pron in F and E • Note ra nge, pa i n

363

3 64

M A I T LA N D ' S P E R I P H ERAL M A N I P U LATION

Isometric tests Muscles in 'plan' including clenching fist in different positions of elbow

•

Other structures in 'plan' Thoracic outlet • Entra pment neuropathy

Pa l pation Temperature • Swe l l i n g and wasting • Altered sensation • Releva nt tenderness (ulnar nerve hypersensitivity) • When 'comparable signs' i l l -defined, reassess 'injuring movement'

•

•

Passive movements Physialagical mavements Routinely • F, E; Sup a n d Pron in F and E Note ra nge, pain, resista nce, spasm a n d behaviour As applicable • E / Ab, E /Ad, F lAb, F /Ad, Ab and Ad in 5' F and E

Check case records etc. Highlight main findings with asterisks

Accessary movements As applicable

1.

-.

+-

....... ca ud.

(humera l l ine) i n 90' el bow F (i) on olecranon (thumbs) (ii) on coronoid (thu mbs) (iii) general humeral line 3. F over wrist i n a nterior elbow l i ne. 4. ....... ceph, ca ud u l n a r l i ne (with wrist deviations) in d ifferent ang les of elbow F and E Note range, pa i n , resistance, spasm and behaviour 5. Ca n a l 's slump test 6. Differentiation tests 7. U LNT

2.

As applicable Speed of tests movements • Specific movements which aggravate • The i njuring movement • Movements under load • Thoracic outlet tests • Muscle power

•

(i) (ii)

The routine exa m i nation of this joint m ust also include exa m ination of the h u merou lnar and radiohu meral joints. Observation *Functiona l demonstration /tests • Their demonstration of their functional movements affected by their disorder • Differentiation of their demonstrated fu nctional movement(s) Brief appraisal Active movem ents (move to pain or move to limit) • As described for the elbow joint Isometric tests Other structures in 'plan' Thoracic outlet • Entra pment neuropathy

•

Passive movements Physiological movements • As for elbow joint

Instructions to patient

on olecranon on coronoid

Reproduced by kind permission from Maitland

(1992).

Accessory movements Routinely 1. Ab and Ad of el bow i n 5' F (Su p RI U) 2. ....... ceph, caud (ulnar line) in different angles of elbow F and E and different angles of Sup and Pron (using wrist deviations) without compression and with compression 3. t and ; , each in fu l l pronation and fu l l supi nation 4. Supi nation I pronation with compression As applicable 1. Ca na l's s l u m p tests 2. Differentiation tests 3. ULNT

Palpation + When 'comparable signs' i l l-defi ned, reassess 'injuring movement'

•

Check case records etc. Highlight main findings with asterisks

Instructions to patient Reproduced by kind permission from Maitland

(1992).

The elbow complex

In standing •

• •

• •

Observation of: - alignment faults: from front, back and side - asymmetry: adaptive and protective deformity - impairment signs: swelling, thickening - structural impairment: olecranon, epicondyles Present pain Functional demonstration/active functional movements and differentiation including functional stability of the shoulder and wrist/hand If necessary tests - elbow Brief apprillsal/screening shoulder

C3-C7 passive physiological intervertebral move ments (PPIVMs) (Maitland et a1200l)

In side lying •

In prone lying • •

•

In sitting • •

•

•

•

Cervical spine brief appraisal/screening tests including lower cervical quadrant and cervical movements under compression (Maitland et a1200l) Thoracic spine brief appraisal/screening (Maitland et a1200l) Long sitting slump, including biasing towards sympathetic chains and rib pressure to reproduce arm pain/symptoms (Butler 2000) Grip strength in full elbow extension, including alignment faults at the wrist and shoulder

•

• •

• • •

•

•

•

•

•

•

Palpation for signs of impairment (joint lines, peripheral nerves, common flexor and extensor origins in particular) Isometric testing: (1) grip strength in elbow extension; (2) wrist extension; (3) individual metacarpal extension, especially the third which is the insertion site for extensor carpi radialis brevis Elbow passive movements Elbow extension, extension/adduction, extension/abduction Elbow flexion, flexion/adduction, flexion/abduction Pronation/supination Differentiation tests in flexion/extension or pronation/supination Accessory movements: radiohumeral, radioulnar, radioannular, humeroulnar Longitudinal movement caudad and anteroposterior movement on the first rib Cervical anteroposterior movement (Maitland et a1200l) Shoulder quadrant and locking position (for medial elbow pain) Brief appraisal tests/screening wrist and hand and inferior radioulnar joint Upper limb neural provocation tests (ULNPT) (Butler 2000)

Olecranon accessory movements in elbow flexion posteroanterior movement of the head of the radius in elbow extension Passive accessory intervertebral movements (PAIVMs) cervical and thoracic spine Rib movements

Preca utions and planning •

•

In supine •

C7-T4 PPIVMs (Maitland et a1200l)

•

Explanation: The patient should b e informed at every stage of examination and treatment. The therapist should inform the patient, as far as is possible, about the nature of the problem, the options for treatment (including benefits and risks) and the expected responses to treatment. Warning: After examination (and first treatment) the patient should be warned that there may be some treatment soreness over the next day or so. This is because the joint has been moved, both during examination and treatment, in ways that it has not been moved before or for a while. The therapist should check the case notes and medical imaging, and plan treatment and reassessmen t.

PHYSICAL EXAMINATION: THE ELBOW COMPLEX

Observation •

In most cases patients with elbow pain will have no obvious visual abnormalities.

•

Fractures or definite trauma often present with swelling or bony deformity.

•

Prominence and local swelling of the lateral epi condyle may be a feature of so-called tennis elbow.

•

Antalgic postures may include holding the elbow flexed to avoid painful extension or keeping the forearm pronated to avoid painful supination.

•

If the patient holds the arm above the head to gain relief from throbbing pain around the elbow and forearm, there may well be a CS--6 nerve root lesion.

365

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M A ITLAN D'S P E R I PH E RA L M A N I P U LATI O N

Functional demonstration/i njuring movements/ active fu nctional movements and differentiation of these movements (to P, or l i mit) Observe for abnormalities in quality of movement and common alignment faults, for example the patient may rotate the shoulder to avoid having to supinate the forearm. During grip strength tests in elbow extension over activity of extensor carpi radialis brevis may result in the wrist excessively radially deviating and the elbow flexing. The patient may also grip with the wrist in flex ion causing overactivity of the flexor carpi ulnaris. If elbow pain is reproduced with the grip strength test but is relieved as the alignment faults are corrected, this should be incorporated into functional rehabilitation. Active movements or brief appraisal of the elbow should include flexion, extension, pronation and supina tion (Figs 12.2-12.5). If active movement is pain free, the patient can be asked to flick the elbow further into the movement as a means of applying natural overpressure. Only if the patient has a consistent, reproducible functional demonstration will further differentiation be possible: •

•

•

A patient with deep anterior elbow pain may demonstrate that the pain is always felt when the elbow is bent from 75 to 95°. If the painful move ment is repeated with compression or distraction of the radiohumeral joint, compression or distraction of the humeroulnar joint, or repeated flexion/exten sion movement in different positions of pronation/ supination, a more accurate localization of the source of the symptoms will help in the choice of treatment technique (Figs 12.6-12.9).

Figure 12.2

Elbow flexion.

Figure 12.3

Elbow extension.

A patient with lateral elbow pain may demonstrate that the pain is always felt when twisting (pronat ing) the forearm while using a screwdriver (loaded). If the painful movement is performed with radio humeral compression or distraction, superior radio ulnar joint compression or in different positions of flexion and extension, an accurate treatment tech nique can be determined (Figs 12.10-12.14). A patient with tennis elbow and lateral epicondy lalgia may complain of lateral elbow pain when gripping a golf club. The patient may be able to demonstrate, consistently, the reproduction of this pain. In the painful position accessory movements on the head of the radius may reveal to the examiner any articular involvement. In the painful position, the addition of shoulder depression and contralateral cervical lateral flexion may reveal any radial nerve entrapment or neural mechanosensitivity. The lower cervical quadrant or cervical compression screening

The e l bow complex

Figure 12.4

Elbow supination.

Figure 12.6

Elbow flexion to 75·.

Figure 12.5

Elbow pronation.

Figure 12.7

Radiohumeral compression.

367

368

M A ITLA N D 'S P ERIP H ERAL M A NIPU LATIO N

Figure 12.8

Figure 12.10

Humeroulnar compression.

Radioulnar pronation.

Figure 12.9

Figure 12."

Different positions of pronation/supination.

Radiohumeral compression added.

The e l bow complex

Figure 12.12

Radiohumeral distraction added. Figure 12.14

Su perior radioulnar compression added.

tests may reveal cervical intervertebral involvement. An increase in pain with isometric testing of wrist and finger extension (in the absence of any other movement-related signs) may suggest musculotendi nous origins to the patient's symptoms. Interestingly, Su et al (1994) suggested from a study on grip strength in different positions of the shoulder and elbow that, in a population of Taiwanese women, grip strength was greatest with the elbow straight and the shoulder in full elevation. A further suggestion is that this position allows the back extensors and shoulder girdle muscles to work synergically to stabilize the arm. In clinical practice, physiotherapists faced with a patient with unresolving elbow pain while gripping will visit the thoracic spine and shoulder girdle areas in search of impairments. Mobilization of the thoracic spine and better functional stability of the shoulder girdle (relief of pain inhibition) are often the 'kick starters' of the return of pain-free grip strength.

If necessary tests Figure 12.13

Different positions of flexion I extension.

Frequently elbow pain is associated with vigorous sporting activity or injury. In such cases it may only be

369

370

M A ITLAN D'S P E R I PH E R A L M A N I P U LATI O N

possible to reproduce the patient's pain by asking them to perform the offending activity at speed (throwing a cricket ball or equivalent), repeatedly (table tennis backhand) or for a sustained period (grip ping a ski pole).

Isometric testing Isometric testing has long been the mainstay proced ure of manual therapists in evaluating muscle dis orders either of the contractile fibres or of the origin and insertion. Cyriax and Cyriax (1983) were staunch advocates of the use of isometric testing to isolate muscle pain, but, in reality, isometric testing alone has limita tions. Treatment of other presenting signs such as neural mechanosensitivity or joint signs, followed by reassessment of the pain with isometric testing, will only then reveal the true extent of the muscle involvement. Isometric testing as a pain provocation procedure is required in cases of lateral elbow pain when grip and loaded wrist or finger extension are painful. The authors consider that the best position for isometric testing is with the patient lying supine and the elbow fully extended and pronated. Pronation is thought to exert more tension on the common extensor origin. In supination the origin is thought to be pro tected and stabilized more by the origin of the biceps. Stoddard (1971) advocated the use of tendon palpa tion during isometric testing as a prerequisite to local ization of his adapted Mill's manipulation. Commonly the middle finger reproduces lateral elbow pain most readily when resisted isometrically in wrist extension. Extensor carpi radialis attaches to the third metacarpal and provides the most extensive component of the common extensor origin (Karnien 1990).

Palpation A detailed knowledge of surface anatomy (Hoppenfeld 1976) will enhance the clinician's ability to feel relevant changes in the structures around the elbow. Figure 12.15 shows some relevant sites for palpation of the lateral aspect of the elbow. Palpation of the soft tissues in the olecranon during passive elbow extension can reveal signs comparable with the disorder. Sensitivity (allodynia, secondary hyperalgesia) of palpation sites around the elbow in the absence of signs of tissue damage or inflammation may be due to pain-producing mechanisms beyond the potentially nociceptive local structures (Chapter 10).

(b)

Olecranon fossa Common extensor origin --�,I Radiohumeral joint line

-...:;;;;; ; ;;;;-";:j

---

Annular ligament

Figure 12.15

Palpation sites, lateral elbow pain.

Upper l i m b neural provocation tests (ULNPT) The potential for nerve entrapment around the elbow is always a strong possibility (Corrigan & Maitland 1983) given that the ulnar (superficial), median (pass through pronator teres) and radial nerves (pass through the supinator tunnel) are all in close proximity to vulnerable entrapment sites (Butler 2000). The ulnar nerve test (ULNPT 3) (Fig. 12.16) should be part of the physical examination if the patient com plains of medial elbow pain and symptoms in the dis tribution of the ulnar nerve. For example, a patient may complain of medial elbow pain and paraesthesia in the little finger when performing an overhead smash at badminton, thus suggesting a potential ulnar nerve entrapment. If the ULNPT 3 reproduces the patient's symptoms and further increase of shoulder girdle depression makes the symptoms worse or release of shoulder depression eases the symptoms, it is fair to say that ulnar nerve mechanosensitivity has been demonstrated.

The elbow com p l ex

Figure 12.16

Ulnar nerve test.

The median nerve test (ULNPT 1, 2a) (Fig. 12.17) should be part of the physical examination if the patient complains of anterior elbow pain with symp toms in the distribution of the median nerve. For exam ple, a patient may complain of a feeling like a tight piece of elastic through the front of the elbow with tin gling of the thumb and index finger when carrying a heavy load of shopping in the hand. As with the ulnar nerve, if testing (ULNPT 1, 2a) provokes the symptoms and the addition and subtraction of shoulder girdle depression increases and decreases the symptoms, respectively, it is clear that median nerve mechanosen sitivity is being demonstrated. The radial nerve test (ULNPT 2b) (Fig. 12.18) should be part of the physical examination if the patient complains of lateral elbow pain with symptoms in the distribution of the radial nerve. For example, a patient may complain of lateral elbow pain and cramp in the forearm and between the thumb and index finger dor sally after spending an hour at the computer key board. Once more, if relevant testing (ULNPT 2b) provokes the patient's symptoms and shoulder girdle depression and elevation increases and decreases the symptoms, it is likely that the radial nerve is more mechanosensitive than it should be. Butler (2000) presents a 'wise action' rationale for the manipulative physiotherapy management of such cases of entrapment including the mobilization of the relevant interface tissue sites and the restoration of peripheral nerve 'slide' and 'tension'.

Passive movements ( joi nts) The elbow complex consists of the humeroulnar, radiohumeral and radioulnar / radioann ular joints (see

Figure 12.17

Median nerve test: (a) ULNPT 1 ; (b) ULNPT 2a.

Figure 12. 18

Radial nerve test.

Fig. 12.1). Any of these joints can be a source of elbow pain. Differential examination of each joint is an important skill: •

If the elbow is held 10° short of full extension, there is an amplitude of abduction and adduction move ment. During this abduction/ adduction movement,

37 1

372

M AITLAN D'S P E R I P H E RA L M AN I PU LATI O N

Figure 12.19 Elbow joint: (a) abduction, h umerou lnar approximation and olecranon abd uction in olecranon fossa ; (b) adduction, humerou lnar distraction and olecranon adduction in olecranon fossa. the olecranon process swings from side to side in the olecranon fossa, the head of the radius being compressed and distracted from the capitulum as the radius moves cephalad and caudad in the supe rior radioulnar joint (Fig. 12.19). •

•

•

Also note that when the elbow joint is in extension and overpressure is added to supination and prona tion, the olecranon process rotates in the olecranon fossa (Fig. 12.20). When the elbow is in full flexion there is also an addi tional degree of abduction and adduction movement. When the wrist is ulnar deviated the radial head moves caudad; during radial deviation it moves cephalad.

It is also important to produce movement in any one of the three joints without producing movement in the other. Testing movement of one bone on the other (e.g. radius on ulna) must be done by the physiotherapist's fingers and thumbs. When movements are tested, the site of the pain felt by the patient is a guide to deter mining the joint(s) at fault. Examination of flexion, extension, pronation and supination alone is insuffi cient to determine the normality or otherwise of the elbow joints.

Full use of accessory and joint play movements must be examined in detail if important comparable signs are not to be missed. It is important to assess the range of lateral movement of the elbow when it is held a few degrees from the extended position. Mennell (1964) dis cussed the importance of this assessment. Extension in adduction and extension in abduction are also important movements of the elbow to exam ine, as is flexion in both abduction and adduction. Figure 12.21 represents the degree of adduction and abduction possible in full extension (line X2, Y2), 10° of flexion (line Xl, YI) and all points in between. There is a greater degree of adduction/ abduction in 100 of flex ion than in full extension of the elbow. If the elbow, firmly held in adduction, is moved from extension through 10° of flexion, i.e. from X2 to Xl' it will be felt that the movement is not a straight line but has a curve near the limit of extension. The flexion movement in abduction from Y2 to Yj also follows a slight curve though it is less marked. The procedures adopted to examine and treat these movements are the techniques of extension/ adduction and extension/ abduction. If a patient subconsciously demonstrates a through range painful disorder with elbow pronation and supination, the therapist should be alert to the pOSSibil ity of the radioulnar joint being the problem. As well as

The elbow comp lex

Figure 12.20 Elbow joint: (a) supination of olecranon process in olecranon fossa ; (b) pronation of olecranon process in olecranon fossa.

Figure 12.21 Range of elbow abduction / adduction in the last 1 0' of elbow extension (only approximate degrees used) viewed from the a nterior aspect of the wrist in the anatomical position. The complete line represents the path traversed by the wrist during passive extension (a) with the elbow pressured into adduction (Xl X2) and (b) with the elbow pressured i nto abduction (Yl YJ The a rrowed circu lar areas represent the scouring movements (E/Ad at X2; E / Ab at Y2) used in examination and treatment.

Central longitudinal axial line Full extension

Full extension

l'

l'

2'

2'

3'

- - - - -:- - - - - - � - - - - - - 3°

4'

4'

5' 6'

' , _ _ + _ _ _ _ _ _ � _ - - _ _ , _ _ _ - - - � - - - - - _ _ _ _ _ _ � - - _ - - _ 60

7'

7'

I

I

I

I

•

�

1

I

,

,

,

I

8' go -

10' Flexion

from full extension

8' - - -

�- - -

- - -

� ,

- - - - -

-� ,

- - - - -

�

- - - - - -

t - - - - - �- -

-

-

g'

: V1'---+ 1 ' - � 0' 1 0' -f--'--'--�--r---+-----r------r3' 3' l' 2' l' 4' 2' 4' 1 0' Flexion , , from full 4' Adduction 4' Abduction

available

available

extension

373

3 74

MAITLA N D' S P E R I P H E R A L M A N I P U LATI O N

pronation and supination, the superior radioulnar joint has passive accessory movements of the head of the radius on the ulna: these posteroanterior and antero posterior movements can be performed with the fore arm in any degree of elbow pronation or supination, flexion or extension. Longitudinal movements cepha lad and caudad of the radius on the ulna are the two remaining accessory movements, though they have limited practical application. All of these movements can be performed with or without compression of the head of the radius against the ulna (see Box 12.5). If the patient has pain within the elbow posteriorly and this is only reproduced with firm overpressure to supination or pronation, this could be due to swinging of the olecranon process in the fossa. In such cases the olecranon should be examined with thumb pressure against the olecranon process in the neutral or prona tion/supination positions. The radiohumeral joint can be painful in pronation, supination and flexion/ extension. To the painful move ment (see Fig. 12.11, flexion 90°) should be applied a compressive force through the patient's hand so as to compress the head of radius against the capitulum. To localize the movement as much as possible to the radio humeral joint the pressure should be transmitted through the patient's thenar eminence with the wrist deviated radially, directing the force through the radius. The compression technique should be performed through as large a range of elbow flexion to extension or pronation to supination (in different positions of flexion/extension) as is possible.

Figure 12.22

EXAM INATION AND TREATMENT TECHNIQUES: E LBOW COM PLEX

Extension I adduction (Fig. 1 2.22) •

Differentiation tests When supination or pronation provokes the patient's symptoms and it is necessary to differentiate between the radiohumeral and the superior radioulnar joints as the source, the rotary movement is performed with the wrist held in ulnar deviation (to lessen the stress on the radiohumeral joint) and then repeated with the wrist in radial deviation. Different positions of flexion/ extension may also help to make the differentiation. Also, if there is intra-articular involvement of the super ior radioulnar joint, adding medially directed pressure against the proximal end of the radius during the rotary movement will increase the pain response (see Fig. 12.14). When flexion or extension provokes the patient's symptoms, the position (of flexion or extension and ulnar deviation) should be held while the head of the radius is moved back and forth (AP-PA). If the dis order lies in the humeroulnar articulation, movement of the radius will not make any difference to the pain response.

Elbow joint: extension I adduction

Direction: Elbow is flexed 10° from full extension and held in adduction. During the first few degrees of extension held in adduction the forearm moves parallel to the elbow sagittal plane. A point is reached where the elbow abducts and adducts again (similar to the mound of the shoulder quadrant). There is no locking position but the feel is similar to that of the shoulder as the point of abduction on the roll-over is reached (see Fig. 12.21) and the extension in adduction continues to Xl. Once the point of roll-over is passed the glenohumeral joint will automatically medially rotate if the adduction pressure is maintained sufficiently.

•

Symbol: Elbow E/ Ad.

•

Patient starting position: Supine, lying far enough from the edge of the couch for the patient's elbow to lie just beyond the edge when the arm is abducted 30°.

•

Therapist starting position: Standing by the patient's right shoulder facing the patient's feet.

Localization of forces (position of therapist's hands) •

•

•

The left forearm rests in front of and just medial to the patient's shoulder. The fingers of the left hand support tl1e patient's elbow posteriorly from the medial side. The thumb of the left hand extends around the medial epicondylar ridge of the humerus to reach the front of the patient's elbow.

The e l bow complex

•

•

•

•

•

•

•

The back of the left hand rests against the surface of the couch at its edge. The left hand medially, the fingers and couch poste riorly, the thumb anteriorly and the left thigh later ally, firmly fix the patient's elbow. The right hand grasps the patient's supinated right wrist. The right thumb is placed over the anterior surface of the wrist. The fingers are placed over the dorsum of the wrist. The supination is not held strongly at the limit of the range. The patient's glenohumeral joint is medially rotated to stabilize the elbow more easily during the adduc tion. Therefore the abduction counterpressure afforded by the therapist's left hand is being assisted by the edge of the couch.

App/ication of forces by therapist (method) •

•

Figure 12.23

•

The part of the extension/adduction range which has been lost should be sought; the examination or treat ment is directed at this particular part of the range. The limited movement is approached: (1) by an adduction or extension/adduction movement or (2) by a scouring circular movement (see Fig. 12.21): 1. performed as a grade III or IV: III the pressure maintaining adduction is almost completely released to allow the joint to relax to the position almost midway between abduction and adduc tion before oscillating back to the adduction posi tion; IV the pressure maintaining adduction limits the oscillation to a small amplitude 2. performed by maintaining the adduction pres sure while flexing and extending the elbow across the limitation. -

•

•

•

Elbow joint: extension / abduction.

In treatment, the movement of extension/ adduction can be scoured in much the same way as was des cribed for the glenohumeral joint. The scouring movement is represented at X2 by the arrowed cir cular arcs in Figure 12.21.

Often found to be painful and restricted in patients with chronic tennis elbow (Hyland et aI 1990). Particularly valuable for minor but troublesome dis orders of the humeroulnar and radiohumeral joints. A test which can be used when the elbow needs to be excluded as a source of symptoms.

-

•

•

If the limitation is painful the adduction pressure can be eased as the pain and limitation are approached.

The arc of movement can be performed when extend ing towards the limit or adducting towards it.

Uses •

•

The extension/ adduction movement is only used in the treatment when grade III or IV is required. When the elbow joint is the source of minor symp toms and its movements appear to be normal, this accessory movement or functional corner position may be diminished and painful.

Extension I abduction (Fig. 1 2.23) •

Direction : Extension/abduction should be checked from the fully extended position through the first 10° of flexion. As with extension/ adduction, a point is reached during this range of flexion where the arm must be allowed to adduct if the flexion movement is to be continued. Beyond the point of maximum abduction the arm moves laterally again, but this lat eral movement will be a lateral rotation of the gleno humeral joint rather than an abduction of the elbow. There is not the same feel of a locking position with this movement as there is with adduction but it is still obvious that the movement from Y1 to Y2 in Figure 12.21 is not a straight line but is slightly curved. Any loss of the smooth contour of the curve can be appre ciated and can be treated by movement into this position.

375

376

M AITLAN D'S P E R I P H E RA L M AN I PU LATI O N

•

•

•

Symbol: Elbow E / Ab. Patient starting position : Supine, lying far enough from the edge of the couch for the patient's elbow to lie just beyond the edge when the arm is abducted 30°. Therapist starting position: Standing by the patient's right shoulder facing the patient's feet.

Localization of forces (position of therapist's hands) •

•

•

•

•

•

•

•

•

•

•

The left forearm rests in front of and just medial to the patient's shoulder. The fingers of the left hand support the patient's elbow posteriorly from the medial side. The thumb of the left hand extends around the medial epicondylar ridge of the humerus to reach the front of the patient's elbow. The back of the left hand rests against the surface of the couch at its edge. The left hand medially, the fingers and couch posteriorly, the thumb anteriorly and the left thigh laterally, firmly fix the patient's elbow. The right hand grasps the patient's supinated right wrist. The fingers of the right hand spread over the front of the patient's wrist to hold the patient's supinated wrist from the medial side. The right thumb is placed over the posterior surface of the wrist. The supinated wrist is not held strongly at the limit of the range. The patient's glenohumeral joint is held in slight lateral rotation so that the abduction movement can be directed against the therapist's thigh which then acts as a fulcrum. The patient's elbow must be fully fixed by the therapist's hand against a very firm fulcrum.

Application of forces by therapist (method) •

•

Figure 12.24

2. performed by maintaining the abduction pressure while flexing and extending the elbow across the limitation. •

•

If the limitation is painful the abduction pressure can be eased as the pain and limitation are approached. The arc of movement can be performed when extend ing towards the limit or abducting towards it.

Uses •

•

•

The part of the extension/abduction range which has been lost should be sought; the examination or treatment is directed at this particular part of the range. The limited movement is approached: (1) by an abduction or extension/abduction movement or (2) by a scouring circular movement (see Fig. 12.21 ) : 1 . performed a s a grade III or IV : III the pressure maintaining the abduction is almost completely released to allow the joint to relax to the position almost midway betwe.en adduction and abduc tion before oscillating back to the abduction pos ition; IV the pressure maintaining the abduction limits the oscillation to a small amplitude.

Elbow joint: flexion I adduction.

•

•

-

The extension/ abduction movement is only used in the treatment when grade III or IV is required. When the elbow joint is the source of minor symp toms and its movements appear to be normal, this accessory movement or ju nctional corner position may be diminished and painful. In treatment, the movement of extension/ abduction can be scoured in much the same way as was described for the glenohumeral joint. The scouring movement is represented at Y2 by the arrowed cir cular arc in Figure 12.21. Particularly valuable for minor but troublesome dis orders of the humeroulnar and radiohumeral joints. A test which can be used when the elbow needs to be excluded as a source of symptoms.

Flexion I adduction (Fig. 1 2.24) •

Direction: Adduction movement in full elbow flexion.

-

•

Symbol: Elbow F / Ad.

The e l bow comp l ex

•

•

Patient starting position: Supine in the middle of the couch and the elbow fully flexed and pronated. Therapist starting position: Standing by the patient's right hip facing the patient's head.

Localization of farces (position of therapist's hands) •

•

•

•

•

•

The left hand holds the patient's fully pronated wrist. The fingers of the left hand are placed over the back of the patient's wrist. The thenar eminence and thumb are placed over the front of the patient's wrist. The right hand grasps firmly around the patient's upper arm at the junction of the middle and lower thirds from the medial side in such a way as to hold the upper arm laterally rotated. The slack in the soft tissues of the upper arm must be taken up fully. Both forearms (therapist) are rotated opposite to each other.

Application offarces by therapist (method) •

•

•

The flexion/adduction movement is performed entirely by the therapist's left hand and arm while medial rotation of the glenohumeral joint is pre vented by the firm grasp of the patient's upper arm with the therapist's right hand.

Figu re 12.25

•

If medial rotation is not prevented the adduction strain at the patient's elbow will be lost. The treatment movement can be performed as a large amplitude oscillation through 10-15° (III) or a small amplitude movement through 3-4° (IV).

•

•

•

Flexion/adduction is used when a grade III or IV movement is required. Minor elbow symptoms, particularly of the humeroulnar and radiohumeral joints. When the elbow needs to be excluded as a source of symptoms.

•

•

•

•

•

Flexion I abduction (Fig. 1 2.25) •

•

The right hand grasps the patient's supinated wrist from the medial side. The fingers spread across the front of the wrist. The thumb is placed across the back of the pa tient' s wrist. The left hand grasps the patient's upper arm at the junction of the middle and lower thirds (with the patient's glenohumeral joint in medial rotation) in such a way as to prevent lateral rotation of the glenohumeral joint. The slack in the soft tissues of the upper arm must be taken up fully. Both forearms (therapist's) are rotated opposite each other.

Direction: Abduction movement in full elbow flexion.

•

Therapist starting position: Standing by the patient's right hip facing the patient's head.

Localization of forces (position of therapist's hands)

•

Uses

E lbow joint: flexion I abduction.

Symbol: Elbow F / Ab. Patient starting position: Supine, lying in the middle of the couch with the elbow fully flexed and supinated.

Application of forces by therapist (method) •

The flexion/abduction movement is produced by the therapist fully flexing the patient's elbow and then displacing the patient's wrist laterally with an

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M A ITLAN D'S P E R I PH E R A L M A N I P U LATI O N

abduction movement o f the elbow, while applying an equal counterpressure with the left hand to pre vent any lateral rotation of the glenohumeral joint. •

If this counterpressure is not applied adequately the sideways movement of the patient's wrist will consist of lateral rotation of the glenohumeral joint without there being any abduction of the elbow.

•

•

The grasp of the patient's right wrist is such that relaxation in this area and throughout the arm is encouraged. The amplitude of movement varies but is usually approximately 20-30° and is performed slowly and smoothly.

Uses Clinical groups 1 and 3b. • Recent injury or acute episode of OA or RA. • Very painful elbow conditions where the radiohumeral or humeroulnar joint is involved. •

Uses •

•

•

Flexion/abduction is used when a grade ill or IV is required. Minor elbow symptoms particularly of the humeroulnar or radiohumeral joints. When the elbow needs to be excluded as a source of symptoms.

Extension (Fig. 1 2.26) • •

Direction: Elbow extension movement. SymboL: Elbow E.

Grade /II (IV) •

•

Patient starting position: Supine lying with the arm abducted approximately 15° so that the wrist is clear of the edge of the couch. Therapist starting position: Standing by the patient's right shoulder facing the patient's feet.

Localization of forces (position of therapist's hands) The left hand supports under the patient's elbow from the medial side. • The left forearm holds the patient's shoulder down. • The right hand grasps the patient's partially supinated wrist laterally. • The thenar eminence and thumb point distally across the front of the patient's wrist. • The fingers hold across the back of the patient's wrist and hand. •

Grade /I •

Patient starting position: Supine, lying in the middle of the couch.

•

Therapist starting position: Standing by the patient's right hip facing the patient's head with the right knee on the couch.

Localization of forces (position of therapist's hands) The left hand supports laterally around the patient's right arm just above the elbow. • The thumb is placed anteriorly. • The fingers spread posteriorly. • The right hand grasps the palm of the patient's supinated hand. • The right thumb reaches between the patient's thumb and index finger to the back of the patient's hand. • The medial three fingers reach around the patient's hyperthenar eminence to the back of his hand. • The index finger points proximally over the anterior aspect of the patient's wrist. • Moving close to the elbow the thigh is used as a stop at the required angle. •

Application of forces by therapist (method) • The oscillatory movement is performed entirely by the therapist's right arm while the therapist's left hand acts as a comfortable support around the patient's elbow.

Application of forces by therapist (method) • The oscillatory movement is performed entirely by the therapist's right arm. The patient's right hand is stabilized by the grasp of the wrist. • The amplitude of the elbow movement is approximately 20-30° (grade ill). • For through-range pain the movement is performed slowly and smoothly. • For chronic end-of-range pain and stiffness the movement is performed as a staccato flicking movement.

Variations in the application of forces: grade /II (IV) •

Therapist starting position: Standing by the patient's right hip facing the patient's head.

Localization of forces (position of therapist's hands) The patient's right arm is lifted first so that it can be held against the therapist's right side. • Both hands hold around the elbow. •

The el bow complex

379

J

Figure 12.26

•

E l bow joint: (a) extension, grade I I ; (b,c) extension grade I I I / IV; (d) pa l pation in olecranon fossa in extension.

The thumbs are placed anteriorly to the joint and the fingers of both hands overlap posteriorly.

Application of forces by therapist (method) • Feel for the soft tissue movement between the olecranon and the margins of the olecranon fossa during extension. This soft tissue palpation should be compared with the normal elbow.

•

•

Normally the fingertips should easily fit into the space between the process and the fossa margins. The feeling should be that of clean bony margins. Palpation of these margins can also be carried out with the patient prone, lying with the upper arm supported on the couch and the hand and forearm hanging down to the floor.

MAITLA N D ' S PERI P H ERAL M A N I P U LATI O N

380

Figure 12.26 (Continued) •

(e, f) further examination of the olecranon.

Thumb pressure or the heel of the hand can then be applied to the olecranon medially, laterally, caudally and with compression (Fig. 1 2.26e, f).

Uses g rade I I I (IV) Limitation of elbow extension due to injury, resolving episodes of OA or RA or fracture involving stiff and stiff/painful humeroulnar or radiohumeral joints. • Patients with elbow disorders in clinical groups 2 and 3b. • The alternative method is best used for the last 30° of extension when the patient needs to relax more.

•

Flexion (Fig. 1 2.27) • • •

Direction: Elbow flexion movement. SymboL: Elbow F. Patient starting position: Supine, lying in the middle

Localization of forces (position of therapist's hands) The left forearm crosses the patient's right upper arm so that the left hand can support under the patient's elbow from the medial side. • The right hand grasps the patient's partially supinated wrist from the lateral side. • The fingers lie across the back of the patient's hand. • The thumb lies between the patient's thumb and index finger into the palm. • The stop is provided by the left forearm in contact with the patient's right wrist from in front as the elbow is flexed to the required degree.

•

Application of forces by therapist (method) The oscillatory movement, performed by the therapist's right arm, is taken back and forth through 20-30° slowly and smoothly up to the stop provided by the left forearm. • As the range improves the forearm can be lowered. •

of the couch.

Grade 1/ •

Therapist starting position: Standing by the patient's right shoulder facing the patient's feet.

Grade 1/1 and IV (almost full range) •

Therapist starting position: Standing by the patient's right side distal to the elbow, facing the patient's head.

The elbow complex

Figure 1 2.28 caudad.

•

Figure 1 2.27 Elbow joint: (a) flexion grade I I ; (b) flexion grades I I I and IV.

Localization of forces (position of therapist's hands) The left hand supports the patient's right upper arm just above the elbow. • The right hand holds the back of the patient's right hand. • The thumb of the right hand passes through the patient's first interosseous space. • The medial three fingers spread medially around the patient's fifth metacarpal. • The index finger extends distally along the back of the hand. • The patient's partially supinated elbow is flexed. Application of forces by therapist (method) The oscillatory movement is produced entirely by moving the patient's right arm while the therapist's left hand acts as a support under the elbow. • Grade III movements are performed as large amplitude movements of 1 0-30° into stiffness.

Grade IV movements are performed as small amplitude movements of 3-4° into stiffness.

Flexion with longitudinal movement caudad (Fig. 1 2.28) •

•

•

Elbow joint: flexion with longitudinal movement

• •

•

Direction: Elbow flexion combined with a longitudinal movement caudad. Symbol: F / ...... caud. Patient starting position: Supine, lying in the middle of the couch. Therapist starting position: Standing by the patient's right hip facing the patient's head.

Localization of forces (position of therapist's hands) The right hand flexes the patient's elbow to 90°. • The right hand grasps round the medial aspect of the patient's supinated wrist. • The fingers spread across the front of the wrist. • The thumb is placed across the back of the wrist. • The supinated left forearm just proximal to the wrist is placed in the 'crook' of the patient's elbow. • The flexion of the patient's elbow is then continued until the left wrist is squeezed firmly between the patient's forearm and upper arm.

•

381

MAITLA N D ' S PERI P H ERAL M A N I P U LATI O N

382

Figure 12.29 (90' flexion).

Elbow joint: longitudinal movement caudad

Application of forces by therapist (method) • The small oscillatory movements are produced by the therapist's right arm. • Care is needed to maintain the therapist's wedged wrist in a constant proximity to the patient's elbow because the tendency will be for it to be squeezed out. • A wrong degree of supination forming the wedge will make the position uncomfortable for the patient.

Figure 12.30 Elbow joint: l ongitudinal movement caudad (90' flexion), a Iternative position.

Uses (all flexion techniques) •

•

•

Clinical groups 1, 2, 3a and 3b adapted to the desired effect. Pain and/ or stiffness following injury or fracture affecting the humeroulnar and radiohumeral joints in particular. Flexion with longitudinal caudad may be of value for disorders where symptoms are minor and not obviously detected on routine testing.

1 0 _____.

• •

•

Direction: Longitudinal movement caudad in 90° of elbow flexion, i.e. in line with the humerus. Symbol: ....... caud. Patient starting position: Supine, lying in the middle of the couch with the elbow flexed to 90° or to the limit of the available range. Therapist starting position: Standing by the patient's right elbow facing the patient's right knee.

Localization of forces (position of therapist's hands) •

The right hand supports the back of the patient's supinated right wrist in its neutral position.

9

____

7

____

8

1 1 _____.

Longitudinal movement ca udad (el bow in 90° flexion) (Figs 1 2.29- 1 2.3 1 ) •

____

1 0 .. •

..

Prox HU, RH

7

..

•

..

Distal HU, RH

1 1 .. •

..

Prox HU (>-<)

8

.. •

..

12 .. •

..

Prox RH ( .t. )

Distal HU (distraction)

9 .. •

..

Distal RH ( ! )

Figure 12.31 Elbow joint: longitudinal movements, humeral l ine. 7-9, ca udad; 10-12, cephalad. Reproduced by kind permission from A. R. Blake.

•

•

•

The fingers of the right hand grasp around the patient's medial metacarpals. The thumb goes through the first web space of the patient's right hand. The heel of the left hand is placed over the anterior aspect of the patient's upper right forearm.

The el bow complex

•

•

•

The fingers of the left hand spread distally down the front of the patient's forearm. The left thumb is spread laterally around the patient's forearm. The three medial fingers spread medially.

Application offorces bV therapist (method) •

•

•

•

The slack of the scapulothoracic depression must be taken up before alternating pressures are applied against the forearm to produce the distraction movement. There is very little movement of the elbow in this direction and it is almost impossible to feel any localized accessory movement unless the 'alterna tive method' below is used. The movement can be combined with an increase in elbow flexion or the therapist can carry the patient's hand with the movement, maintaining a constant elbow angle. The heel of the left hand can be positioned so as to move: (1) both the radius and ulna; (2) the radius alone; (3) the ulna alone.

Variations in the application of forces •

Therapist starting position: Standing by the patient's right hip facing the patient's head.

Localization of forces (position of therapist's hands) The right upper quadriceps area supports the patient's flexed elbow. • The hands grasp the patient's forearm near the elbow. • The pads of the thumbs are placed against: (1) the coronoid process; (2) the head of the radius anteriorly, or (3) both together. • The fingers of the right hand spread medially around the patient's forearm. • The fingers of the left hand spread laterally. • The index fingers are positioned so that their lateral margins are in contact with the distal margins of the medial and lateral epicondyles.

•

F i gure 1 2.32

Superior radioulnar joint: supination grades I-IV.

for the patient and all the feeling of the movement will be lost by the therapist. •

This technique can be performed in different posi tions of elbow flexion.

Uses • •

When symptoms are minimal (clinical groups 2, 3b). Stiffness and pain of this accessory movement at the limit of or in flexion.

Note: It is also technically possible to perform a longitu dinal movement cephalad with the elbow in 90° of flex ion. Th.e patient once more lies supine with the elbow flexed to 90°. If tl1e shoulder is also flexed to 90° and the patient's forearm and elbow are supported by the ther apist's left hand and arm, the therapist's right thumb or the heel of the therapist's left hand can be placed on: (1) the olecranon and the radius; (2) the olecranon alone; (3) fue radius alone. Movement is performed by tl1e therapist's body and right arm in line with the humerus, in effect producing a longitudinal cephalad movement in the humeral line (Fig. 12.31).

Supination (Figs 1 2.32, 1 2.33) Application of forces by therapist (method) • The movement is produced by the arms of the ther apist acting through the pads of the thumbs while counterpressure is exerted through the index fin gers against the epicondyles. •

The pressure must not be created by the thumb flex ors as the movement then becomes uncomfortable

• • •

•

Direction: Supination of the forearm and elbow. SymboL: Sup. Patient starting position: Supine, lying in the middle of the couch with the elbow flexed to 90°. Therapist starting position: Standing by fue patient's right side beyond the flexed elbow, facing the patient's head.

383

M A ITLAN D 'S P E R I PH E RA L M A N I PU LATI O N

384

•

The patient's wrist must be stabilized to prevent it flapping around.

Grades III and IV •

In addition to the above, the patient's elbow must be supported medially by the therapist to prevent any glenohumeral adduction.

Grade IV+ •

Therapist starting position: Standing by the patient's flexed right elbow.

Localization of forces (position of therapist's hands) The left and right hands hold the patient's fully supinated radius and ulna respectively; the hold is far enough distally to stabilize the hand. • The left forearm is fully supinated. • The lateral surface of the distal phalanx of the index finger holds the distal end of the radius posteriorly. • The pad of the thumb holds anteriorly. • The right hand holds the distal end of the ulna. • The thumb and thenar eminence point distally over the posterior surface of the ulna. • The fingers hold the ulna anteriorly. • The forearms are directed opposite each other at right angles to the coronal plane of the patient's fully supinated wrist. •

Figure 1 2.33

Su perior radioulnar joint: su pination g rade IV+.

Grades II, III and IV Localization of forces (position of therapist's hands) The left hand supports under the patient's elbow. • The right hand grasps the patient's supinated wrist from the medial side. The fingers spread across the front of the wrist and • carpus. • The thumb holds across the back of the wrist and carpus. •

Application of forces by therapist (method) The therapist's forearms are directed in the same line and the movement is produced as the patient's forearm is supinated a further 2-3° by a rocking action of the therapist's pelvis and trunk through the hands to the radius and ulna and then released (IV - to IV + then IV+ to IV -). • A small amplitude of movement is, therefore, used. If the elbow supination range is limited, the • therapist's body is turned to the right an appropriate amount so that the forearm direction is changed. •

Uses •

Application of forces by therapist (method) Grade /I •

•

•

The movement is performed from mid pronation/ supination or into as much supination as is indicated. The therapist's wrist supinates and flexes to produce the movement. A flicking action of the th�rapist's right hand may be needed if the symptoms are not so severe or irritable. The movement must be slow and smooth if the elbow is very painful.

•

Mainly for a painful or stiff superior radioulnar joint or stiffness of the olecranon which swings at the extreme of supination. With compression of the radiohumeral joint through the heel of the patient's hand via the radius.

Pronation (Figs 1 2.34, 1 2.35) • • •

Direction: Pronation of the forearm and elbow. Symbol: Pron. Patient starting position: Supine, lying in the middle of the couch with the elbow flexed to 90°.

The elbow complex

Figure 1 2.35 •

Su perior radiou l n a r joint: pronation, g rade IV+.

The therapist's right hand stabilizes the patient's upper arm preventing abduction of the shoulder.

Grade IV+ •

Figure 1 2.34

Superior radiou lnar joint: pronation.

Grades II, III and IV •

Therapist starting position: Standing by the patient's right hip facing the patient's head.

Localization of forces (position of therapist's hands) The right hand supports under the patient's flexed right elbow so that the fingers can reach the lateral surface. • The left hand grasps the pronated forearm distally. • The fingers of the left hand extend across the dorsum of the wrist and hand to reach the carpus. • The thumb extends around the anterior surface of the wrist and hand so that the wrist is fully stabilized. • The rotary movement is performed by slight flexion of the therapist's glenohumeral joint combined with left shoulder and elbow extension, thus assisting the forward movement of the therapist's arm. • This action is combined with full flexion of the therapist's wrist and fingers to produce pronation.

•

Therapist starting position: Standing by the patient's elbow, facing across the body, the patient's elbow being flexed to 900 and pronated.

Localization of forces (position of therapist's hands) The left and right hands grasp the distal ends of the radius and ulna, respectively. • The thenar eminence of the left hand is placed against the dorsal surface of the radius. • The thumb of the left hand extends distally across the back of the patient's wrist. • The fingers grasp anteriorly around the radius. • The right hand, fully supinated, grasps the distal end of the ulna. • The heel of the right hand and thumb point proximally against the anterior surface of the ulna. • The fingers grasp around the ulna to reach the posterior surface. • The forearms are directed opposite each other. •

Application of forces by therapist (method) The therapist's forearms are directed in the same line and the movement is produced as the patient's forearm is pronated a further 2-30 by a rocking action of the therapist's pelvis and trunk through the hands to the radius and ulna and then released (N - to N + , N + to N - ) . A small amplitude movement i s therefore used. • • If the elbow pronation range is limited, the therapist's body is turned to the left an appropriate amount so that the forearm direction is changed.

•

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M A ITLAN D'S P E R I PH E R A L M A N I P U LATI O N

Figure 1 2.36

Superior radioul nar joint: (a) anteroposterior movement i n su pination ; (b) anteroposterior movement i n pronation.

Uses •

•

Mainly for painful or stiff superior radioulnar joint or stiffness of the olecranon as it swings at the extreme of pronation. With compression of the radiohumeral joint through the heel of the patient's hand via the radius.

Anteroposterior movement of the head of the rad i us (Fig. 1 2.36)

•

•

Application of forces by therapist (method) • The therapist gradually applies pressure with the thumbs so that they sink into the relaxed muscle tissue until they contact the head of the radius. •

•

Direction: Anteroposterior movement of the head of the radius in relation to the trochlear of the humerus and the ulna.

• •

Symbol: t Patient starting position: Supine, lying in the middle

•

of the couch. •

Therapist starting position: Standing by the patient's right side beyond the slightly flexed right elbow, facing the patient's head.

In supination Localization of forces (position of therapist's hands) The therapist's right side supports the back of the patient's supinated forearm.

•

The pads of the thumbs are placed over the anterior surface of the head of the radius. The fingers of the left and right hands spread over the lateral and medial surfaces of the upper end of the patient's forearm.

The oscillatory movement is produced by the thera pist's body and arms acting through the thumbs, which act like springs. The movement must not be produced by the thera pist's thumb flexors as this will be uncomfortable for the patient and the therapist will lose all feel to the movement.

In pronation Localization of forces (position of therapist's hands) The right hand holds the patient's pronated left wrist around its lateral border. • The thumb of the right hand crosses the back of the patient's wrist.

•

The elbow complex

• •

•

•

•

The fingers cross in front of the patient's wrist. The patient's forearm is held in pronation as the anteroposterior movement tends to produce supination. The therapist's side supports the patient's forearm. The pad of the left thumb is placed against the head of the radius anteriorly. The fingers of the left hand spread around the lateral surface of the patient's forearm.

Application o{ forces by therapist (method) • The oscillatory movement is produced by the therapist's left arm acting through the stable left thumb while the pronation of the patient's forearm is maintained by the grip of the therapist's right hand.

Uses •

•

•

•

•

•

• •

Lateral epicondylalgia (tennis elbow) where joint signs are evident. As a mobilization of the interface of a mechano sensitive radial nerve at the elbow. Mobilization in the proximity of the common extensor origin, or mobilization to reduce pain inhibition of the common extensor origin's associated contractile elements. Painful loss of range of elbow flexion, extension, pronation and supination due to acute injury or mechanically generated inflammation. Through-range mobilization of pain and stiffness in the anteroposterior direction. Minor symptoms which can be directly reproduced in this direction. Combined with the posteroanterior direction. Most relevant for use in disorders of the radiohumeral and superior radioulnar joints.

Posteroanterior movement of the head of the radius (Fig. 12.37) •

• •

•

Direction: Posteroanterior movement of the head of the radius in relation to the trochlear of the humerus and the ulna.

Figure 1 2.37 Su perior radioulnar joint: posteroa nterior movement in supination.

In supination Local ization of forces (position of therapist's hands) The right hand holds the patient's supinated right wrist from the medial side. • The right thumb is placed across the front of the patient's wrist. • The fingers spread across the back of the wrist. • The pad of the left thumb, pointing distally, is placed against the dorsal surface of the head of the radius. • The fingers of the left hand are placed against the front of the distal end of the patient's upper arm to provide counterpressure for the movement. • The patient's wrist is stabilized in supination as the movement tends to produce pronation. •

Application of forces by therapist (method) • The movement is produced by small adduction movements of the therapist's left shoulder com bined with slight forearm supination (therapist's) to exert pressure against the head of the radius with the left thumb. •

Symbol: ; Patient starting position: Supine, lying in the middle of the couch with the elbow flexed 30° and either fully supinated or fully pronated. Therapist starting position: Standing by the patient's right side distal to the slightly flexed elbow, facing the patient's head.

The oscillatory movement should not be produced by the therapist's thumb flexors as the feeling of movement will be lost and the pressure will be uncomfortable to the patient and the operator.

In pronation •

The same localization offorces and application of forces are applied with the exception that the patient's forearm and wrist are held in pronation.

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M A ITLA N D'S P E R I PH E R A L M A N I PU LATI O N

• •

•

line of the forearm (in any position of elbow flexion, extension, pronation, supination; examine in the mid position of all these movements initially for best effects). Symbol: ...... caud. Patient starting position: Supine lying in the middle of the couch with the elbow mid-way between flexion, extension, pronation and supination. Therapist starting position: Standing by the patient's right side just beyond the elbow.

Localization of forces (position of therapist's hands) •

•

• • •

•

•

•

Figure 1 2.38 Su perior radiou lnar joint: longitudinal movement caudad.

•

Uses •

•

•

•

•

• •

As grade I or II in acute tennis elbow, stable fracture of the head of the radius or injury where movement-related pain has an early onset and is early limiting this movement direction. As an interface mobilization for a mechanosensitive radial nerve at the elbow. As a grade ill or IV for osteoarthritis (non-severe or irritable) causing stiffness and pain or stiffness in disordered radiohumeral or superior radioulnar joints. Where painful joint signs are causing pain inhibition of the wrist and forearm extensor muscles. Minor symptoms which can be directly reproduced in this movement direction. Combined with the anteroposterior direction. Most relevant for use in the radiohumeral and superior radioulnar joints.

Longitudinal movement caudad (radioulnar) (Fig. 1 2.38) •

Direction: Longitudinal movement caudad of the radius in relation to the humerus and ulna in the

The therapist's right side has the patient's right forearm resting against it. The left hand holds across the front of the patient's upper arm proximal to the elbow. The fingers of the left hand spread laterally. The thumb of the left hand is placed medially. The web of the first interosseous space is the main point of contact with the patient's upper arm. The right hand grasps the anterior surface of the patient's mid-supinated carpus. The thumb of the right hand grasps around the radial surface proximal to the base of the fifth metacarpal. The middle finger and thumb reach as far as possible around the posterior surface of the carpus. The right forearm must be brought into the same line as the patient's forearm.

Application of forces by therapist (method) •

•

• •

•

When this technique is used in treatment as a grade IV the slack of the soft tissues must be taken up first. As the therapist pulls with the right hand the therapist's left hand sinks into the patient's flexor muscle tissue to hold the upper arm firmly. Slack must be taken up at the wrist. Small oscillatory movements can be performed by a pulling action of the therapist's right arm counteracted by a stabilizing pressure through the therapist's left hand. The movement can be enhanced by adding ulnar deviation in rhythm with the pulling action.

Variations in the application of forces With adjustment of the right hand position, the longi tudinal caudad movement can also be produced at: 1. both the radius and the ulna at the same time 2. the ulna alone by grasping around the ulna with the right hand and combining the pull on the ulna

The el bow comp lex

2

3

lll

5

Figure 1 2.39 Superior radiou lnar joint: longitudinal movement cephalad.

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•

•

•

When this movement direction is most painful and restricted. For very painful intra-articular radiohumeral or humeroulnar disorders where this movement affords relief of pain. To complement pain-free movement of flexion, extension, pronation or supination at the elbow. As an accessory movement grade IV at the limit of stiff painless pronation or supination (stiff superior radioulnar joint). As a part of joint differentiation testing at the elbow.

Longitudinal movement cephalad (radioulna r) (Figs 1 2.39, 1 2.40) •

Direction: Longitudinal movement cephalad of the radius in relation to the humerus and ulna in the line of the forearm (in any position of elbow flexion,

Prox HU, RH

2 .. . �

Prox HU

3 .. . �

Prox RH

4 .. • �

Distal HU, RH

5 .. • �

Distal HU

6 .. • �

Distal RH

Figu re 1 2.40 Elbow j oint: long itudinal movement, forearm l ine. 1 -3, cepha lad; 4-6, caudad. Reproduced by kind permission from A. R. Blake, 2004.

with a radial deviation of the patient's wrist to enhance the longitudinal movement 3. the radius alone as described above.

Uses

.. • �

extension, pronation, supination; examine in the mid position of all these movements initially for best effects). ceph.

•

Symbol:

•

Patient starting position: Supine, lying in the middle

......

of the couch with the elbow mid-way between pronation and supination and in 90° of flexion. •

Therapist starting position: Standing by the patient's right side beyond the flexed elbow, facing the patient's head and crouching over the patient's hand.

Localization of forces (position of therapist's hands) •

• •

•

The right hand grasps the patient's hand as if shaking hands. The right wrist extends along with the patient's. The left hand supports under the distal end of the patient's right upper arm. The right hip supports the patient's right hand.

Application of forces by therapist (method) •

The small oscillatory pressure is produced through the patient's wrist along the line of the shaft of the

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MAITLA N D 'S P E R I PH E R A L M A N I P U LATI O N

radius together with radial deviation o f the patient's wrist. •

•

The heel of the therapist's hand is in contact with the patient's thenar eminence in radial deviation of the patient's wrist to enhance the movement direc tion required. Further movement of elbow flexion, extension, pronation and supination can be explored with the radiohumeral joint compressed in this manner.

Variations in the application of forces By adjusting the grip with the right hand the pressure can also be applied to:

•

• •

both the radius and the ulna together by the therapist applying pressure through the heel of the patient's hand without any deviation of the wrist

2. the ulna alone by the therapist applying pressure through the ulna via the heel of the therapist's hand contacting the patient's hypothenar eminence. The addition of ulnar deviation of the patient's wrist will emphasize the pressure through the ulna alone 3. the radius alone as described above (Fig. 12.40).

Uses • •

•

•

Generally used as a grade IV mobilization. To help in the differentiation of radiohumeral intra-articular disorders. As a technique to reproduce pain from the radiohumeral joint with compression added. As an accessory movement grade IV at the limit of stiff painless pronation or supination (stiff superior radioulnar joint).

E L B O W D I SO R D E R S A N D TH E I R CLI N I CAL P R O F I LES I ntroduction In the introduction to this chapter the elbow region was likened to a peripheral transitional area making it particularly vulnerable to injury and strain. With this in mind, the most common types of elbow neuromusculo skeletal disorder fall into the following broad categories: •

•

•

Trauma particularly fractures of the head of radius and olecranon and subluxation of the head of radius Overuse strain especially tennis elbow, or lateral epicondylalgia (Box 12.6), and golfer 's elbow, or medial epicondylalgia Nerve entrapment especially the ulnar, median and radial nerves -

-

-

Rheumatoid arthritis Less common conditions such as osteochondritis dissecans (Corrigan & Maitland 1983), olecranon bursitis and myositis ossificans.

Maitland (1991) has categorized elbow disorders by their common clinical characteristics. The purpose of this is to help establish the role which mobilization/ manipulation can play in such disorders. The main characteristics to consider are: • •

1.

Osteoarthritis (mechanical, degenerative, traumatic or systemic) which may include impairment due to loose bodies

•

tennis elbow joint stiffness chronic minor joint pain.

Tennis elbow If the term tennis elbow is used accurately, passive movement of the elbow joint will be full and painless. Under these conditions, passive movement techniques have no place in treatment. The Mill's manipulation (Stoddard 1971) can pro duce a good result; however, in the opinion of Maitland (1991), it does so because it manipulates the joint and not because it has stretched the tenomuscular junction. Stoddard (1971) describes the Mill's manipulation as 'forced extension of the elbow while keeping the wrist and fingers fully flexed'. The more effective technique, which Stoddard suggests as a modification, is to gap the elbow into adduction with a sharp flick of the forearm. The term tennis elbow in the majority of cases is used loosely and careful examination will reveal that often there are a variety of joint signs contributing to the generation of the patient's symptoms. Box 12.7 highlights the limitations of the diagnosis in this case and the primacy of selecting treatment techniques based on the clinical information as it emerges. When minor joint signs are present they should be used as the passive movement treatment techniques. Initially the joint signs alone should be treated until a clear picture of the pattern of progress can be pre dicted. It may then be necessary to treat the tenomus cular or other components while continuing to treat the joint signs as well. All tennis elbows that have become chronic will have joint signs due to deconditioning as part of the disorder.

Joint stiffness It is clear that judicious, thoughtful and controlled stretching of the elbow (grades III and IV) is unlikely to cause myositis ossificans.

The elbow com p l ex

Exam i nation

Cl i n ical evidence / 'brick w a l l ' thinking

Kind of disorder

Often m u lticomponent, m u l tid imensional, m u lti mechanism. The key is to recog n ize the sign ifica nt movement-related e lements and involvement of structures of the movement system, including joints, nerves, tendon i nsertions, referred pain mechanisms and mechan isms prod ucing secondary hyperalgesia and a l l odynia. Most com monly pa i n on the lateral side of the elbow which i n h ibits or i m pa i rs activities i nvolving the hand in gripping or m a n i pu lating objects such as lifti ng a teacup, shaking hands or working on a computer (Vicenzino 2003)

Body ch a rt fea tu res

Lateral elbow pain. Joint: deep aching pa i n within the joint; band of pa i n a round the joint; feel i ng of stiffness. Nerve entrapment: burn i n g ; l ines of pain; feel i ng of tight elastic band p u l l ing through the elbow; accom panying sensitivity to touch (a l l odynia, hyperalgesia). Pain, dysaesthesia, paraesthesia in the d istribution of the cutaneous su pply of the relevant entrapped nerve. Muscle: pain loca l to the common extensor origi n ; sore, bruised feel i n g ; feel i ng of weakness in the a rm and tiredness of the forearm m uscles. Other sources: heaviness of the whole arm; dysaesthesi a ; excessive sweating; hot/cold feelings accompany sympathetic mainta ined pa i n ; the characteristic dermatomal distribution of nerve root pai n ; the vague patchy aching characteristic of referred ca rdiogenic pa i n

Activity limitations/ 24-hour behaviour of symptoms

Reduced grip strength often accompa nied b y pain. Pai n and weakness reproduced d u ring activities i nvolving g ri pping. Joint d isorders accompan ied by stiffness and l i mitation by pai n d u ri n g activities which i nvolve el bow flexion, extension, pronation or supination depending on the predominant joint i nvolved, such as screwdriving or sawing. Morning stiffness is com mon i n a rth ritic joints or inflammatory a rthropath ies. Disorders involving nerve entrapment w i l l be affected by activities w h ich enha nce the mecha nosensitivity of the affected nerve, including activities which lengthen or compress a l ready sensitive neura l tissue such as keyboard use, carrying shopping or d irect contact through pressure on su perficial nerves. Night pain is a common consequence of nerve entra pment. Muscle tissue or tenoperiosteai disorder w i l l show up as pain or pain i n hibition during gripping activities. However, g ripping is a l so known to cause comp ression on sensitive nerves or stra i n on painful joints. Referred pain from the cervical spine is genera l ly u naffected by activities which would usua l ly stress the tissues a round the elbow

Present/ past history

According to Vicenzino (2003) the at-risk populations a re players of racket sports or sport i nvolving g ripping activities, fish processors and industrial workers where repetitive manual tasks a re involved. Musicians and keyboard operators ca n be added to this l ist. The cond ition is prone to recurrent bouts and is characterized by a protracted history

Specia I questions

M R I shou ld be considered to exclude other cond itions or i njury to underlying bone. If these a re not suspected no further screening is recommended. Consider cardiac pai n i n t h e left arm

Source / mechanisms of symptom production

Primari ly degenerative tendonopathy, chemica l / mechan ical nociception (intra- and periarticu lar tissue) or periphera l neurogenic pain from nerve entra pment. Consider a lso nerve root pain and elements of mechan ica l ly generated sym pathetic maintained pain

Cause of the sou rce

Consideration should be g iven to the cervical spine (G u n n Et Milbrant 1 976), neura l tissue involvement (Albrecht et a l 1 997) and imbalance o f extensor ca rpi radialis brevis (Kamien 1990)

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M A I T L A N D ' S P E R I P H E R A L M A N I P U LATI O N

Contributing factors

Occupation ; pre-existing degenerative changes i n tendon connective tissue ; central sensitization of nociceptive tissue

Observations

Swe l l i ng or prominence of the latera l epicondyle ; overactivity of ECRB (elbow flexed); trophic changes and forearm m uscle wasting i n cases where there has been prolonged neu rological compromise

Functional demonstration of active movements

Grip strength test with elbow in extension and pronation ; minor restriction of joint movements (flexion, extension, pronation, supination) ; cervical sensitizing movements may show the degree of pathoneurodynam ics with el bow movement

If necessary tests

Lower cervical quadra n t, cervical compression tests for referred pai n ; fl ick at the end of elbow flexion, extension, pronation, supi nation as overpressure if movements previously symptom free

Other structures in plan

Screening tests for shoulder, wrist and hand, thoracic spine

Isometric/m uscle length tests

Pai n and weakness with g rip strength test; a l ig n ment fau l ts i n g rip with ECRB overp u l l ; isometric testing of wrist extension and, especial ly, third digit painful

Neurological exa m i nation

Sensory loss and motor loss in peripheral nerve distribution if nerve entrapment at the elbow; neurological changes if nerve root lesion

Neurodynamic testing

Often evidence of mechanosensitivity on testing of the ULNPT 2b (radial nerve) and occasiona lly ULNPT 1 and 2a (median nerve)

Passive movement

Spongy thickening and swe l l i ng in the olecra non fossa may be pa l pable and cause lateral elbow pain

Pa l pation findings

Soft tissue changes evident over the joint line of the radiohumera l joint and annular ligament if there is i nvolvement of these joints. Tenderness and swelling of the common extensor origin may be palpable and pal pation of su perficial nerves arou nd the elbow may reveal mechanosensitivity to touch

Accessory / physiolog ica I combi ned movements

Often u n revealing a part from reproduction of symptoms and joint signs with extension, adduction, extension / abd uction, flexion / add uction, flexion / abd uction, extremes of pronation and supination, and a nteroposterior/ posteroanterior on the head of the radius

Mobil ization / ma n i pu lation tech n iq ues preferred

Often fit i nto the category of chronic m i nor symptoms in which case the preferred techniques w i l l be e l bow extension / adduction grade IV to IV + and accessory movements at the l i m it of range, usually a nteroposterior/ posteroanterior on the head of the radius in pronation. The desired effects of such tech niques are pain rel ief and restoration of ideal function. Associated techniques to consider are cervical lateral g l ide and neurodyna mic 'sliders' and 'tensioners' (Butler 2000) if such structural components are present. In the past the Mil ls' manipu lation (Stoddard 1 9.71 ) has been advocated as an effective method of dea l i ng with 'ten nis el bow' and Cyriax ( 1 982) has advocated the use of tra nsverse friction to the common extensor origin

Other m a nagement strategies

Cortisone injection (Cyriax 1 982, Verhaar et a 1 1 995) ; muscle i mbalance correction (Sahrmann 2001 ) ; thera peutic exercise progra mme, mobil ization with movement, sport taping (Vicenzino 2003)

Prog nosis / natu ra I history

Depends on the identification of the com plex interrelationship between the actual components, m echanisms and d i mensions

Evidence base

Vicenzino (2003) i n his masterclass concludes that ' ... essential ly, therapeutic exercise forms the mai nstay of the progra mme. Ma nual therapy and sport taping are useful adjunctive therapies to ach ieve ra pid pain relief that a l l ows for effective and timely physical conditioning of the affected m uscles'

The el bow comp lex

Cli nical presentation A. Loca l lateral epicondylar pain only (j) with gripping. Came on after cha nging a ca r wheel. 'Pu l l ' felt while changing a nut. • Cervical spine, thoracic spine .1 .1 • Shoulder .1.1, el bow E I Ab (j) slight • Isometric wrist extension (j)++ B. Aching 'arm especia l ly around the outer side of the elbow and i nto the forea rm. Occasional pins and needles a round the back of the thum b. Some neck stiffness. Arm aches with sitting. • Elbow .1.1, isometrics .1.1 • Shoulder quadrant: loca l soreness in the shou lder at the pea k of the quadrant • Cervical rotation to the side of the a rm - pain reduced by a few degrees • ""l. T 2 / 3 , loca lly sore and stiff C.

Band of pain below latera l epicondyle (j) with twisting movements of the forea rm. Aches at the end of the day with use. • Elbow - EI Ab (j)++ • Pronation end of ra nge (j) • ULNT 2b 'pul ls' down arm (different from other side) • C5-6 stiff, sore loca l ly • 1 head of radius in pronation (j)+

If a patient has a stiff and painful elbow (clinical groups 3a and 3b), mobilization techniques should be directed towards influencing the movement-related pain first until a clear picture of the irritability and behaviour of the pain emerges. Once this is known, treatment can be directed towards stretching the elbow in any direction, provided progression of the strength of the technique used does not unfavourably alter the pattern of pain. In such cases the stretching technique will be completely safe. The stretching techniques for a stiff elbow should consist of: 1. physiological movement grade IV or IV - provided pain is minimal 2. accessory movements grade IV or IV- with the joint supported at the limit of the physiological range 3. interspersing between physiological IV and accessory IV at the limit of range 4. grade IT + or lll - through as large a range as possible to minimize the effects of treatment soreness.

• •

•

• •

•

Supine: flexion and extension, p l u s A b and Ad Supination and pronation plus ( t ) and ( ; ) a n d pi us com pression Longitu d i n a l caudad (humeral l ine) i n 90° elbow flexion Olecranon movements Functional test, g rip (sm a l l and large) in F, E, Sup, Pron. Isometric tests

Test movements begin as IV- with observation for pain response. If pain free, adequate overpressure is applied u ntil pain is provoked or the movement is judged 'clear: When a positive pain response is provoked, that test movement may need to be differentiated to determ ine the specific joint at fau lt. and lor other movements may need to be tested so as to either exclude or incriminate other joints as contributing to the symptoms. If a l l test movements appear 'clear' at first exa m i nation, they should be repeated more strongly. If sti l l 'clea r', they may prove positive when repeated at the next consultation.

Chronic m inor joint pain When a patient's elbow symptoms are comparatively minor, or are longstanding but still having an effect on the patient's daily life, there are certain passive exami nation tests which must be assessed (Box 12.8). In examination and then treatment, accessory movements at the limit of the various ranges of move ment may help to determine which of the three elbow joints is primarily at fault. Extension/abduction and extension/ adduction may well provide the most com parable joint signs in such cases; accessory movements at limit and E/ Ab and E / Ad are therefore most com monly used in treatment. The elbow joint can easily be overtreated, whether pain or stiffness is the prime consideration. If a tech nique such as extension is being used it is vital that the patient's arm is completely relaxed during the treat ment and the technique should be completely free of even the most minor feeling of discomfort (II, lll-) (see Fig. 1 2.26a). If the patient's symptoms are comparatively mild and extension is being used, a gentle grade IV can be considered as a relevant treatment technique, applied more slowly than usual so as to provoke only a minimal

393

3 94

M A I T LA N D 'S P E R I P H E RA L M A N I P U LATI O N

• • •

Supine: E / Ab-Ad and 'scouring' Su pination and pronation with IV+ O P Olecranon tests

amount of pain. This will ensure that the patient's pain is not exacerbated.

Proving the elbow unaffected The elbow joints can be screened thoroughly to prove that they are unaffected in disorders of the upper limb where the elbow could be a source, or cause of the source, of the patient's symptoms (Box 12.9). These three passive movements should be performed as grade IV + movements.

Composite elbow Table 12.2 lists the test movements that need to be per formed if it is not clear which of the three elbow joints is responsible for the patient's symptoms. Further differen tiation of the test movements should reveal which joint is the source. For example, supination at its limit may be painful. This could be due to torsion of the humeroulnar joint or spin of the head of the radius against the ulna and sliding of the head of the radius under the capitu lum. Supination can then be performed in ways that will establish which joint is causing the patient's pain.

CAS E ST U DY 1 2 . 1 A C L I N I CAL EXA M P L E O F R E C O R D I N G - T H E E L BOW R E G I O N

@ @ * CD @

Sleep ./ Works as a m icrobiolog ist scraping Petri dishes. CD with scraping g radually i EOD

Past/ present history * CD started after a game of tennis. Tried overhead tennis serve (unusual). • Never had CD before. Ache after game CD++ the next day. Si nce then a l ittle better but not that much improved. Been there for 4/ 1 2. No treatment as yet. • Had @ for a while before CD. This is the same as it a lways is. Ca n not remember ever i nj u ring shoulder. Only comes on when reaching above head. • *@ was a little worse for a few days after the tenn is. Has had @ before. Sti l l there now. • # forearm as a child on the same side. •

Special questions General health ./. No X-rays, no med ication. Hypothesis Elbow new use strain, compensation for a stiff shoulder (consistent behaviour of symptom area CD and definite nature of onset ma kes a loca l com ponent more l ikely).

•

•

•

•

M rs C i s a 47-yea r-old m icrobiologist who e njoys playing ten nis.

Kind of disorder E lbow pa i n with gripping a n d carrying heavy shopping bags. Body chart Areas of symptoms are as outlined in Fig u re 1 2.41 . Activity limitations/ 24-hour behaviour of symptoms ** CD i i l ifting a heavy shopping bag i nto the car boot ! in a few m i n utes CD i stretching a rm out and g ri pping, sometimes shoots u p a n d down the arm

! q uickly if the object l ifted is not heavy or not lifted for a long time i when reaching above head height ! im mediately i there most of the time; aches after shopping for '/, hour sore i n the morning for '/, hour stiff morning, aches EOD (end of day)

The history suggests that the recovery has not been as expected for a loca l com ponent alone (i.e. healing time expired). Therefore suggestive of the symptoms being mai nta ined by cervica l / thoracic component. Shoulder needs return ing to ideal mobility to prevent recurrences. The severity and irritabil ity suggest that exa mi nation and treatment can be to the limit of movement d i rections.

Physical examination Observatio n : 'protects' a rm when moving it; pseudo winging ® sca pula • Present pa i n : CD, @ • Functional demonstration and differentiation : CD i gri p and lift a 2 kg weight Stretch arm out, 'pul ls' u p and down arm (i nconsistent) Diff: FD + Sh Dep + Cx LLF 45', can't fu l ly stretch arm, pulls more up and down CD ISO Active (if necessary) tests (excluding test brief • a ppraisa l ) :

•

The e l bow complex

3 'Stiff

P+N Cough/Sneeze Spinal cord

CD and ® often together

Cauda eq. Dizz.

CD separate Figure 1 2.41

Plan for Rx l -4

• Cx lower 0 @ (Cx E ././ + RLF ././ + RR 20' @) • Cx RR ./ 70' @; RLF 'stiff' 45' @; LLF 'tig ht' 45'

• •

•

,/ ,/ ,/

Body c h a rt of M rs C.

• ® sh ./ IV- @

•

,/ ,/

Elbow F ././, E ././, Pron ././, Sup ././ Wrist F ././, E ././, Dev ././ Palpation (el bow) : G) moderate pressure latera l epicondyle only Joint l i ne RH 'sore' Palpation radial N - i sensitivity: radial border wrist; over RH joi nt Isometric tests: ././ ULN PT / Neuro: U LN PT 2b + sh Ab 30' 'pu l ls through elbow' / ti ght. Neuro ././ Passive movements Uoints) : Elbow E / Ad IV + G) � head of radius G)++ - change from flexion, repeat � G) less (therefore more l ikely RH than RU) sh O @ peak Cx n, ""1, -- , -- C1 -C7 /Tl NAb.

""1 T4/ 5 midrange stiff loca l (Fig. 1 2.42)

pa i n ++ (sore, l i ke G))

Treat spine first as this component is l i kely to be mainta i n i n g and preventing fu l l recovery loca l ly (neurophysiological ly?). The h istory suggests this as a possibility. Rx l -4

""1 T4 IV x 2 '

x 4

Ouick, staccato Loca l ly sore in rhythm

C/O: G) PO% FD better stretching. G) sti l l there with twisti n g b u t less sh 0 IsO @ ISO Cx ././, U LNT ././ El bow E/ Ad ISO Pa l pation latera l epicondyle less sore by 50% Nerve pa l pation better

Plan for Rx5-6

""1 T4 has i m p roved G) by 50% but then progress slowed, therefore start to treat loca l sym ptoms.

395

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M A IT LA N D ' S P E R I P H E R A L M A N I PU LATI O N

R2 (IV+)

c

o

Plan for Rx7-9

Prog ress slowed again loca l ly, sti l l some local signs therefore prog ress. Local Rx related to FD. Rx7-9

IN elbow E / Su p D I D ; head of radius IV+ X 2' X 3 CD in rhythm

AS

Figure 1 2.42

R1

p 1(loc)

L

;T4/5

S

CD rarely now, occasional ache FD .1'.1' Sh ISO Elbow E/ Ad .1'.1'

Plan

Shoulder ISO therefore treat and clear Sh a as a contributing factor to lessen the risk of compensatory overuse at the elbow in future.

Movement diagram for passive testing ofT4/5.

Rx5-6

I N elbow E, mid Pron / S u p D I D ; head of radius IV X 2 ' X 4 CD i n rhythm

CD � a nother 30% FD better now with twisting Sh a ISO Elbow E/ Ad - pa l pation better by 30% more � T4 .1'.I'

References Albrecht, S., Cordis, R., Kliehues, H. & Noack, W. 1997. Pathoanatomic findings in radiohumeral epicondylopathy. A combined anatomic and electromyographic study. A rchives of Orthopaedic and Trauma Surgery, 116, 157-163 Burton, A. 1988. A comparative trial of forearm strap and topical anti-inflammatory as adjunct to manipulative therapy in tennis elbow. Manual Medicine, 3, 141-143 Butler, D. S. 2000. The Sensitive Nervous System. Adelaide: NOI Group Corrigan, B. & Maitland, G. D. 1983. Practical Orthopaedic Medicine. London: Butterworths Cyriax, J., ed. 1982. Treatment by manipulation, massage and injections In Textbook of Orthopaedic Medicine, 11th edn. London: Bailliere Tindall Cyriax, J. H. & Cyriax, P. J. 1983. Illustrated Manual of Orthopaedic Medicine. London: Butterworths Gifford, 1. S. 1986. Differentiation of elbow pain. The elbow symposium. Manipulative Physiotherapists Association of Australia (SA Chapter), 22 June 1986 GU1l1l, C C & Milbrandt, W. E. 1976. Tennis elbow and the cervical spine. CMA Journal, 114, 803-807 Hoppenfeld, S. 1976. Physical Examination of the Spine and Extremities. New York: Appleton Century Crofts Hyland, S., Nitchke, J. & Matyas, T. 1990. The extension-adduction test in chronic tennis elbow: soft

tissue components and joint biomechanics. Australian Joumal of Physiotherapy, 36, 147-153

Karnien, M. 1990. A rational management of tennis elbow. Sports Medicine, 9, 173-191 Maitland, G. D. 1977. Peripheral Manipulation, 2nd edn. London: Butterworths Maitland, G. D. 1991. Peripheral Manipulation, 3rd edn. London: Butterworth-Heinemann Maitland, G. D. 1992. Neuro/musculoskeletal Examination and Recording Guide, 5th edn. Adelaide: Lauderdale Press Maitland, G. D., Hengeveld, E., Banks, K. & English, K., eds. 2001 . Maitland's Vertebral Manipulation, 6th edn. Oxford: Bu tterworth-Heinemann Mennell, J. McM. 1964. Joint Pain. London: Churchill Livingstone; Boston: Little, Brown Mulligan, B. 1995. Manual Therapy - 'NAGS', 'SNAGS', 'MWMS' etc., 3rd edn. Wellington: Plane View Services Quintart, C, Reignier, M. & Ballion, J. M. 1998. Tennis elbow: surgical findings in 17 cases and etiopathogenic hypothesis [article in French]. Acta Orthopaedica Be/gica, 64, 170-174 Sahrmann, S. A. 2001 . Diagnosis and Treatment of Movement Impairment Syndromes. St Louis: Mosby Shapiro, R. & Nyland, J. A. 1994. Biomechanics of the elbow. Journal of Back and Musculoskeletal Rehabilitation, 4, 1-6 Stoddard, A. 1971. Manipulation of the elbow joint. 1, 57, 259-260

The e lbow com plex

Su, C. Y, Lin, J. H., Cheng, K. F. & Sune, V. T. 1994. Grip strength in different positions of the elbow and shoulder. Archives of Physical and Medical Rehabilitation, 73, 812-815 Verhaarm, L Walenkamp, G., Van Mameren, H. et al. 1995. Local corticosteroid injection versus Cyriax-type physiotherapy for tennis elbow. Journal of Bone and Joint Surgery (Br), 77B, 128-132

Vicenzino, B. 2003. Lateral epicondylalgia: a musculoskeletal physiotherapy perspective. Manual Therapy, 8, 66-79 Wright, A. & Vicenzino, B. 1997. Lateral epicondylalgia II: therapeutic management. Physical Therapy Reviews, 2, 39-48

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Chapter

13

The wrist and hand complex

THIS CHAPTER INCLUDES: • • •

Key words for this chapter Glossary of terms for this chapter The role of manipulative physiotherapy in the management

•

•

and rehabilitation of wrist and hand disorders Subjective exa mi nation of the wrist and hand Integ rated physical exa mi nation of the wrist and hand

•

•

Examination and treatment tech niq ues A case exa mple of a wrist and hand disorder

KEY WORDS Inferior radioulnar joint, radiocarpal,

m idcarpa l, intercarpal, carpometacarpal,

m etacarpophalangeal, interphala ngeal.

GLOSSARY OF TERMS

of the fascia of the pa I m of the hand characterized by progressive flexion contracture of the l ittle and ring fingers. Non-prehensi l e function - the use of the hand for activities other than gripping, such as pushing, pulli ng, weig ht-bea ring and non-verbal com mun ication. Rehabilitation - physiotherapy is primari ly a rehabil itation profession. Rehabil itation, therefore, is the restoration of function through therapeutic intervention and training.

Sensory and motor representation in the sensory and motor cortex, the hand, and especia lly the thu mb, has a much greater representation than many other body areas. Sudeck's atrophy - reflex sympathetic dystrophy of the extremities (the hand and foot), often a conseq uence of inj u ry to the hand or foot. The d isorder is cha racterized by severe pain, swelling, trophic changes and progressive stiffening of the joi nts.

Carpal tunnel syndrome entrapment of the median nerve within the carpa l tunnel at the wrist. Symptoms are experienced in the cuta neous d istribution of the median nerve. Night pain is a key feature. De Quervain's tenosynovitis synovitis of the tendon sheath of the abductor pollicis longus and extensor pol licis longus. Dupuytren's contracture a predomina ntly inherited d isorder

INTRODUCTION The physiotherapy and occupational therapy manage ment of neuromusculoskeletal disorders of the wrist and hand is a speciality in its own right and, in the UK,

warrants its own special interest group (The British Association of Hand Therapists - BAHT). The complex composition of the carpus and the variety of structures which course through it into the fingers warrants care and detail in examination and physical treatment.

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MA IT LAN D'S PERIPHERA L MANIPU LAT ION

The complex and detailed role of the wrist and hand in both prehensile and non-prehensile functions and the fineness of this organ's sensory and motor representation also warrants attention to detail in the clinical study of the relationships between the joints, muscles and nerves of the wrist and hand. This becomes evident when disorders of the wrist and hand result in impairment and activity limitations of pre hensile and non-prehensile function. Mobilization/manipulation has a place in the man agement of neuromusculoskeletal disorders of the wrist and hand alongside many other rehabilitation strategies. This chapter offers the clinician an oppor tunity to examine and physically treat the articular impairments of wrist and hand disorders and, at the same time, to recognize the influence of the neural, musculotendinous, fascial and vascular systems upon such disorders. The aim of the manipulative physio therapist, therefore, is to contribute to both the physi cal and psychosocio-economic rehabilitation of the patient with wrist and hand impairments. However, the wrist and hand present the manipula tive physiotherapist with particular difficulties which must be taken into consideration if the desired effects of intervention are to be achieved. These difficulties are as follows.

Deciding if the symptoms are due to impairment of the structures in the hand or are being referred or generated from more remote sources The first means of deciding this is to ask the patient to clarify whether the pain is coming from the wrist or the hand. If this is not clear and the patient is unsure, a whole series of criteria may be considered. By using larger than normal body charts for the wrist and hand the precise area of the patient's symptoms can be documented. In such cases a clear relationship between the patient's pain (symptom) and a known anatomical structure Goint, nerve, muscle/tendon) may become evident. The description of paraesthesia may reveal, for example, that it is in the cutaneous distribu tion of the median nerve, and therefore carpal tunnel syndrome may be a more favoured hypothesis than a CS/6 nerve root lesion. The patient's activity limitations will be a good clue as to whether there is a local or a remote source to the symptoms. If the movement system structures of the wrist and hand are impaired the patient will have lim itation of prehensile and non-prehensile function and be unable to fully extend the hand (e.g. when waving) because of pain and stiffness across the back of the wrist suggestive of a local impairment. Alternatively, the wrist and hand may start to ache and feel tired

•

•

• •

•

• •

Tendon / ligament lesions: tendon i njury l igament spra i n Du puytren's contracture (postoperative) Sudeck's atrophy Joint disease: osteoa rth ritis (especia l ly of the first carpometacarpal joint) rheumatoid a rth ritis Bone disease (e.g. osteochondritis of the lu nate) Nerve entrapment (median, ulnar and radial nerve entrapment) Fractures (Colles, Sm ith's, scaphoid and metaca rpa ls in particular) Major trauma Work-related upper limb disorders

gradually throughout the day, suggesting mechanisms other than just local pain being involved. The present and past history of the wrist and hand disorder should suggest a relationship between the symptoms and trauma or mechanical stresses. Corrigan and Maitland (1983) suggest that recognizable disorders which are common to the wrist and hand are likely to need mobilization/manipulation at some stage in their natural history (Box 13.1).

Finding consistency in functional demonstrations There are an infinite variety of positions in which the wrist and hand can function. This makes consistency in the repeated measurement of functional demonstra tions challenging. It therefore becomes more relevant to use the functional demonstration to identify the movement directions which make up the impairment. In this way a relevant and detailed model of establish ing articular movement impairment can be developed. For example, a patient may complain of wrist pain upon opening a jam jar. On analysis of the functional movement concerned it can be established that prona tion of the wrist and hand is the painful movement. By differentiation of this painful movement it is possible to establish whether the inferior radioulnar joint or the radiocarpal joint is the source of the pain. If the radiocarpal joint is the source, further differentiation will establish whether it is movement between the scaphoid, lunate or triquetral bones and the radius/ fibrocartilaginous disc which is painful. In this way a specifically directed mobilization technique is more likely to influence the joint signs.

The wrist and hand complex

Deciding on the true nature of pain provoked by palpation Quite often, when physically examining the wrist and hand, it is a challenge to establish whether the pain provoked is due to local tissue sensitivity or pain related to movement of a particular joint: •

•

•

•

Stressing a non-painful joint, such as the same joint in the opposite hand, will help the physiotherapist to establish and calibrate the patient's individual pain acceptance to mechanical stresses. Maitland et al (2001) suggest that, in relation to segmental vertebral mobility testing, pain which is experienced as being deep and/or spreading is characteristic of movement-related pain and is not a normal response to mechanical articular stresses. Recent onset symptoms (pain) which correspond to a traumatic or injurious event will be accompanied by the cardinal sign� of inflammation, such as swelling, heat, redness and signs of sympathetic activity (e.g. sweating). If a disorder is resolving, pain will be accompanied by comparable signs in soft tissues, alignment and movement analysis (pain will be related to resistance).

Deciding what should be the normal or ideal range for a particular wrist or hand movement (Fig. 13.1) Kapandji (1982) has suggested that the following ranges of movement are considered as normal average values for the wrist and hand: •

•

•

wrist flexion and extension 8 5° each (movement taking place primarily at the radiocarpal and midcarpal articulations) wrist radial deviation 15°, wrist ulnar deviation 45° (movement taking place primarily at the radiocarpal joint with accompanying movement at the radioulnar, intercarpal and carpometacarpal joints) wrist pronation 8 5°, supination 90° (movement taking place primarily at the inferior and superior radioulnar joints, accompanied by rotation at the radiocarpal, midcarpal and carpometacarpal joints).

The carpal bones can be described in terms of their rows for examination, differentiation and localization of treatment (Fig. 13.2): the proximal row of carpal bones consists of the scaphoid, lunate, triquetrum and pisiform; the distal row of carpal bones consists of the trapezium, trapezoid, capitate and hamate. These rows therefore are components of the radiocarpal, midcarpal and carpometacarpal joints.

The carpal bones can also be described in terms of pillars (Fig. 13.3): the' lateral pillar consists of the scaphoid and trapezium/trapezoid, the central pillar consists of the lunate and capitate and the medial pil lar consists of the triquetrum/pisiform and hamate. The value of this is that, ideally, the mobility within the central pillar should be greater than the medial and lateral pillars when individual carpal mobility is tested (Kapandji 1982). The intercarpal joints and intermetacarpal joints also exhibit a degree of hollowing and flattening which, in this text, is described as horizontal flexion and extension. The metacarpophalangeal (MCP) joints can flex on average to 90° (similar to the interphalangeal (IP) joints) and can be passively rotated by 600. The sequence for examination and treatment of the MCP and IP joints is described in detail later. A good working knowledge of surface anatomy (Hoppenfeld 1976, Kesson & Atkins 1998 ) will enhance the clinician's accuracy in localization and application of forces during movement analysis of the wrist and hand.

SUBJECTIVE EXAMINATION Information from the subjective examination of the patient with wrist and hand symptoms will help to establish the kind of disorder being presented, the source of the patient's symptoms and the degree to which daily activity is limited by the severity, irritabil ity and nature of the disorder (Chapter 5). Information about the history of the symptoms will help to estab lish the nature of the onset, the directions and degree of injuring forces and the present stage of the dis order's natural history. Special questions will establish any precautions and contraindications to treatment and whether there are any intrinsic or extrinsic predis posing factors or barriers to an ideal rate of recovery.

Question 1 . The patient's main problem(s) •

•

•

A good working knowledge of surface anatomy of the wrist and hand will help to team up the patient's wrist and hand symptoms with a recognizable joint, peripheral nerve or muscle. Activity limitations which include the prehensile or non-prehensile functions of the wrist and hand will strengthen the hypotheses suggesting a local disorder. A strong relationship between the symptoms and mechanical trauma or stress to the wrist and hand is what the clinician should expect. Essentially, the

401

402

MAI T LAND'S PERI PHERA L MANIPULATION

Figure 1 3.1 (a) The carpal and metacarpal bones of the left hand; (b) palmar aspect; (c) dorsal aspect. (b) and (c) reprodu ced from Wil liams, P. L. and Warwick, R. 1 973, Gray's Anatomy 35th edn. Edi n b u rg h : Chu rchill Livingstone, pp. 336-337, by courtesy of the publishers.

Capitate Hamate Trapezium T rapezoid Scaphoid Lunate Triqu etrum Pisiform ( b)

2nd

3rd

-l--f-:H-- Metacarpal bones Trapezoid -+---f"'TTrapezium ------"'., Scaphoid -------""'<: Capitate

3rd

(c)

Metacarpal --I+<:�+ bones

2nd

-tr�"'h,.L.-f- Styloid process

Capitate --\--:7-=� ----"'j<-- Hook of hamate

+--"""oi--- Trapezoid

Hamate ---r-�

" ...,4-

__

Triqu etrum --� -,.'---- T riqu etrum Lunate

patient would be expected to complain of pain, stiffness, swelling, loss of function, loss of feeling, and weakness of the wrist and hand.

Areas of symptoms As discussed earlier in this chapter, a large or 'real size' wrist and hand chart should be used so that the precise area of the patient's symptoms can be represented more accurately (Fig. 13.4). In this way the area which the patient describes as being painful is often diagnos tic in itself. A band of pain across the wrist is common in radiocarpal joint disorders; inferior radioulnar joint pain is usually felt locally and deep. Any referred pain is usually felt to spread from the joint towards the

Lunate -----">
T rapezium

"7""---- Scaphoid

I

Articulate with radius

elbow. Pain arising from any of the intercarpal joints is always felt locally, although it may radiate out from a central point of the disordered joint. Pain from the intermetacarpal joints will be felt locally at their bases and over the joint. Pain and swelling over the extensor pollicis longus tendon would be expected in a diagno sis of de Quervain's tenosynovitis. Paraesthesia of the thumb, index, ring and half the middle finger would be a common presentation in carpal tunnel syndrome (Figs 13.5, 13.6). The manner in which patients verbally and non verbally describe their symptoms can help to establish common characteristics of mechanical disorders of the wrist and hand. For example, the patient may rock or move a particular joint while describing the aching or

The wrist and hand complex

403

]

�

Right hand

Shar P deep occasional (inferior radioulnar) ,

Band ache deep, intermittent (radiocarpal)

Carpometacarpal Midcarpal Radiocarpal

Figure 13.2

Rows of carpal bones.

Figure 13.4

Right hand: a reas of symptoms.

h��<---Extensor pollicis longus

Lateral pillar Central pillar Medial pillar

Figure 13.3

Pillars of carpal bones.

Figure 13.5

soreness they feel within it. Alternatively, descriptions of heaviness and tiredness of the whole hand may lead to suspicions of less direct mechanisms of symptom production.

Behaviour of symptoms over 24 hours If the wrist and hand are the source of the patient's symptoms, hand functions will be compromised or restricted by pain, stiffness, protective spasm or other

Extensor poliicis longus.

associated signs such as weakness, pain inhibition or loss of feeling. Prehensile functions which may be compromised include forearm twisting (pronation, supination), wrist flexion, extension, ulnar and radial deviation, the func tion of opposition and manipulative or gripping activities; non-prehensile functions which may be compromised include pushing, pulling or weight bearing activities.

404

M AITLAN D'S P E R I P H ERAL M A N I P U LATI O N

•

•

Cutaneous supply of the median nerve in the hand

Tendonitis would be accompanied by a history of activity causing friction of the tendon within its sheath resulting in a synovial reaction. Osteoarthritic disease will follow episodes of symptoms relating to episodes of new or unusually heavy activity.

Special questions The main area of concern with wrist and hand symp toms is whether any neurological compromise is tak ing place or could be effected by physical examination and treatment. Vascular or metabolic disorders may also present with symptoms in the hands (Chapter 10). Figure 13.6 the hand.

Cutaneous supply of the median nerve in

The stage of the disorder and the severity and irrit ability of the symptoms will determine the degree of impairment experienced by the patient. For example, a patient who has a I-week history of a badly sprained wrist will use the hand less than someone with stiff ness 1 2 weeks after a Colles fracture. The loss of hand function may also impact on the cog nitive and emotional dimensions of the patient's experi ence of these impairments. The hand is an immense sensory and communication organ which, if impaired, will affect many aspects of the patient's daily life. Night-time is usually a time of relief from mechani cal symptoms. However, patients with peripheral nerve entrapments often suffer more from their symptoms at night. Morning stiffness would be expected when patients suffer from osteoarthritic or degenerative dis orders. Morning soreness is common in patients with inflammatory components to their disorders.

PHYSICAL EXAMINATION Boxes 13.2-13.10 summarize the physical examination of the joints of the wrist and hand (Maitland 1992).

In standing Observation •

•

Grip strength test/functional demonstration •

•

History (present and past) The history (present episode and past episodes) of the patient's symptoms should correspond to one of the recognizable patterns described by Corrigan and Maitland (1983): •

•

Tendon/ligament injuries and fractures should correspond to a recognizable traumatic event or mechanical stress which would explain the onset of symptoms. Nerve entrapments may correspond to particular activities which would predispose to such events (e.g. carpal tunnel syndrome associated with pressure changes within the tunnel as in pregnancy or occupations which involve constant compromise of the tunnel and its contents).

General dexterity and willingness to use the wrist and hand. Inspection - including cardinal signs of injury or inflammation, deformity, trophic changes, circulatory changes.

•

•

Look for alignment faults with grip, including the ability to fully oppose the thumb and the range of finger flexion. Look for gripping with the wrist in flexion or gripping with the wrist deviating (usually radial because of overpull of extensor carpi radialis brevis). Analyse and record the ranges of movement, the symptom response and the quality of movement. For pain arising from the inferior radioulnar joint the functional demonstration may involve the action of turning on a tap. The point at which the pain comes on with supination is determined and in this position the ulna can be moved further into the range to determine any increase in pain.

Screening tests •

For the shoulder/shoulder girdle complex (Chapter 11): shoulder flexion, abduction, HBB, HF, LR with overpressure (if necessary).

The wrist and hand complex

A. Move to

pain or

move to

limit

B. Chronic - minor wrist /hand symptoms Mandatory passive movement test, when chronic symptoms occupy any part of the area from the lower third of the radius and ulna to the mid-metacarpals (thumb excl uded). Supine: • • • • • •

Flexion and extension Supination and pronation (through metacarpals) Radial and ulnar deviation AP / PA movement HF and HE Longitudinal caudad and cepha lad

Test movements begin as IV- with observation for pain response. If pain free, adeq uate overpressure is applied until pain is provoked or the movement is judged 'clear'. When a positive pain response is provoked, that test movement may need to be differentiated to determ ine the specific joint at fault. a n d / or other movements may need to be tested so as to either exclude or incriminate other joints as contributing to the symptoms. If all test movements appear 'clear' at first examination, they shou ld be repeated more strongly. If still 'clear', they may prove positive when repeated at the next consultation. C. Proving the wrist / hand is u naffected F and E (fingers to wrist) • Supi nation and pronation • Wrist deviations • � ceph, ca ud •

The routine exami nation of this joint m ust a lso i nclude exa mination of the wrist, as supination and pronation a lso occur as accessory movements of the wrist joint. Observation "Functional demonstration /tests Theirdemonstration of their functional movements affected by their d isorder • Differentiation of their demonstrated fu nctional movement(s)

•

Brief appraisal Active movements (move to • • •

In sitting •

Wrist Ab, Ad (F and E) Supination, pronation Note ra nge, pa in

Passive movements Physiological movements Routinely

Sup and Pron Note ra nge, pa in, resista nce, spasm and behaviour

•

Accessory movements As applicable

1.

3.

pronation and supination. These movements can include asking the patient to flick the elbow further into the end of the range to act as overpressure (if necessary). This will also include brief appraisal of the inferior radioulnar joint. The speed with which the movement can be performed may determine the firmness or gentleness of further testing.

limit)

Isometric tests

2.

Far the elbow (Chapter 12): elbow flexion, extension,

move to

Other structures in 'plan' • Thoracic outlet • Entra pment neu ropathy • Tendon sheaths

Reproduced by kind permission from Maitland (1992).

•

pain or

Routinely

4. 5. 6.

t,;

(a) i n neutral (a lso i) (b) at limit of pronation (c) at limit of supination Sup / Pron with compression Sup and Pron d ifferentiating for wrist Note range, pain, resistance, spasm and behaviour Ca na l's s l u m p test Differentiation tests ULNT

Pa l pation + When 'comparable sig ns' il l-defined, reassess 'inj uring movement'

•

Check case records etc. Highlight main findings with asterisks

Screening tests for the cervical spine: lower cervical

Instructions to patient

quadrant, cervical movements under compression (Maitland et a12001).

Reproduced by kind permission from Maitland (1992).

405

406

MAITLAND'S PER IPHERAL MANIPU LAT ION

The routine exa mination of this joint m ust include the inferior radioul nar joint and intercarpal joints.

Routinely • •

Observation ·Functional demonstration /tests • Their demonstration of theirfu nctional movements affected by their disorder • Differentiation of their demonstrated functional movement(s)

Active movements (move to

Accessory movements Routinely:

pain or

move to

limit)

•

•

F, E, Ab, Ad, Sup, Pron Note range, pain (repeated and rapid) Clenching fist

4. 5.

6. 7. 8.

Isometric tests Other structures in 'plan' As applicable •

• •

Fu l l active resisted movement through range for 'sheaths' Thoracic outlet Entra pment neuropathy

Passive m ovements

-- , +-

, ....... ceph and caud

1. F and E differentiating 2.

Routinely •

; , t,

As applicable

3.

Brief appraisal

F, E, radial and u l nar deviation, Sup and Pron Note range, pain, resistance, spasm and behaviour. All without and with com pression as applicable

Sup and Pron differentiating Meniscus Pisiform Wrist t, ; , -- ,+- in supination, neutral and pronation and in varying positions of flexion and extension Ca nal's slump test Differentiation tests ULNT

Palpation • Include tendon sheaths and 'anatom ical snuff box' as applicable • + When 'comparable sig ns' i l l-defined, reassess 'injuring movement' Check case records etc. Highlight main findings with asterisks

Physiological movements

Instructions to patient Reproduced by kind permission from Maitland (1992).

Box 1 3.5 The routine exa mination of these joi nts must also incl ude exa mination of the wrist joi nt, carpometacarpal (CI MC) joi nts and pisiform movements." Observation ·Functiona I demonstration / tests • Their demonstration of theirfunctional movements affected by their d isorder • Differentiation of their demonstrated functional movement(s)

Isometric tests

Passive movements Physiological movements Routinely

1. Wrist F, E, Ab, Ad, Sup, Pron 2.

M idcarpal F and E Differentiating F and E 4. Individual carpometacarpal (CI MC) F and E Note range, pain, resistance, spasm and behaviour 3.

Brief appraisal Active movements (move to

Other structures in 'plan' • Add fu l l active resisted movement through range for 'sheaths' • Thoracic outlet • Entrapment neuropathy

pain or

move to

limit)

The wrist and hand complex

5. Canal's slu m p tests

Accessory movements Routinely

1.

; and t (varying ang les and points of contact).

t

(i.e. g l iding of each carpal bone on adjacent carpal bone) 2. HF and HE of carpus 3. "Pisiform, without com pression and with compression, --++ , ++- , ....... ceph and caud, distraction 4. C / M C joints (a) ; and f (varying angles and points of contact), t (b) --++, ++- of metacarpals on carpus, with and without abduction and adduction (c) ::J and c: metacarpals Note range, pain, resistance, spasm and behaviour

The routine examination of these joints m ust incl ude examination of intercarpal joints, and proximal and distal intermetacarpal joints and spaces. Observation *Functiona I demonstration I tests • Theirdemonstration of their functional movements affected by their disorder • Differentiation of their demonstrated functional movement(s) Brief appraisal Active movements (move to

pain or

move to

limit)

Isometric tests Other structures in 'plan' Fu l l range active! resisted wrist and finger F for sheaths • Thoracic outlet • Entrapment neuropathy •

6. Differentiation tests 7. ULNT Palpation Include tendon sheaths • + When 'comparable signs' ill-defined, reassess 'injuring movement' •

Check case records etc

.

Highlight main findings with asterisks

Instructions to patient Reproduced by kind permission from Maitland (1992).

Accessory movements Routinely

1. ; and t (varying ang les, medial, lateral, ceph, caud), t 2. --++ and ++3. Abd uction and add uction 4. Com bining (2) with (3) 5. ::J and c: of metacarpals All with and without com pression Note range, pain, resistance, spasm and behaviour As applicable

1. Canal's slump test 2. Differentiation tests 3 . ULNT

Palpation Incl ude tendon sheaths • + When 'comparable signs' ill-defined, reassess 'injuring movement' •

Check case records etc.

Passive movements Physiological movements

Highlight main findings with asterisks

Routinely

1. Ind ividual C/ MC F and E 2. HF and HE of carpus and d ifferentiating 3. HF and HE of metacarpals Note range, pain, resistance, spasm and behaviour

}

Instructions to patient Reproduced by kind permission from Maitland (1992).

407

408

MAITLAND'S PERIPHERA L MANIPU LATION

[

As applicable

Observation "Functional demonstration /tests • Theirdemonstration of their functional movements affected by their disorder • Differentiation of their demonstrated functional movement(s)

3.

Differentiation tests ULNT

Accessory movements Routinely

; and t of each metacarpal in relation to its neighbour (bases and heads) 2. Individual HF or HE (bases and heads) Note range, resistance, pain, spasm and behaviour 1.

Brief appraisal Active movements (move to

1. Canal's slu m p tests 2.

pain or

move to

limit)

Isometric tests Other structures in 'plan' • Fu l l active resisted movement through range for 'sheaths' • Thoracic outlet • Entrapment neu ropathy Passive movements

Pal pation • Incl ude tendon sheaths • + When 'com parable sig ns' i l l-defined, reassess 'injuring movement' Check case records etc. Highlight main findings with asterisks

Physiological movements Routinely

Instructions to patient

HF and HE of metacarpals (on bases and heads) Note range, pain, resistance, spasm and behaviour

Reproduced by kind permission from Maitland (1992).

Observation

•

•

"Functional demonstration /tests • Theirdemonstration of their functional movements affected by their d isorder • Differentiation of their demonstrated functional movement(s) Brief appraisal Active movements (move to

•

Passive movements Physiological movements Routinely

F, E Note range, pain, resistance, spasm and behaviour •

As applicable pain or

move to

limit)

Routinely

F, E, spreading; fist /grip Note range and pain, repeated and rapid •

Isometric tests

•

As applicable

•

Fu l l active resisted movements through range for 'sheaths' Joint restriction d. m uscle / tendon restriction

Joint restriction d. m uscle / tendon restriction

Accessory movements Routinely

1. ...... ceph and caud, Ab, Ad, ...... , --, ;, ; , :J

2.

Other structures in 'plan' •

Thoracic outlet Entrapment neuropathy

c:

The above in different positions of other physiological ranges

As applicable

1. Same movements u nder com pression

2.

Ab, with ...... and --

The wrist and hand complex

3.

Ad, with

-+

and --

4. Canal's sl ump tests 5. Differentiation tests

Check case records etc. Highlight main findings with asterisks

6. ULNT

I nstructions to patient

Palpation • Include tendon sheaths • + When 'comparable sig ns' il l-defined, reassess 'injuring movement'

Reproduced by kind permission from Maitland (1992).

Box '!!3.:!9

-1!!!!I�

The routine exami nation of this joint m ust incl ude the adjacent intercarpal joints and wrist. Observation 'Fu nctional demonstration/tests • Theirdemonstration of theirfunctional movements affected by their disorder • Differentiation of their demonstrated functional movement(s) Brief appraisal Active movements (move to pain or move to limit) • Add active movements of thumb including gripping and fist Isometric tests Other structures in 'plan' • Fu l l active resisted movements through range for 'sheaths' • Joint restriction d. m uscle / tendon restriction • Entrapment neuropathy Passive movements Physiological movements Routinely

1. Thumb F, E, Ab, Ad 2. Differentiating F, E, Ab, Ad Rotn and opposition 3 . HF and HE of carpus Note range, pain, resistance, spasm and behaviour

Accessory movements Routinely

1 . ; and; of first metacarpal on trapeziu m

2 . -+ a n d - - against metacarpal on carpus, with and without abduction and adduction, with and without com pression. 3. :J and c: of metacarpal, with and without compression

4. t adjacent intercarpal and 1 st C/ MC joint Note range, pain, resistance, spasm and behaviour As applicable

1 . I nterca rpa I tests 2. C / MC ; with E 3. Canal's slump tests 4. Differentiation tests 5. ULNT

Palpation • Include tendon sheaths • + When 'com parable signs' i l l -defined, reassess 'injuri ng movement' Check case records etc. Highlight main findings with asterisks

Instructions to patient Reproduced by kind permission from Maitland (1992).

409

MA ITLAN D'S P E R I P H ERAL M A N I PU LAT I O N

410

Observation *Functional demonstration/tests Their demonstration of theirfunctional movements affected by their disorder • Differentiation of their demonstrated fu nctional movement(s) •

2.

3.

Brief appraisal Active movements (move to • Clench fist and test grip • F, E, Ab and Ad of wrist • Sup and Pron

pain or

move to

limit)

4.

5.

Isometric tests Other structures i n plan '

'

Passive movements

(b) midcarpal (c) carpometacarpal Radial and ul nar deviation (a) radiocarpal (b) midcarpal (c) carpometacarpal Supi nation and pronation (a) radiocarpal (b) i nferior R / U joint ...... caud and ceph (a) radiocarpal (b) intercarpal (c) carpometaca rpal HF and HE (a) i nterca rpa I (b) carpometacarpal (c) i ntermetacarpal

As required

Whole hand 1. F and E 2. Radial and u l nar deviation 3 . Sup and Pron 4. ...... ceph and caud 5. HF and HE 6. Pisiform 7. ; , ; , --+ , -- in different positions of wrist Sup, Pron, F and E 8. Sheaths 9. Tendon length and function 10. Meniscus Differentiating as required

1 . F and E

Other test movements

1 . ; , \. , / , ; , I, \ ,

t (from inferior R/ U to heads

of metacarpals) 2. Canal's slump tests 3. ULNT Palpation + When 'compa rable signs' ill-defined, reassess 'injuring movement'

•

Check case records etc. Highlight main findings with asterisks

Instructions to patient Reproduced by kind permission from Maitland (1992).

(a) radiocarpal

•

•

Screening tests for the thoracic spine: active movements with overpressure added (Maitland et al 2001). Slump test, long sitting slump test, including bias towards the thoracic sympathetic chains (Butler 2000).

•

•

In supine lying •

Inspection and palpation •

•

Identification of surface anatomy landmarks (Hoppenfeld 1976). Identification of signs of movement impairment (temperature changes, excessive sweating, soft tissue changes including swelling and soft tissue thickening, bony abnormalities such as exostosis).

Palpation of the median, ulnar and radial nerves around the wrist and hand for mechanosensitivity, symptom reproduction and signs of swelling or thickening (Fig. 13.7). Palpate tendons and tendon sheaths where tenosynovitis may be evident (extensor pollicis longus in particular). Brachial and radial pulses to check for circulatory viability.

Active movements of whole hand •

Active movements of the whole hand with grade III + overpressure as necessary (recording range, symptom response and quality of movement) and

The wrist and hand complex

Ulnar nerve 1-+-+--.----1- Median nerve

1+---f-+----1-f--f-- Radial nerve (superficial branch)

Superficial branch of ulnar nerve

Muscular branch of

Dorsal branch of ulnar nerve Digital branch of ulnar nerve

Figure 13.7

Figu re 13.8

Whole hand supination.

Figure 13.9

Inferior radio u l nar and radiocarpal supination.

Superficial nerves.

brief appraisal tests should include flexion, extension, radial deviation, ulnar deviation, pronation, supination, horizontal flexion, horizontal extension, compression, distraction, anteroposterior and posteroanterior movements.

Differentiation of movements reproducing pain •

•

•

Pronation/supination: differentiate between inferior radioulnar, radiocarpal, midcarpal and carpometacarpal (Figs 13.8-13.13). Flexion/extension: differentiate radiocarpal and midcarpal (see Figs 13.20-13.25). Radial! ulnar deviation: differentiate inferior radioulnar, radiocarpal and midcarpal (see Figs

13.26-13.29). •

Horizontal flexion/extension: differentiate between proximal and distal carpal rows and intermetacarpal joints (see Figs 13.34, 13.35).

411

412

MAITLAND'S PERIPHERA L MANIPULATION

Figure 13.10

Release radiocarpal supination.

Figure 13.12

Increase radiocarpal supination.

Figure 13. 1 1

Release radioul nar supination.

Figure 13.13

Increase radioul nar supination.

Passive movements wrist and hand Whole hand movements, differentiating rows: •

Inferior radioulnar joint: pronation, supination, anteroposterior / posteroanterior movement,

•

longitudinal movement cephalad and caudad, compression, movements under compression. Radiocarpal joint: flexion, extension, radial deviation, ulnar deviation, medial rotation, lateral

The wrist and hand complex

•

•

•

•

rotation, anteroposterior/posteroanterior movements, transverse movement medially, transverse movement laterally, horizontal flexion, horizontal extension, compression, distraction, movements under compression/ distraction. Midcarpal joint: flexion, extension, horizontal flexion, horizontal extension. Intercarpal movements: anteroposterior/ posteroanterior movements of individual bones or over the joint line, with inclinations. Intermetacarpal joints: anteroposterior/ posteroanterior movements, horizontal flexion, horizontal extension. Carpometacarpal, metacarpophalangeal, interphalangeal joints: flexion, extension, abduction, adduction, medial rotation, lateral rotation, anteroposterior/posteroanterior, transverse medial, transverse lateral, compression, distraction, movements under compression/distraction.

In prone lying •

EXAMINATION AND TREATMENT TECHNIQUES WRIST AND HAND

Differentiation testing of the wrist and hand Differentiation of pronation/supination • •

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•

Especially wrist flexors and extensors, through range metacarpophalangeal and interphalangeal flexion and extension, thumb extension and abduction.

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• •

Screening tests

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Screening cervical spine: anteroposterior movement, C2-7, passive physiological intervertebral movements (PPIVMs) (Maitland et aI200l). Screening first rib: longitudinal movement caudad, anteroposterior/posteroanterior movement (Maitland et aI2001). Screening shoulder: shoulder quadrant/locking position (Chapter 11). Screening elbow: elbow extension abduction/ adduction, flexion adduction/abduction, pronation, supination (Chapter 12). Upper limb neural provocative tests (ULNPTs): ULNPTs relevant to the median ulnar and radial nerves (Butler 2000).

Flexion- see Figures 13.20-13.22. Extension - see Figures 13.23-13.25.

Differentiation of radial and ulnar deviation

•

•

Whole hand- see Figures 13.8-13.13. Inferior radioulnar pronation and supinationsee Figures 13.15 and 13.17. Radiocarpal pronation and supination - see Figures 13.32 and 13.33.

Differentiation of flexion/extension •

Isometric testing

Cervical and thoracic spine palpation and segmental mobility testing, including mobility testing of the ribs (Maitland et aI200l).

•

Ulnar- see Figures 13.26 and 13.27. Radial- see Figures 13.28 and 13.29. Longitudinal caudad/cephalad of the inferior radioulnar joint - see Figures 12.38 and 12.39. Localization of forces to radiocarpal, midcarpal and carpometacarpal - see Figures 13.27 and 13.29.

Differentiation of horizontal flexion/extension • •

Intercarpal - see Figures 13.34 and 13.35. Intermetacarpal- see Figures 13.43.

Supination (Figs 1 3. 1 4, 1 3. 1 5) Method This technique is identical to that described for Figures 12.32 and 12.33.

In side lying •

•

Screening of scapulothoracic movements: elevation, depression, protraction, retraction, rotation (Chapter 11). Screening of C7-T4: PPIVMs (if necessary) (Maitland et aI2001).

Pronation (Figs 1 3.1 6, 1 3. 1 7) Method This technique is identical to that described for Figures 12.34 and 12.35.

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MA ITLAN D'S P E R I P H ERAL M A N I PU LATI O N

Figure 1 3. 14

Figure 13. 1 5 IV+.

Inferior radioulnar joint: supination grades I-IV.

Inferior radiou l n a r joint: supination grade

Figure 13. 1 6

Inferior radiou lnar joint: pronation.

Figure 13.17 grade IV+.

Inferior radioulnar joint: pronation,

The wrist and hand complex

Inferior radioulnar joint posteroanterior and anteroposterior movements (Fig. 13. 1 8) •

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Direction: The PA and AP movements are referred to as movements of the ulna on the radius because it is easier to stabilize the comparatively large distal end of the radius and produce the movement by push ing the distal end of the ulna. Symbols: ; , t Patient starting position: Supine in the middle of the couch with the elbow flexed to 90°. The AP and PA movements are of the largest amplitude possible with the inferior radioulnar joint positioned mid way between pronation and supination. The move ments can be produced in any position of pronation and supination. Therapist starting position: Standing by the patient's right side just beyond the flexed elbow, facing the patient's left shoulder.

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•

Application of forces by therapist (method) •

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The thumb and index finger of both hands hold the patient's forearm midway between pronation and supination. The thumb of the left hand posteriorly and the flexed index finger anteriorly hold onto the distal end of the radius.

A PA movement of the ulna on the radius is produced by pressure against the posterior surface of the ulna with the therapist's right thumb and an equal and opposite pressure against the anterior surface of the radius with the left index finger. An AP movement of the ulna on the radius would be produced by an opposite action.

Variations in the application of forces •

Localization of forces (position of therapist's hands) •

The remaining fingers flex to add lateral support to the index finger which makes the main point of contact. The right hand holds the distal end of the ulna with an identical grip.

For stronger movement stretching at the limit of supination or pronation the therapist should grasp the radius and ulna more firmly between the thenar eminences rather than just using the thumbs and index fingers. In this way the PA and AP stretching can be performed more strongly at the limit of supination or pronation by a pushing and pulling action of the arms.

Uses • •

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Mainly clinical groups 2 and 3b. Patients with stiffness or pain and stiffness with pronation or supination. Postfracture or postimmobilization pain and stiffness in pronation or supination.

Inferior radioulnar compression (Fig. 13. 1 9) •

• •

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Direction: Compression of the radius and ulna towards each other at the inferior radioulnar joint. Symbol: >--< Patient starting position: Supine in the middle of the couch with the elbow flexed to 90° and the forearm in the mid pronation/supination position. Therapist starting position: Kneeling by the patient's right side beyond the flexed elbow.

Localization of forces (position of therapist's hands) • •

Figure 13.18 Inferior radiou lnar joint: posteroanterior and anteroposterior movements.

Both hands grasp the patient's right hand. The thumbs and thenar eminences, pointing towards the patient's fingers, cover the posterior surface of the patient's wrist meeting in the midline.

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M AITLA N D ' S P E R I P H ERAL M A N I P U LATI O N

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•

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The fingers reach around to meet anteriorly i n the midline. The heel of the left hand cups around the lateral surface of the distal end of the patient's radius. The heel of the right hand cups around the distal end of the patient's ulna. Both arms are directed opposite to each other at right angles to the patient's forearm.

•

The same grip can be used to distract or separate the distal ends of the radius and ulna.

Uses •

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When pain in the inferior radioulnar joint is aggravated by gripping activities. When pain is provoked on squeezing the radius and ulna firmly together at the inferior radioulnar joint.

Application of forces by therapist (method) •

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Firstly, supination and pronation are produced by a twisting in opposite directions of the heels of the therapist's cupped hands, pivoting around stationary fingers and thumbs. Pronation of the patient's forearm is produced by pronation of the therapist's left forearm and supination of the right forearm so that the heels of the therapist's hands move away from each other. Supination is produced by supination of the therapist's left forearm combined with pronation of the right. A back-and-forth rocking movement between supination and pronation is continued while compression is maintained between the therapist's two arms.

Inferior radioulnar joint longitudinal movement caudadl cephalad Method This technique is identical to that described for Figure 1 2.38 (caudad) and Figure 1 2.39 (cephalad).

Variations in the application of forces These longitudinal movements are described as being longitudinal movement of the radius on the ulna. The reasons for presenting the movement as being that of the radius on the ulna are: 1.

is to carry out ulnar deviation of the hand, which pulls the radius in a caudad direction.

Variations in the application of forces •

As a brief appraisal test for the joint, the radius can be compressed strongly against the ulna at the same time as rocking the radius and ulna back and forth against each other.

the ulna is relatively more stable at the elbow

2. one of the best ways of producing this movement

Cephalad longitudinal movement of the radius on the ulna is produced by radial deviation of the wrist.

Longitudinal movement cephalad •

•

•

Emphasis is placed on the exact position of the patient's hand and the direction of the pressure applied by the therapist's hand. The patient's hand must be tilted towards radial deviation (abduction) and the therapist should apply contact mainly through the base of the patient's thenar eminence so that the pressure is in a straight line with the shaft of the radius.

During radial deviation of the patient's hand there is a cephalad longitudinal movement of the radius in relation to the ulna.

Longitudinal movement caudad •

•

•

Figure 13.1 9

I nferior radiou lnar joint: com pression.

The therapist must grasp around the patient's hand immediately adjacent to the base of the first metacarpal and the pisiform. During the movement longitudinally the patient's wrist should be deviated towards the ulnar side (adduction).

During ulnar deviation of the patient's wrist there is a caudad longitudinal movement of the radius in relation to the ulna.

The wrist and hand complex

Uses •

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Application of forces by therapist (method)

Limited or painful radial and ulnar deviation of the wrist and hand. Painful restricted longitudinal movement of the radius on the ulna at the inferior radioulnar joint.

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Wrist flexion (general) (Fig. 1 3.20) • • •

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Direction: General flexion of the wrist and hand. Symbol: F. . Patient starting position: Supine in the middle of the plinth with the elbow flexed to 90° and midway between pronation and supination. Therapist starting position: Standing by the patient's right side beyond the flexed elbow.

Uses •

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Localization of forces (position of therapist's hands) •

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The right hand grasps around the medial border of the patient's right hand. The thumb is placed against the dorsum of the patient's metacarpals. The fingers are placed in the palm of the patient's hand. The left hand stabilizes the patient's forearm midway between supination and pronation immediately proximal to the carpus.

Figure 13.2 0

Wrist flexion (general).

Starting midway between flexion and extension the therapist's thumb flexes the patient's wrist and hand to the limit of its range; the therapist's fingers then return the patient's wrist to its starting position. The therapist's index finger is positioned near to the patient's metacarpophalangeal joints so as to control the return movement.

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As examination of wrist flexion with the addition of overpressure if necessary. As a general mobilization of wrist and hand flexion. Recovery of flexion after Colles fracture. As a through-range mobilization for patients with osteoarthritis of the wrist. As a neurodynamic mobilization technique in the ULNPT 2b position (radial nerve entrapment).

Radiocarpal flexion (Fig. 1 3.21 ) •

Direction: Flexion localized to the radiocarpal joint only.

Fi g u re 13.21

Radiocarpal flexion.

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MAITLAN D'S P E R I P H ERAL MAN I P U LATI O N

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Symbol: Radiocarpal F. Patient starting position: Supine, lying in the middle of the couch, forearm and wrist supinated. Therapist starting position: Standing by the patient's right hip facing the right shoulder.

Midcarpal flexion (Fig. 1 3.22) •

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Localization of forces (position of therapist's hands) •

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Both the therapist's hands hold the patient's supinated and extended arm at the wrist. Both thumbs point proximally on the anterior surface of the proximal row of the carpal bones. The fingers are placed across the back of the carpus. The flexed index fingers form the main point of contact against the proximal row of the carpal bones posteriorly. The index fingers and thumbs grasp immediately opposite each other mainly around the scaphoid and lunate but also including the triquetrum. The thumbs make contact through the base of their terminal phalanges rather than their tips.

•

Localization of forces (position of therapist's hands) •

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Application of forces by therapist (method) From a position midway between flexion and extension, the patient's wrist is moved downwards towards the floor while the carpus, held firmly between the therapist's index fingers and thumbs, is flexed on the radius and ulna. While performing this movement the carpus must be held firmly.

The tips of both thumbs are placed over the anterior surface of the distal carpal row (i.e. the trapezium, trapezoid, capitate and hamate). The index fingers, pointing towards each other and reinforced by the middle fingers overlie the posterior surface of the proximal carpal bones (i.e. scaphoid, lunate, triquetrum and pisiform).

Application of forces by therapist (method) •

•

Direction: Flexion localized to the midcarpal joint, i.e. between the proximal and distal rows of the carpal bones. Symbol: Midcarpal F. Patient starting position: Supine in the middle of the couch with the arm and wrist supinated. Therapist starting position: Standing by the patient's right side facing the right shoulder.

•

•

Flexion at the midcarpal joint is produced by a tilting action of flexion of the patient's hand pivoting through the thumb tips which apply pressure to the proximal carpal row anteriorly. Counterpressure is applied to the proximal carpal row posteriorly by the index fingers. If performed correctly there should be no radiocarpal or carpometacarpal movement.

Variations in the application of forces •

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The point of contact of the thumbs can be adjusted to influence movement more at the scaphoid, lunate or triquetrum. The flexion can also be repeated in varying positions of radial or ulnar deviation.

Uses •

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•

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As a localized mobilization of the radiocarpal joint. To mobilize the radiocarpal joint after scaphoid fracture. Combined with horizontal extension to assist in the rehabilitation of patients with carpal tunnel syndrome. As part of the process of differentiating wrist pain coming from the radiocarpal or midcarpal joints.

Figure 1 3.22

Midcarpal flexion.

The wrist and hand complex

Summary • •

Application of forces by therapist (method)

Thumbs against the distal row anteriorly. Index fingers against the proximal row posteriorly.

•

Uses • •

Localization of flexion to the midcarpal joint. Differentiation of pain originating from the radiocarpal or midcarpal joints.

Uses •

Wrist extension (general) (Fig. 1 3.23) • • •

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Direction: General extension of the wrist and hand. Symbol: E. Patient starting position: Supine in the middle of the couch with the elbow flexed to 90° and midway between pronation and supination. Therapist starting position: Standing by the patient's right side beyond the flexed elbow.

Localization of forces (position of therapist's hands) •

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The right hand grasps around the medial border of the patient's right wrist. The thumb is placed against the dorsum of the patient's metacarpals. The fingers are placed in the palm of the patient's hand. The left hand stabilizes the patient's forearm midway between supination and pronation immediately proximal to the carpus.

Figure 13.23

Wrist extension (general).

Starting midway between flexion and extension the therapist's fingers extend the patient's wrist and hand to the limit of its range; the therapist's thumb then returns the patient's wrist to its starting position.

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As examination of wrist extension with the addition of overpressure (up to III + ) if necessary. As a general mobilization of wrist and hand extension. Recovery of extension after fracture immobilization or injury. As a through-range mobilization for patients with osteoarthritis of the wrist. As part of a neurodynamic mobilization technique in the ULNPT 1 position (carpal tunnel syndrome).

Radiocarpal extension (Fig. 1 3.24) • •

Direction: Extension localized to the radiocarpal joint. Symbol: E.

Figure 13.24

Radiocarpal extension.

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MAITLA N D'S P E R I P H ERAL M A N I P U LATI O N

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Patient starting position: Supine, lying in the middle

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of the couch with the forearm partially pronated. Therapist starting position: Standing by the patient's right hip facing the right shoulder.

Midcarpal extension (Fig. 1 3.25) •

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Localization of forces (position of therapist's hands) •

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Both the therapist's hands hold the patient's pronated and extended arm at the wrist. Both thumbs point proximally on the posterior surface of the proximal row of the carpal bones. The fingers are placed across the front of the carpus. The flexed index fingers form the main point of contact against the proximal row of the carpal bones anteriorly. The index fingers and the thumbs grasp immediately opposite each other, mainly around the scaphoid and lunate but also including the triquetrum. The thumbs make contact with the base of their terminal phalanges rather than their tips.

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Localization of forces (position of therapist's hands) •

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The proximal end of the distal phalanx of each thumb is placed immediately over the distal margin of the proximal row of the carpal bones posteriorly. The reinforcing index fingers lie firmly against the anterior surface of the distal row of the carpal bones.

Summary •

Application of forces by therapist (method)

Direction: Extension localized to the midcarpal joint, i.e. between the proximal and distal rows of the carpal bones . Symbol: Midcarpal E. Patient starting position: Supine, lying in the middle of the couch with the arm and wrist pronated. Therapist starting position: Standing by the patient's right side facing the right shoulder.

•

Thumbs against the proximaL row posteriorly. Index fingers against the distaL row anteriorly.

The extension movement is produced through a very firm localized grasp with the fingers and thumbs while lowering the wrist towards the floor as the wrist is extended. The oscillation is completed by returning the patient's arm to the starting position while at the same time returning the extended radiocarpal joint to its mid position.

Variations in the application of forces •

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The point of contact of the thumbs can be altered to influence movement more at the scaphoid, lunate or triquetrum. The extension can be repeated in varying positions of radial and ulnar deviation.

Uses •

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As a localized mobilization of the radiocarpal joint. To mobilize the radiocarpal joint after fracture of the wrist or injury. Combined with horizontal extension to assist in the rehabilitation of patients with carpal tunnel syndrome. As part of the process of differentiating wrist pain coming from the radiocarpal or midcarpal joints.

Figure 13.2 5

Midcarpal extension.

The wrist and hand complex

Application of forces by therapist (method) •

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A tilting action is produced through the index fingers against the distal row of the carpal bones, with the bases of the thumbs preventing movement of the proximal row. There should be no extension of the radiocarpal or the carpometacarpal joints.

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Localization of forces (position of therapist's hands) •

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Uses • •

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Localization of extension to the midcarpal joint. Differentiation of pain originating from the radiocarpal or midcarpal joints.

Therapist starting position: Standing by the patient's right side facing the patient's feet.

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The right hand grasps the patient's forearm distally. The index finger of the right hand stabilizes around the styloid process of the ulna. The left hand grasps the anterior and posterior surface of the metacarpals. The fingers of the right hand reach around the ulnar border of the patient's hand. The thumb of the left hand holds through the patient's first interosseous space.

Wrist ulnar deviation (general and localized) (Figs 1 3.26, 1 3.27) • • •

Direction: Ulnar deviation of the wrist and hand . Symbol: Ulnar deviation- general and localized. Patient starting position: Supine in the middle of the couch with the elbow flexed to 90° and the forearm in its mid pronation/supination position.

Figure 13.26

Wrist ulnar deviation (general).

Application of forces by therapist (method) •

The oscillatory movement performed in any part of the range is produced by a supination action of the therapist's right forearm, and a pronation action returning the wrist and hand to its starting position.

Figure 13.27

Wrist ulnar deviation (local).

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MAITLA N D ' S P E R I P H ERAL M A N I P U LATI O N

Variations in the application of forces (for the purpose of differentiating the source of wrist pain)

the carpometacarpal joint the distal row is stabi lized and the metacarpals are tilted into ulnar deviation.

Localization to the radiocarpal joint •

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•

The tips of the thumb and index finger of the left hand stabilize the distal ends of the ulna and the radius medially and laterally in a pinch grip. The tips of the thumb and index finger of the right hand hold the proximal row of the carpal bones from medially and laterally in a pinch grip. As the thumb and index finger of the left hand stabilize the ulna and radius, the thumb and index finger of the right hand can tilt the proximal row of the carpal bones into ulnar deviation.

Localization to the midcarpal and carpometacarpal joints •

The same methods of localization of forces and application of forces are adopted. However, for the midcarpal joint the proximal row of the carpal bones is stabilized and the distal row is tilted. For

Uses •

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Wrist radial deviation (general and localized) (Figs 13.28, 13.29) •

Wrist radial deviation (general).

Direction: Radial deviation of the wrist and hand.

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Symbol: Radial deviation- general and localized.

Localization of forces (position of therapist's hands) •

Figure 1 3.28

General ulnar deviation of the wrist and hand or localization to the appropriate joint. Pain and stiffness with ulnar deviation (mainly clinical groups 2, 3a and 3b).

This is the same as for ulnar deviation with the exception that the therapiSt's left thumb holds the radial stylOid and the right hand grasps the metacarpals.

Figure 1 3.29

Wrist radial deviation (local).

The wrist and hand complex

Application of forces by therapist (method) •

This is the same as for ulnar deviation with the exception that the movement produced by the therapist's forearm is radial deviation.

Variations in the application of forces •

The method of localization of forces and application of forces to the radiocarpal, midcarpal and carpometacarpal joints alone is the same as that described for ulnar devia tion with the exception·that the joints in question are moved in the direction of radial deviation.

Application of forces by therapist (method) •

•

Variations in the application of forces •

Uses •

These are the same as those described for ulnar deviation.

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• •

•

The movement can also be performed by using the couch and the left hand to stabilize the radius and ulna while the right hand grasps the back of the patient's carpus and directs the posteroanterior movement through the heel of the therapist's hand towards the floor.

Uses •

Radiocarpal posteroanterior movement (Fig. 13.30)

The oscillation starts from the neutral position of the wrist and hand and is taken to the limit or appropriate point in the range by an equal and opposite movement of the therapist's forearms. The patient's hand should be kept straight to prevent flexion and extension of the wrist.

As a grade I or II movement for very painful wrists.

Direction: Movement of the proximal row of the carpal bones on the radius and fibrocartilaginous disc in the posteroanterior direction.

Symbol: ; Patient starting position: Supine in the middle of the

couch, elbow flexed to 90° and the forearm in its mid pronation/supination position . Therapist starting position: Standing by the patient's right hip facing the patient's head.

Localization of forces (position of therapist's hands) •

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•

• •

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• •

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The left hand holds the posterior surface of the patient's hand. The right hand holds the anterior surface of the distal forearm. The right hand is fully supinated and extended at the wrist. The fingers of the right hand point proximally. The heel of the right hand is placed level with the distal end of the radius and ulna. The fingers of the right hand grasp around the patient's forearm. The heel of the left hand should lie over the carpus. The fingers of the left hand grasp round the patient's thumb. The thumb of the left hand grasps around the ulnar border of the patient's hand. The therapist should draw the patient's wrist and hand towards their body and crouch, directing both forearms opposite to each other.

Figure 1 3.30

Radiocarpal posteroanterior movement.

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MAITLA N D ' S P E R I P H ERAL M A N I P U LATI O N

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•

A s a grade III o r I V movement for a predominantly stiff joint. As a screening test in physical examination with the addition of sufficient overpressure (usually III + ) .

Radiocarpal anteroposterior movement (Fig. 1 3. 3 1 ) •

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Direction: Anterior movement o f the carpus in relation to the radius and fibrocartilaginous disc. Symbol: t Patient starting position: Supine in the middle of the couch with the elbow flexed and forearm in the mid pronation/supination position. Therapist starting position: Standing between the patient's right side and the elbow and facing away from the patient.

Localization of forces (position of therapist's hands) •

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• •

•

•

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The right hand grasps the patient's palm from in front. The thumb of the right hand holds around the ulnar border of the patient's hand. The fingers hold around the radial border. The patient's thumb lies between the therapist's ring and middle fingers. The heel of the right hand forms the main point of contact against the carpus anteriorly. The base of the left thumb is placed opposite the distal border of the radius posteriorly. The fingers of the left hand grasp around the radius. The therapist should draw the patient's wrist and hand towards their body and crouch, directing both forearms opposite each other.

Application of forces by therapist (method) •

The oscillation starts from the neutral position of the wrist and hand and is taken to the limit or appropriate point in the range by an equal and opposite movement of the therapist's forearms.

Variations in the application of forces •

The movement can also be performed by using the couch and the left hand to stabilize the radius and ulna while the right hand grasps the front of the patient's right hand and directs the anteroposterior movement through the heel of the therapist's hand towards the floor.

Uses •

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•

As a grade I or II movement for very painful wrists. As a grade III or IV movement for a predominantly stiff joint. As a screening test in physical examination with the addition of sufficient overpressure (usually III + ).

Radiocarpal supination (lateral rotation) (Fig. 1 3.32)

Figure 1 3.31

•

Direction: Supination or lateral rotation of the

•

Symbols: Sup / c:

carpus in relation to the radius and ulna.

Radiocarpal anteroposterior movement.

The wrist and hand complex

425

1 •

•

Patient starting position: Supine, lying in the middle of the couch with the elbow flexed and the forearm in its mid pronation/supination position. Therapist starting position: Standing by the patient's flexed right forearm.

Localization of forces (position of therapist's hands) •

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•

•

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The left hand holds the patient's forearm adjacent to the wrist. The left thumb hooks around the lateral border of the distal end of the radius, reaching to the posterior surface of the radius. The index finger of the left hand makes firm contact against the anterior surface of the distal end of the ulna. The right hand holds across the posterior surface of the proximal row of the carpal bones. The thumb of the right hand hooks around the scaphoid to hold it firmly anteriorly. The index finger of the right hand lies across the proximal row of the carpal bones, making firm contact with the triquetrum.

Application of forces by therapist (method) •

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•

Further supination of the inferior radioulnar joint is prevented by the therapist's left hand. Supination or lateral rotation of the radiocarpal joint is produced by the therapist's right arm acting through the right wrist and hand. The tip of the therapist's right thumb and the distal end of the proximal phalanx of the index finger are the parts through which all of the pressure is transmitted to the carpus, while the therapist's left thumb and index finger provide counterpressure.

Variations in the application of forces •

The supination or lateral rotation movement can be performed in this manner in any position of forearm supination or pronation.

Uses •

To increase the range of radiocarpal supination (e.g. after Colles or scaphoid fracture).

Radiocarpal pronation (medial rotation) (Fig. 1 3.33) •

Direction: Pronation or medial rotation of the carpus in relation to the radius and ulna.

• •

•

Symbol: Pron/ :J Patient starting position: Supine, lying in the middle of the couch with the elbow flexed to 90° and the forearm in its mid pronation/supination position. Therapist starting position: Standing by the patient's right hip facing the patient's shoulder.

Localization of forces (position of therapist's hands) •

• •

• •

•

The left hand holds the distal end of the patient's forearm. The left thumb hooks posteriorly around the ulna. The base of the left index finger is placed against the anterior surface of the radius. The right hand grasps around the carpus. The right thumb hooks around the triquetrum anteriorly. The index finger of the right hand presses firmly against the posterior surface of the scaphoid.

Application of forces by therapist (method) •

Figure 1 3.32

Radiocarpal supination (lateral rotation).

The movement is produced by the pressure of the therapist's left hand against the patient's carpus

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MA ITLAN D'S P E R I P H ERAL M A N I PU LAT I O N

while the therapist's right hand stabilizes the patient's forearm by applying an equal and opposite counterpressure.

Variations in the application of forces •

The pronation or medial rotation movement of the radiocarpal joint can be performed in any position of forearm pronation or supination.

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Localization of forces (position of therapist's hands) •

•

Uses •

To increase the range of radiocarpal pronation or medial rotation.

Radiocarpal lateral transverse movement •

• •

Direction: Transverse lateral movement of the carpus in relation to the radius and ulna.

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•

•

Symbol: -+ Patient starting position: Supine, lying on the couch with the right ann abducted so that the wrist

lies at the edge of the couch, with the patient's hand beyond it and the thumb pointing towards the floor.

Therapist starting position: Standing beyond the patient's right wrist facing the patient's feet.

The left hand holds firmly around the distal end of the patient's radius and ulna immediately around the styloid processes. The knuckles of the left hand, between the patient's distal forearm and the surface of the couch, stabilize the patient's wrist. It may also be necessary for the therapist's forearm to rest across the patient's forearm or elbow to stabilize the patient's arm. The right hand grasps around the posterior surface of the patient's hand. The right thumb and index finger grasp the carpus around the triquetrum and the pisiform adjacent to the ulnar styloid process.

Application of forces by therapist (method) •

•

The movement of the patient's hand towards the floor is produced through the therapist's left arm and shoulder. The therapist's left hand should move as a single unit with the patient's hand.

Variations in the application of forces The lateral transverse movement can be performed: 1. with the hand in any position of radial or ulnar

deviation

2. with inclinations anteriorly or posteriorly 3. with the WTist in any position of pronation and supination

4. with the radiocarpal joint surfaces compressed together or distracted. The choice depends on the variation whic11 best repro duces the patient's symptoms or achieves the desired effects.

Uses •

The movement is most effective as an oscillatory grade IV to IV + or as a large amplitude grade III.

Radiocarpal medial transverse movement

Figure 1 3.33

•

Direction: Transverse movement medially of the

•

Symbol: --

carpus in relation to the radius and ulna.

Radiocarpal pronation (medial rotation).

The wrist and hand complex

•

•

Patient starting position: Supine, lying in the middle of the couch with the right arm abducted, the patient's wrist lying at the edge of the couch with the hand beyond it and the thumb pointing towards the ceiling. Localization of forces, Application of forces, Variations and Uses are as described for transverse movement laterally.

•

Variations in the application of forces •

•

Intercarpal horizontal extension (Fig. 1 3.34) •

Direction: Extension of the carpal bones in a horizontal plane.

• •

•

Symbol: Intercarpal HE. Patient starting position: Supine, lying in the middle of the couch with the elbow flexed to 90° and the forearm supinated. Therapist starting position : Standing by the patient's right side beyond the flexed and supinated forearm, facing the patient's head.

Localization of forces (position of therapist's hands) •

•

The tips of the pads of both thumbs, placed against the centre of the carpus posteriorly, hold the patient's hand from the back. The index and middle fingers hold around the pisiform medially and the carpometacarpal joint of the thumb laterally.

The action is produced by extension of the therapist's wrists and facilitated by pushing the patient's hand away with the thumbs.

The movement can be localized to the proximal or distal row of the carpal bones using the tips of the thumbs. The movement can also be localized to each carpal bone as well as inclining thumb pressure medially, laterally, cephalad, caudad or diagonally (see Fig. 6.14).

Uses •

• •

The mobilization of individual carpal bones into horizontal extension. Stretching the anterior carpal structures. As an interface technique for median nerve entrapment in the carpal tunnel.

Intercarpal horizontal flexion (Fig. 1 3.35) •

Direction: Flexion of the carpal bones in a horizontal plane.

Application of forces by therapist (method) •

The OSCillatory movement is produced by thumb pressure against the centre of the carpus posteriorly and pulling against the medial and lateral margins of the carpus with the fingers.

Figure 1 3.34

I ntercarpal horizontal extension.

Figure 13.35

I n tercarpal horizontal flexion.

427

42 8

MAITLAN D'S P E R I P H ERAL M A N I P U LATI O N

• •

•

Symbol: Intercarpal HF Patient starting position: Supine , lying in the middle of the couch with the elbow flexed to 90° and the forearm supinated. Therapist starting position: Standing by the patient's right elbow facing across the patient's body.

Localization of forces (position of therapist's hands) •

•

•

•

• •

•

Symbols: Intercarpal ; , t Patient starting position: Supine, lying in the middle of the couch with the forearm resting on the couch and pronated (posteroanterior) or supinated (anteroposterior). Therapist starting position: Standing by the patient's right side beyond the hand, faCing the patient's head.

The right hand grasps the back of the patient's hand with the fingers pointing distally. The right hand contacts the medial and lateral margins of the carpus. The left thumb tip is placed against the palmar surface of the carpus to apply an anteroposterior pressure to the carpus. The forearms are directed opposite each other.

Application of forces by therapist (method) •

•

The oscillation is produced by opposite pressure through the forearms. The right hand produces a cupping action of the patient's hand around the pivot formed by the therapist's left thumb.

Variations in the application of forces •

•

The left thumb tip and right hand can localize pressure to the carpus as a whole , or to the proximal or distal rows of the carpal bones. The left thumb can localize its pressure to the individual carpal bones anteriorly as well as apply pressure inclined medially, laterally, cephalad, caudad or diagonally.

Figure 1 3 .36

Intercarpal movement posteroanterior.

Figure 1 3.37

Intercarpal movement anteroposterior.

Uses •

•

• •

Local carpal pain and stiffness (rows or individual bones) Recovery of horizontal flexion after fracture or immobiliza tion. Intercarpal stiffness as in Sudeck's atrophy. As an interface mobilization of the carpal tunnel for median nerve entrapment.

Posteroanterior and anteroposterior intercarpal movements (Figs 1 3.36, 1 3.37) •

Direction: Movement of the individual carpal bones in a posteroanterior or an anteroposterior direction in relation the adjacent carpal bone, radius, ulna or adjacent metacarpal.

The wrist and hand complex

429 J

Localization of forces (position of therapist's hands)

•

Mobilization of the intercarpal joints after injury or immobiliza tion.

Posteroanterior •

•

•

The maximum breadth of the thumb tips are placed adjacent to each other on the appropriate carpal bone or intercarpal joint. The fingers spread over the adjacent area of the hand for stability. The arms and thumbs are positioned in a posteroanterior direction.

Anteroposterior •

•

•

The thumbs make contact with the palmar surface of the patient's supinated hand against the appropriate carpal bone or intercarpal joint. The fingers spread over adjacent areas of the hand for stability. The thumbs and arms are positioned in an anteroposterior direction.

Wrist and hand intercarpal longitudinal movement caudad and cephalad (Figs 1 3.38, 1 3.39) •

• •

•

Direction: Longitudinal caudad (distraction) and cephalad (compression) movement of the carpus and hand in relation to the radius and ulna. Symbol: ...... Patient starting position: Supine, lying in the middle of the couch with the elbow flexed to 90°, the wrist in its neutral position and the forearm in its mid pronation/supination position. Therapist starting position: Standing by the patient's right side facing the right shoulder.

Application of forces by therapist (method) •

The posteroanterior or anteroposterior movement is produced by pressure from the therapist's arms being transmitted through the spring-like action of the thumbs against the appropriate carpal bone or intercarpal joint.

Variations in the application of forces •

•

•

•

The posteroanterior or anteroposterior movement can be included medially, laterally, cephalad, caudad or diagonally. A combination of posteroanterior movement of one carpal bone and anteroposterior movement of the adjacent carpal bone can be produced simultaneously by the therapist gripping the individual bones in a pincer grip with the thumbs and index fingers. The opposite movements can then be performed. The posteroanterior movement of the individual carpal bones can be emphasized by the therapist's thumbs posteriorly during the horizontal extension movement. The anteroposterior movement can be emphasized by the therapist's left thumb against the anterior surface of the carpal bones during the movement of horizontal flexion.

Uses • •

Very painful intercarpal movement. Prevention of stiffness in Sudeck's atrophy.

Figure

1 3.38

cephalad.

Wrist and hand longitudinal movement

430

MAITLA N D ' S P E R I P H ERAL M A N I P U LATI O N

•

position, the longitudinal cephalad (compression) movement is produced by directing pressure through the therapist's hand and through the carpus along the line of the radius and ulna. The longitudinal movement caudad (distraction) is produced by a pulling action through the patient's metacarpals in line with the radius and ulna.

Variations in the application of forces •

•

•

The longitudinal movements can be performed with the wrist in flexion, extension, deviation or rotation. The longitudinal movements can be performed in combination with AP and PA of the individual carpal bones. An attempt can be made to bias the movement in line with individual carpal pillars and metacarpals (e.g. biased towards the lunate, capitate and third metacarpal).

Uses • •

Very painful wrist and hand movements. In combination with other movements.

Pisiform movements (Fig. 1 3.40) •

•

Figure 13.39

Wrist and hand long itudinal movement caudad.

Localization of forces (position of therapist's hands) •

•

•

•

•

The left hand holds around the lower end of the patient's humerus from posteriorly. The thumb of the left hand is placed laterally for longitudinal cephalad movement and over the patient's biceps for longitudinal caudad movement. The fingers of the left hand spread around the lower end of the humerus laterally. The right hand adopts the 'shake hands' grip with the thumb and fingers grasping round the patient's metacarpals. The index finger of the right hand extends down the patient's forearm to maintain the neutral wrist position.

•

•

Direction: Movements of the pisiform in a variety of directions in relation to the triquetrum.

SymboLs: ,\ , / , \ , I Patient starting position: Supine, lying in the middle

of the couch with the forearm supinated and the back of the hand resting against the couch or the therapiSt's body. Therapist starting position: Standing by the patient's right hip facing across the patient's body.

Localization of forces (position of therapist's hands) •

The therapist's body and one hand maintain stability of the patient's hand and forearm while the thumb pad of the other hand directs pressure against the different surfaces of the pisiform bone.

Application of forces by therapist (method) •

The oscillation is produced by the therapist's thumb, usually as a grade I I I or IV.

Variations in the application of forces Application of forces by therapist (method) •

With the grasp round the metacarpals, stability of the upper arm and the patient's wrist in its neutral

•

Any direction of movement around the 'clock face' of the piSiform bone is possible depending on the limited or painful directions.

The wrist and hand complex

43 1

]

Figure 1 3.40

Pisiform movements.

Figure 1 3 .41

Carpometacarpal extension.

•

•

Movements can be performed with the thumb also applying a compression force to the pisiform during its movements. By grasping the pisiform between the thumb and index finger laterally it can be lifted away from the triquetrum and therefore moved with the addition of a distraction force.

•

Carpometacarpal extension and flexion (Figs 1 3.41 , 1 3.42) •

Uses • •

A stiff painful pisiform. As an interface technique for ulnar nerve entrapment adjacent to the pisiform or in the wrist.

After injury or laceration of the flexor carpi ulnaris to restore normal stretch capacities.

Direction: Movement of the metacarpals in an extension and flexion direction in relation to their corresponding carpal bones. The same technique can be used to move the metacarpals in the anteroposterior and posteroanterior, transverse medial and lateral, medial and lateral rotation, and the

432

M AITLA N D'S P E R I P H ERAL M A N I P U LATI O N

For extension (CMC of the l ittle finger) •

•

•

•

Use the same grip as above except the pad of the thumb is placed over the hamate bone. The right hand holds the ulnar border of the patient's right hand in order to grasp the fifth metacarpal. The flexed index finger supports the fifth metacarpal distally and anteriorly. The thumb of the right hand makes contact with the base posteriorly.

For flexion • •

•

Both hands hold the patient's supinated hand. The left hand holds the medial border of the patient's wrist. The tip of the left thumb is placed in the palm of the patient's hand over the appropriate carpal bone.

For flexion (for the second CMC joint) •

•

•

Figure 13.42

The right hand holds the second metacarpal through the patient's first interosseous space. The tip of the right thumb is placed against the base of the metacarpal anteriorly. The flexed index finger of the right hand holds against the distal end of the metacarpal posteriorly.

Application of forces by therapist (method)

Carpometacarpal flexion.

For extension •

• •

•

longitudinal caudad (distraction) and longitudinal cephalad (compression) directions. Symbols: Carpometacarpal E, F. Patient starting position: Supine, lying in the middle of the couch with the forearm held close to the therapist's body and in pronation for extension and supination for flexion. Therapist starting position: for extension standing by the patient's slightly flexed right forearm facing across the patient's body; for flexion standing by the patient's upper arm facing the patient's feet.

•

For flexion •

-

•

Localization of forces (position of therapist's hands) For extension (lateral CMC joints) •

• •

•

•

The hands hold the patient's partly pronated hand from its lateral side. The left hand grasps the relevant carpal bone. The right hand grasps the relevant and adjacent metacarpal. The right hand grasps through the first interosseous space. The tip of the right thumb is placed against the base of the metacarpal posteriorly.

The use of grades ill and IV is most common. The movement is produced by the therapist moving the patient's hand away and applying pressure through the thumbs with counterpressure with the fingers to assist the extension. The therapist produces the movement by pushing the patient's hand away and at the same time the therapist's glenohumeral joints are adducted and the elbows extended to transmit pressure through the thumbs to the palm. The movement can be produced either with both thumbs or by stabilizing the carpus with the left hand and flexing the metacarpal with the right.

Variations in the application of forces •

•

The same grip can be used to perform other movements of the CMC joint such as anteroposterior and posteroanterior accessory movements and compression and distraction. A transverse accessory movement can be produced by adjusting the thumb and finger localizations so that movement is produced in the transverse lateral and medial directions.

The wrist and hand complex

433 ]

•

•

Rotation at the joint can be produced by fixing the appropriate carpal bone with one hand and holding onto the appropriate proximal phalanx held in 90° of flexion in the other hand. The appropriate MCP joint is then moved medially and laterally resulting in medial and lateral rotation of the CMC joint. Combinations of movements are also possible including, for example, flexion and extension combined with anteroposterior/posteroanterior movements or rotation with compression/ distraction.

Uses •

Mainly grade III and IV movements for stiff ! painful or stiff CMC joints.

Intermetacarpal movements (Fig. 1 3.43) •

• •

•

Direction: The main movements possible between the metacarpals are general and localized horizontal flexion, general and localized horizontal extension, anteroposterior and posteroanterior movements, and compression (in a transverse direction). Symbols:HF, HE t , ; , >-+-< Patient starting position: Supine lying with the

elbow flexed to 90° and the forearm supinated and held close to the therapist's body. Therapist starting position: for HF, Ap, PA standing facing the back of the patient's flexed and supinated forearm;for HE, compression (transverse) standing beyond the patient's flexed and supinated forearm facing the back of the hand. -

Localization of forces (position of therapist's hands) General horizontal flexion (the whole row of metacarpals) •

•

•

•

•

The pad of the left thumb is placed in the palm of the patient's hand over the distal end of the third metacarpal. The right hand cups across the dorsum of all the metacarpals distally. The right thumb presses against the posterior surface of the second metacarpal. The fingers of the right hand (particularly the index finger) press against the posterior surface of the fifth metacarpal. If the left thumb is placed against the fourth metacarpal this will change the peak of the movement.

Figure 1 3.43

I ntermetacarpal movements: (a) HF; (b) H E.

Local ized horizontal flexion • •

•

•

Both hands grasp the patient's hand. The right thumb holds the patient's fifth metacarpal posteriorly. The tips of the right index and middle fingers hold the fifth metacarpal anteriorly. The left hand holds the adjacent fourth metacarpal between the pads of the index and middle fingers anteriorly and the pad of the thumb posteriorly.

434

MAITLA N D ' S P E R I P H ERAL M A N I P U LAT I O N

General horizontal extension • •

•

Both hands hold the patient's hand. The pads of the thumbs are placed against the distal end of the posterior surface of the third metacarpal. The fingers hold round the medial and lateral margins of the patient's hand to reach to the anterior surface of the second and fifth metacarpals distally.

Localized horizontal extension •

Posteroanterior I anteroposterior movements •

Localized horizontal extension •

The same localization of forces described for localized horizontal flexion apply.

Posteroanterior I anteroposterior •

The same localization of forces described for localized horizontal flexion apply.

Compression (transverse) •

•

•

The 'shake hands' grip is adopted (Le. right hand to right hand). One hand grips around the heads of the metacarpals with one hand. The other hand stabilizes the heads of the metacarpals in a straight line from the radial to the ulnar sides.

Application of forces by therapist (method) General horizontal flexion •

Small or large amplitude movements are produced by the therapist's hands moving in opposite directions.

Local ized horizontal flexion •

•

•

•

While the therapist's left hand stabilizes the fourth metacarpal, the therapist's right hand moves the fifth metacarpal in a circular direction. When the second metacarpal is to be mobilized on the third, the therapist's left hand performs the movement, whereas when the fourth and fifth metacarpals are to be mobilized the therapist's left hand holds the fourth metacarpal while the right hand moves the fifth metacarpal around the fourth. If the third metacarpal is to be mobilized on the fourth the therapist's left hand performs the movement and the right hand acts as the stabilizing force. When the fourth metacarpal is to be mobilized on the third, the reverse is the case.

The same application of forces described for localized horizontal flexion apply except that the movement is one of pivoting towards extension around stabilized adjacent metacarpals. The same application of forces described for localized horizontal flexion apply except that the metacarpals are moved so as to traverse parallel lines in opposite directions (Le. one metacarpal is moved anteroposteriorly or posteroanteriorly in relation to the stabilized neighbouring metacarpal).

Compression (transverse) •

The movement is produced by the therapist alternately squeezing and relaxing the gaps around the patient's metacarpal heads.

Uses •

Movements do not usually become disturbed unless caused by trauma.

Metacarpophalangeal and interphalangeal joint flexion and extension (described for Mep joints) (Figs 1 3.44, 1 3.45) •

Direction: Flexion and extension of the proximal

•

phalanx in relation to the metacarpal, or of the interphalangeal joints. Symbols: MCP, IP F, E.

General horizontal extension •

The extension movement is performed by a pulling action with the fingers of both hands pivoting the patient's metacarpals around the thumbs on the third metacarpal while at the same time pushing the patient's hand away (as a grade ill large amplitude).

Figure 13.44 flexion.

Metacarpophalangeal and interphalangeal joint:

The wrist and hand complex

43 5 ]

•

•

Patient starting position: Supine, lying with the elbow flexed and forearm supinated. Therapist starting position: Standing by the patient's side facing across the body at the level of the patient's flexed elbow.

Localization of forces (position of therapist's hands) (for the index finger) •

•

The right hand holds the proximal phalanx of the patient's index finger between the thumb and the index finger, both of which are directed proximally. The left hand stabilizes the patient's hand, particularly around the second metacarpal between the thumb and index finger.

Application of forces by therapist (method)

•

The joint is flexed comfortably, at the limit of the range if necessary (e.g. a small amplitude grade IV is performed by the therapist's right hand while the metacarpals are stabilized with the left hand).

The flexion and extension can be combined with anteroposterior / posteroanterior movements at their limit, or with compression/ distraction.

Uses •

Stiff fingers.

Metacarpophalangeal and interphalangeal joint abduction and adduction (described for Mep joint) (Figs 1 3.46, 1 3.47) •

• •

Flexion •

Variations in the application of forces

•

Direction: Abduction and adduction of the proximal phalanx in relation to the adjacent metacarpal or at the interphalangeal joint. Symbols: Mep, IP Ab, Ad. Patient starting position: Supine, lying in the middle of the couch with the elbow flexed and pronated for adduction and supinated for abduction. Therapist starting position: Standing by the patient's side at the level of the elbow facing across the patient's body.

Extension •

•

•

Extension is produced by the combined action of extending the proximal phalanx on the metacarpal and the metacarpal on the phalanx. Alternatively, the movement can be produced by stabilizing the metacarpal and moving the proximal phalanx into extension. Small or large amplitudes can be used.

Figure 1 3.45 extension.

Metaca rpophala ngeal and interphalangeal joint:

Localization of forces (position of therapist's hands) (for the index finger) Abduction •

•

The left hand holds the posterior surface of the patient's right hand. The right hand holds the patient's index finger.

Figure 1 3.46 abduction.

Metacarpophalangeal and i nterphalangeal joint:

436

MAITLA N D ' S P E R I P H ERAL M A N I P U LATI O N

•

•

•

•

The left hand holds the posterior surface o f the patient's hand from the radial side. The left thumb, pointing distally, is placed against the lateral surface of the second metacarpal distally. The fingers of the left hand grasp the ulnar border of the patient's hand. The pad of the right thumb, pointing proximally, stretches along the lateral surface of the proximal phalanx to its base.

•

•

• •

•

The left hand holds the posterior surface of the patient's hand around its radial border. The left thumb wedges into the second interosseous space as much as possible. The fingers of the left hand reach around the patient's thumb and through the first interosseous space to stabilize the patient's hand. The right hand grasps the patient's index finger. The pad of the right thumb, pointing proximally, holds against the medial surface of the proximal phalanx.

Application of forces by therapist (method)

Variations in the application of forces The abduction/adduction movements can be com bined with: 1. 3.

•

The oscillatory movement is produced by movement of the therapist's two hands combining abduction with pushing the patient's hand away. Small or large amplitude movements can be performed in any part of the range.

Figure

1 3.47

adduction.

compression or distraction

Metacarpophalangeal and interphalangeal joint:

inclinations anteriorly or posteriorly.

Uses • •

Stiff fingers. Restoration of movement after collateral ligament injury.

Metacarpophalangeal and interphalangeal joint medial and lateral rotation (described for Mep joints) (Figs 1 3.48, 1 3.49) •

Abduction •

The oscillatory movement is produced by the therapist's arms acting through both hands while pushing the patient's hand away.

2. a transverse glide

Adduction •

Adduction

• •

Direction: Medial rotation or lateral rotation of the phalanges in relation to stabilized metacarpals or at interphalangeal joints. Symbols: MCP, IP :J , c: Patient starting position: Supine, lying in the middle of the couch with the elbow flexed and the forearm in its mid pronation/supination position.

Figure

1 3 .48

medial rotation.

Metacarpophalangeal and interphalangeal joint:

The wrist and hand complex

•

Therapist starting position : Standing by the patient's side, level with the flexed elbow and facing across the patient's body.

•

•

Localization of forces (position of therapist's hands) (for the index finger)

• •

Medial rotation •

•

•

•

The left hand stabilizes the second metacarpal by holding it firmly between the fingers anteriorly and the thumb posteriorly. The right hand holds the slightly flexed index finger in 10° of Mep flexion and 80° of proximal IP flexion. (The maximum range of medial rotation is obtained when the Mep is positioned in a few degrees of flexion as this is tl1e joint's mid flexion/ extension position. However, the degree of flexion/extension used in treatment will be determined by the presenting pain and stiffness). The tip of the right thumb is placed against the medial aspect of the proximal IP joint. The tips of the right index and middle fingers are placed against the lateral surface of the patient's middle and distal phalanges.

Lateral rotation •

•

The left hand holds across the posterior surface of the patient's hand. The fingers of the left hand are threaded around the lateral border of the hand.

•

The index finger passes through the first interosseous space to reach the palm of the patient's hand. The remaining fingers grasp around the thenar eminence. The right hand holds ilie patient's flexed finger. The right thumb is placed against the lateral surface of the proximal IP joint. The index finger of the right hand is placed against the medial surface of the distal IP joint.

Application of forces by therapist (method) Medial rotation •

•

The movement is produced entirely by ilie ilierapist's right hand while the left hand stabilizes the patient's hand. The therapist pivots the distal phalanx around the therapist's iliumb tip causing the patient's proximal phalanx to medially rotate.

Lateral rotation •

The therapist produces the rotation by movement of the left hand and forearm while ilie ilierapist's right hand stabilizes the patient's hand.

Variations in the application of forces •

The rotation can be performed with compression or distraction or in any position of flexion, extension, abduction or adduction.

Uses • •

Stiff fingers. With compression in minor symptoms produced by osteoarthritis.

Metacarpophalangeal and interphalangeal joint longitudinal movement caudad (distraction) and cephalad (compression) - described for the Mep joint (Figs 1 3.50, 1 3.51 ) •

• •

•

Figure 1 3.49 Metacarpophalangeal and interphalangeal joint: lateral rotation.

Direction: Longitudinal movement caudad (distraction) and cephalad (compression) of the proximal phalanx in relation to ilie adjacent metacarpal or at the IP joint. Symbols: Mep, IP ...... , >--< Patient starting position: Supine, lying in the middle of the couch with the elbow flexed to 90° and the forearm in its mid pronation/supination position. Therapist starting position: Standing by the patient's right side, level with the forearm and hand, facing across the patient's body.

43 7

43 8

M A ITLAN D'S P E R I P H ERAL M A N I P U LATI O N

•

•

•

•

The proximal IP joint of the left index finger holds the anterior surface of the distal end of the metacarpal. The left thumb holds firmly against the shaft of the metacarpal posteriorly. The right hand grasps the patient's index finger in a similar fashion, i.e. the fully flexed index finger holds the patient's proximal phalanx anteriorly and the thumb grasps along the shaft of the same phalanx. The patient's MCP joint is then positioned midway between its other ranges to permit maximum caudad movement.

Longitudinal cephalad •

The same localization of forces as for longitudinal caudad is applied except the fingers and palm hold the whole of the patient's index finger, which should be slightly flexed at each IP joint.

Application of forces by therapist (method) Figure 1 3.50

Metacarpophalangeal a n d i nterphalangeal joint: longitudinal movement caudad (distraction).

Longitudinal caudad •

•

The movement is produced by the therapist pulling the hands away from each other to produce distraction with the MCP joint slightly flexed. This slight flexion is maintained by firm pressure against the anterior surface of the patient's metacarpal and phalanx, adjacent to the joints, using the therapist's index finger at the proximal IP joint.

Longitudinal cephalad •

The movement of compression is applied by the squeezing together of the therapist's hands which hold the metacarpal and phalanx firmly.

Variations in the application of forces •

The movements can be performed in isolation or more often combined with flexion, extension, abduction, adduction, AP, PA and rotation.

Uses Fig u re 1 3.51 Metacarpophalangeal and interphala ngeal joint: longitudinal movement cephalad (compression).

• • •

Localization of forces (position of therapist's hands) (for the index finger) Longitudinal caudad •

• •

The left hand grasps firmly around the lateral border of the patient's right hand. The right hand holds the patient's index finger. The left hand holds the second metacarpal between the flexed index finger and thumb.

Stiff fingers. Very painful joint surface disorders (distraction). Minor joint surface disorders (compression).

Metacarpophalangeal and interphalangeal joint posteroanterior and anteroposterior movement (described for the Mep joint) (Figs 1 3.52, 1 3.53) •

Direction: Posteroanterior and anteroposterior movement of the proximal phalanx on the adjacent metacarpal or at the IP joint.

--- ---

The wrist and hand complex

Localization of forces (position of therapist's hands) (for the index finger) •

•

•

•

•

•

The left hand holds the patient's second metacarpal firmly with the fully flexed index finger anteriorly and the thumb posteriorly. The left thumb makes contact with the posterior surface proximal to the joint. The proximal IP joint of the therapist's index finger makes contact with the anterior surface proximal to the joint. The right hand grasps the proximal phalanx of the patient's index finger. The fingers of the right hand hook around the anterior surface of the phalanx. The tip of the right thumb is placed against the head of the proximal phalanx posteriorly.

Application of forces by therapist (method) Figure 1 3.52 Metacarpophalangeal and i nterphalangeal joint: posteroanterior movement.

•

•

Posteroanterior pressure is applied acting through -

the tip of the therapist's right thumb against the posterior surface of the head of the proximal phalanx immediately adjacent to the Mep joint. The flexors of the therapist's thumbs must not produce the movement. Anteroposterior pressure is applied against the head of the proximal phalanx anteriorly by the IP joint of the therapist's flexed index finger. -

Variations in the application of forces •

•

•

The movement can also be performed with the joint surfaces distracted or firmly compressed against each other. The movement can be inclined in a variety of directions. Frequently used in combination with flexion, extension, abduction, adduction or rotation,

Uses Figure 1 3.53 Metacarpophalangeal and i nterphalangeal joint: anteroposterior movement.

•

•

• •

•

Symbols: Mep, IP ; , t Patient starting position: Supine, lying in the middle of the couch with the elbow flexed to 90° and the forearm in its mid pronation/supination position. Therapist starting position: Standing by the patient's side, level with the forearm, facing across the patient's body.

Stiff fingers (at the limit of the stiff physiological movement). Clinical group 1, for very painful joints.

Metacarpophalangeal and interphalangeal joint general flexion, extension and circumduction •

• •

Direction: General flexion, extension and circumduction of the Mep and IP joints. Symbols: Mep, IP F, E, circumduction (general). Patient starting position: Supine, lying in the middle of the couch with the elbow flexed to 90° and the forearm in its mid pronation/supination position.

43 9

440

MAITLA N D ' S P E R I P H ERAL M A N I P U LATI O N

•

Therapist starting position: Standing b y the patient's side, level with the forearm and facing across the patient's body.

Localization of forces (position of therapist's hands) •

•

•

•

The left hand holds across the back of the patient's right hand from the medial side. The fingers grasp the first interosseous space to reach the palm of the patient's hand. The therapist's thenar eminence and thumb of the right hand hold across the back of the patient's hand. The right hand holds the patient's four fingers from the medial side between the fingers anteriorly and the thenar eminence posteriorly.

Application of forces by therapist (method)

Figure 1 3.54

First carpometacarpal flexion.

Figure 1 3.55

First carpometacarpal extension.

With the metacarpals held firmly the following general movements can be performed: 1.

MCP joint flexion with II' extension

3.

MCP circumduction with a circling action of the right hand.

2. MCP extension with II' flexion

Uses • • •

•

As grade II general hand loosening movements. As easing off of treatment soreness. For general stiffness and pain in all joints as in osteoarthritis or rheumatoid arthritis. To loosen off stiffness postimmobilization (e.g. after Colles fracture).

Thumb movements (first carpometacarpal joint) (Figs 1 3.54-1 3 .56) •

•

Direction: Movements of the thumb are identical with those of the fingers even though the planes of the thumb movements are different. The movement of opposition is an additional thumb movement which is a combination of flexion, abduction and rotation. Symbols : l st CMC joint F, E, Ad, Ab, opposition, +--+ ceph, >---< , ; , t :J , <: Patient starting position: Supine, lying in the middle of the couch with the elbow flexed to 90°. Therapist starting position: Standing by the patient's side, level with the flexed elbow, facing across the patient's body. ,

•

•

Localization of forces (position of therapist's hands) Flexion •

•

The left hand stabilizes the patient's wrist with the fingers across the anterior surface and the thumb posteriorly. The left index finger must cross in front of the trapezium to stabilize it during thumb flexion while not obstructing metacarpal movement.

The wrist and hand complex

immediately adjacent to the CMC joint; (2) against the trapezium; (3) on the joint line.

Application of forces by therapist (method) •

•

•

Figure 1 3.56

Carpometacarpal posteroanterior movement. •

•

The right thumb and index finger grasp the patient's thumb with the therapist's thumb across the posterior surface of the metacarpal and the index finger across the anterior surface.

•

Extension •

The same localization of forces as for flexion applies except that the tip of the left thumb is placed against the dorsal surface of the trapezium and the trapezoid.

Adduction, abduction, opposition •

As above, one hand stabilizes the carpus at the trapezium and trapezoid, while the other hand produces the movement of the metacarpal in the desired direction.

Longitudinal cephalad (compression) •

The localization of forces is the same as those described for longitudinal movement cephalad of the index finger.

The localization of forces is the same as those described for rotation of the index finger.

Posteroanterior movement (including anteroposterior, and transverse medial and lateral) • •

•

The right hand grasps the patient's thumb. The left hand grasps the patient's wrist at its radial border. The tips of both thumbs are placed: (1) against the posterior surface of the first metacarpal,

the therapist's right hand while the left hand stabilizes the proximal part of the joint. Extension: the extension movement is produced mainly through the therapist's contact on the anterior surface of the first metacarpal, pivoting it around the therapist's right thumb while the left thumb stabilizes the proximal part of the joint. Adduction, abduction, opposition: these movements are performed in the appropriate direction by the therapist's left thumb and index finger stabilizing the trapezium and trapezoid while the therapist's right thumb and index finger move the metacarpal. Note that the opposition also includes medial rotation as part of the oscillatory movement. Longitudinal movement cephalad and rotation: the application of forces for these movements is the same as those described for the index finger. Posteroanterior (anteroposterior, transverse medial and lateral): the posteroanterior movement, for example, is produced by the pressure of the thumbs against the base of the metacarpal or the index fingers. The pressure should arise from the therapist's arms and must not be produced by the thumb flexors.

Variations in the application of forces •

Any of the above movements can be combined, depending on the directions which are stiff or painful.

Uses •

Rotation •

Flexion: the flexion movement is produced through

•

The thumb is often subjected to osteoarthritic changes so movements which include compression when the symptoms are minor can be most effective. Pain and stiffness in the joint after overuse, trauma or following fracture.

Box 13.11 summarizes the extent of examination required when chronic minor wrist and hand symptoms are present, Box 13.12 shows the screening tests required to prove the wrist and hand are unaffected, and Box 13.13 shows how to examine a thumb with chronic minor symptoms.

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MAITLA N D ' S P E R I P H ERAL M A N I P U LATI O N

lox 1 3 . 1 1 symptoms

r--'• • • • • •

--

.:....

•

• •

-'1

'Sharp' deep int 1

-

Supine: flexion and extension Supination and pronation (through metacarpals) Radial and ulnar deviation AP and PA movement H F and HE Longitudinal caudad and cephalad

Box 1 3 . 1 2

•

Right hand

ChfonIel iftlnor wristl hand

. . :::: : : ::. �. .

Proving the area unaffectecl

F and E (fi ngers to wrist) Supi nation and pronation Wrist deviation ( +-++ ) ceph, caud

Box 1 3. 1 3 Qiiiiii/fll i rtor""liSi·of . ... symptoms Proving that the thumb is, in fact, u naffected F I E, E with (t , i l. Rotn with compression

CASE STU DY 1 3 . 1 W R I ST A N D H A N D D I S O R D E R : EXA M I N AT I O N A N D T R EAT M E N T

Figure 1 3.57 Right hand: area of symptoms.

such as holding door hand les and push ing doors open. As a housewife she was a lso having great difficu lty pegging her washing on the washing line, amongst other things. Mrs I was fed up because she could not complete her daily tasks and she was in a great deal of pain for a few hours after her attem pts to carry out such activities. However, she was happy that she could use her fingers normal ly. She experienced most of her symptoms duri ng the day when she tried to use her hand. Her sleep had not been d isturbed. This suggests problems in the carpus, metacarpals or radioulnar region as the fingers were functioning normally. Both prehensile and non-prehensile functions have been

Kind o f disorder This is a case exa mple of Mrs I, a 56-year-old woman who, when asked, 'What do you feel is you r main problem at present?', replied ' I sti l l cannot use my hand properly, it sti l l h u rts after my fa l l onto it: T his case study w i l l high light the key clinical features of wrist and hand d isorders, a model for identifying movement i m pairments through detailed physical exa m i nation and the context of the use of mobilization I manipu lation in the rehabil itation process. Areas of symptoms The body chart (Fig. 1 3.57) shows the use of 'real size' body cha rts to deta il the exact location of the patient's wrist and hand pain and the referral pattern. Using a larger body chart a lso a l l ows the thera pist to hypothesize about the source of the symptoms in relation to anatomical structures. Behaviour of symptoms (over a 24-hour period) Mrs I explained that her main concern was not being able to use her hand properly d u ring necessary daily activities

impaired quite severely. The disorder also seems to be exhibiting a degree of irritability.

Present and past history of symptoms Present

The symptoms began 6 weeks prior to the date of the physiotherapeutic consu ltation. Mrs I had been shopping and tripped over a raised pavi ng slab. She fel l on her outstretched a rm, was helped by passers-by who phoned for a n a mbulance and she was taken to the local casualty department. An X-ray revealed no Col les fracture but the radiologist suspected a scaphoid fracture. The wrist was put in a cast for 10 days then re-X-rayed. No scaphoid fracture was seen. On having the cast removed Mrs I quickly started to feel the wrist pain which gradually became more severe over the next week or so as she tried to use it. Because of this the casualty officer decided to re-cast the wrist for a further 3 weeks. Mrs I was comfortable in the cast. When it was removed in due course the wrist pain was bearable but beca me unbearable when she tried to use her hand.

The wrist and hand complex

Past history

Screening tests

M rs I could not recal l having problems with the wrist in the past but had suffered several bouts of 'spondylosis' in her neck. Th is was a bit stiff at present which was nothing out of the ordinary.

The cervical spine, shoulder and elbow were screened. The el bow was cleared of a ny impairment. The shoulder was uncomfortable and stiff in the q uadrant (peak) position and the cervical spine was stiff i nto right rotation, right lateral flexion and extension.

Special questions M rs I revealed that she was genera l ly in good health, with no recent weight loss. She had taken painkillers which helped a bit but the wrist was still very painful. There was no family history of osteoporosis that she was aware of and the doctor had not suggested that she have a bone scan. Overall, fram the history, the suggestion is of a local soft tissue injury or bony injury of the wrist and carpus. There may be some contributory mechanisms related to her neck disorder. This may warrant further investigation.

Physical examination General/specific observotion

On general observation it was clear that M rs I was reluctant to use her right hand to its fu l l capacity, as revea led when she removed her coat. Loca lly there was evidence of swe l l i ng having been present around the ca rpus and wrist but no other abnormal features were evident. Functional demonstration

M rs I demonstrated that when she tried to grip a door knob or handle she was unable to do this without experiencing severe pain in the wrist. On ana lysis of the functional demonstration it was evident that wrist extension and forearm / wrist supi nation were the main movement components. When the wrist was in its neutral position M rs I could grip strongly and without pain, suggesting that the problem was in the wrist/carpus as suspected, rather than the fingers. Brief oppraisal

Active wrist extension on its own was lim ited to 40' by the wrist pai n ; active wrist flexion was li mited to 70' by the wrist pai n ; forearm and wrist supi nation

reproduced the wrist pain at 85'. This clearly indicates that the wrist pain is repraduced most readily in wrist extension and supination.

In view of the nature of the injury on the outstretched arm and the potential for impairment of the shoulder and neck to contribute to the disorder's recovery, it would be essential to include treatment of these regions as a necessary part of rehabilitation. However. this was done in conjunction with treatment of the wrist and hand and has not been included further in this case example. The neck, shoulder and hand components were treated separately. Passive movements

The whole hand movement of extension to 40' reproduced M rs I 's wrist pain. Differentiation of wrist extension revealed that pa in was reproduced with radiocarpal extension alone; extension of the midcarpal and carpometacarpal joi nts was much less painful. Supination of the forearm and hand to 85' reproduced the sa me wrist pa in. Differentiation testi ng revealed that when the rad ioca rpal and inferior rad iou lnar joi nts were supinated more (and less) in the painful position, the movements of the radioca rpal joint were much more (or less) painful than the rad ioulnar joint. The conclusion to draw fram this pracess is that the pain appeared to be related to mechanical stresses imposed on the radiocarpal joint, most likely the bones of the proximal row of the carpal bones.

Other general wrist and hand movements were relatively pain free. Further investigation of intercarpal movements revea led that the sa me wrist pain cou ld be reproduced in the ea rly part of the ra nge of movement when the sca phoid was moved i n a n anteroposterior movement in relation to the l u nate. The designated mobilization technique therefore was a grade II anteroposterior intercarpal movement of the scaphoid on the lu nate with the desired effects of reducing the movement-related pain, increasing the pain free range of wrist extension and su pination, and facil itating or complementing a home exercise programme designed to restore fu l l function of the wrist and hand.

References Butler,

D. S. 2000. The Sensitive Nervous System. Adelaide:

The Upper Limb, 5th edn. Edinburgh: Churchill Livingstone Kesson. M.

NOI Group Corrigan, B.

& Maitland, G. D. 1 983 . Practical Orthopaedic

Maitland, G.

Medicine. London: Butterworths

Hoppenfeld, S. 1976. Physical Examination of the Spine and

D. 1992. Neuro/musculoskeletal Examination and

Recording Guide, 5th edn. Adelaide: Lauderdale Press Maitland, G.

Extremities. New York: Appleton Century Crofts Kapandji, 1. A. 1982. The physiology of the joints: annotated diagrams of the mechanics of the human jOints. Volume

& Atkins. E. 1998. Orthopaedic Medicine:

A Practical Approach. Oxford: Butterworth-Heinemann

1,

D., Hengeveld, E., Banks, K. & English, K., eds.

200 1 . Maitland's Vertebral Manipulation, 6th edn. Oxford: Butterworth-Heinemann

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Chapter

14

The hip region

THIS CHAPTER INCLUDES: • • •

•

Key words for this chapter Glossary of terms for this chapter Presentation of the hip as a sou rce of movement dysfu nctions Subjective exa mination principles related to hip movement d isorders

• •

•

Physical exami nation principles Exam ination and treatment tech niques Clin ical profi les of common d isorders related to h i p movement dysfunctions: - osteoarthritis - ath letic groin pain

•

- acetabular labrum tears - trocha nteric bursitis - meralgia paraesthetica (cutaneous lateral femoral nerve entrapment) A case example of a patient with a hip disorder.

KEY WORDS Hip joint. movement disorders,

intra-articu lar d isorders, periarticular d isorders, one-component movement

disorder, multicom ponent movement d isorder.

GLOSSARY OF TERMS

Frequently will need com pression in exa mination or treatment procedu res. M ulticomponent movement disorders - although some patients may be referred with a biomedica l diag nosis which indicates a disorder in one certain area

(e.g. osteoarthritis), frequently more movement components contribute to the disorder. Many problems in the hip a rea show movement dysfunctions of the hip joint in combination with the lumbar spine, sacroi l iac joints, neurodynamic structures and the muscu lar system.

Flexion/adduction - a fu nctional movement of the hip which ca n be used to detect and treat minor or less obvious painfu l restrictions. Intra-a rticu lar d isorders - movement disorders and symptoms coming from intra-articular structu res.

INTRODUCTION The hip is a synovial ball-and-socket joint between the head of the femur (which normally constitutes two thirds of a sphere) and the cup-shaped acetabular cav ity (which constitutes about one-third of a sphere) (Williams & Warwick 1980). In spite of its ball-and socket form, the anterosuperior aspect of the femoral head is not completely covered by the acetabulum

while standing erect, putting the joint in a potentially vulnerable position with regard to its stability. Most coincidence of the articular surfaces is achieved in a position of c. 90° of flexion, including 5° of abduction and 10° of external rotation, coinciding with a quadrupedal position (Palastanga et al 1994). The hip joint plays an important role in the trans mission of forces between the leg and the trunk. The joint must possess great strength and stability as it

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MAITLAN D'S P ERI P H ERAL M A N I P U LAT I O N

As the joint is covered by its surrounding soft tissues and muscles, it cannot be palpated directly. Movement at the hip cannot be produced to the same degree by thumb movements against the head of the femur as can be produced at the glenohumeral joint. The shape of the acetabulum and the accessibility of the head of the femur make this difficult. However, small oscillatory movements of the head of the femur within the acetabulum can be produced, particularly when the leg is used as a lever (Maitland 1991).

Movements and movement disorders of the hip joint

Figure 1 4. 1 Transference of forces between t h e trunk, pelvis and fem u r. Reproduced by kind permission from Pa lastanga et al (1994).

These may be influenced by the neurodynamic system because of the various nerves that surround the joint, for example: • •

•

needs to be capable of supporting the whole weight of the body as in standing on one leg. Furthermore, it needs a stable transference of the weight of the trlll1k on the femur, as for example during walking or run ning (Palastanga et a11994) (Fig. 14.1). This stability is achieved by the joint form, the acetabular labrum, and the iliofemoral, pubofemoral and ischiofemoral liga ments as well as the transverse acetabular ligament (Williams & Warwick 1980). The hip joint permits a wide range of movements associated with locomotor activities. The following ranges of motion for physiological movements are suggested (Soames 2003): •

•

•

The active range of flexion is approximately 120° and extension measures c. 20°. Passive movement can increase to c. 145° of flexion and 30° of extension. Extension beyond 30° is considered not possible due to the tension of the capsular ligaments. Abduction and adduction have a total range of 75°: abduction approximately 45° and adduction 30°. The total range of medial and lateral rotation in adults is c. 90°, decreasing with age.

Intra-articular movements are mostly conjunct rota tions with mainly spin and roll movements. Gliding movements are minimal, especially in the joint's closed packed position of extension/internal rotation/slight abduction, but a certain degree of separation may be achieved by traction (Williams & Warwick 1980) and some joint gliding may be perceived during clinical examination procedures (Maitland 1991, Sims 1999a).

• •

Sciatic nerve and its branches in the buttock area Femoral nerve and its branches at the ventral area of the hip joint and the thigh ilioinguinal nerve Obturator nerve Lateral femoral cutaneous nerve, taking its course under the lateral part of the inguinal ligament towards the lateral border of the thigh.

Muscles As well as the shape of the joint surfaces and the liga ments, the muscles surrounding the joint contribute to the stability of the joint, in particular those muscles which cross the joint transversely. Muscles such as the psoas, iliacus, pectineus, glutei minimus and medius, obturator internus and externus, gemelli, quadratus femoris and piriformiS contribute to keeping the femoral head in close contact with the acetabulum (Palastanga et aI1994).

Nerve supply The hip joint is innervated by fibres of the lumbosacral plexus originating from the levels L2-S1. These nerve fibres also innervate the muscles around the hip. Further more, nociceptive processes originating from the peri or intra-articular hip structure may refer symptoms to the knee region, as the same nerves provide branches to the knee joint (Palastanga et al 1994).

Pathobiological disorders A range of pathobiological disorders may contribute to movement disorders of the hip (Box 14.1).

The h i p reg io n

Soft tissue lesions Tendin itis: adductor, psoas, ha mstring, rectus femoris, gluteal • Bursitis: trochanteric, psoas, ischial • Snapping hip • Capsul itis •

Joint lesions • I nstabil ity of symphysis pubis • Osteoa rth ritis • Septic arth ritis • Monoarth ritis of the hip • Rheu matoid a rthritis Bone d isorders Osteonecrosis • Paget's disease • Acute osteoporosis • Stress fracture in crista il iaca, col l um femoris, greater trocha nter, minor trochanter, la brum acetabuli, acetabulum •

Entrapment neuropathy Lateral femoral cuta neous nerve • Entrapment of i l ioinguinal nerve

•

H i p d iseases in childhood Perthes • Congenital dysplasia • J uvenile chronic polyarthritis • Sl ipped femoral epiphysis •

Post-trau matic lesions Fracture of neck of femur • Acetabulum fracture • Labrum fracture •

Adapted from Corrigan Et Maitland (1994).

Degenerative osteoarthritis Degenerative osteoarthritis (osteoarthrosis) may be the most common cause of referral of patients with hip dis orders to physiotherapists. It is increasingly debated that dysfunctions in the neuromusculoskeletal and articular systems may play an important role in the development of degenerative osteoarthritis (Bullough 1984, Dieppe 1984). It is suggested that an imbalance in the equilibrium of forces on the hip joint, alterations in the centre of gravity, neuromuscular dysfunctions in

the hip abductors, alterations in gait patterns and repeti tive impact loads without sufficient muscular control may be subtle factors contributing to the development of pathological conditions in the capsule, acetabular labrum and cartilage (Sims 1999b). However, there are additional indications that intraosseous hypertension (Arnoldi et al 1972) and neurogenic mechanisms (Weinstein 1992) also contribute to pain and dysfunction. It is advocated that the following objectives in management be pursued (Moncur 1996, Dieppe 1998): •

• • • • •

Treatment should occur in as early a phase as possible Improvement and/or maintenance of joint mobility Improvement of muscular control Normalization of gait patterns Enhancement of aerobic conditioning Education and instruction of the patient in self-management.

These objectives allow physiotherapists to play a crucial role in the treatment of osteoarthritic disorders. In fact there is some evidence that specific exercises delivered by a physiotherapist have direct beneficial effects on pain and observed disability in patients with hip or knee osteoarthritis (Van Baar et al 1998). Furthermore, there are indications that passive mobilizations enhance the reduction of pain and mobility more profoundly than a standardized active exercise protocol alone (Hoekstra 2004).

Compression Frequently in examination procedures compression to the joint surfaces may need to be introduced to repro duce the symptoms. Furthermore, in the progression of treatment, compression may need to be performed if the symptoms seem to derive from an intra-articular movement disorder (see also Chapters 2, 7 and 10).

Mu/ticomponent disorders Disorders of the hip often may be part of multicompo nent movement disorders. Symptoms in similar areas may stem from different sources. Furthermore, due to the close relationship of the sacroiliac joint, lumbar spine and neurodynamic system, treatment of all com ponents, including muscular control, may be neces sary to optimise hip function.

S U BJ E CT I V E EXA M I N AT I O N In assessing movement disorders related to the hip, the physiotherapist needs to consider various sources and contributing factors in the clinical reasoning processes,

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MAITLAN D ' S PERI P H ERAL MAN I PULAT I O N

Lumbar spine

Neurodynamic structures

Movement dysfunctions

Mechanosensitivity

Hip joint

Hlp disorder

Periarticular Intra-articular

Pain, Stiffness, Movement disorder

+-+ Sacroiliac joint

r------,

Muscles and soft tissues

Tenderness, length, recruitment/coordination Figure 1 4.2 Various sources a nd/ or contributing factors which need to be taken i nto consideration in the analysis of movement disorders of the hip.

as functional anatomic properties of the pelvis and lumbar spine are in direct relationship with movement functions of the hip joints and different sources may refer symptoms into the same body areas (Fig. 14.2). Additionally, it needs to be considered if muscle recruitment patterns, possible changes in muscle length, habitual movement patterns and changes in propriocep tive feedback contribute to the patient's disorder. Some patients may show large impairments of hip function with great restriction of mobility, without having much pain and little restriction of daily life functions. However, limitations of daily life activities may develop once a critical limit of movement restric tion is reached. The required range of movement for some activities is described as follows (Soames 2003): •

• • • •

Walking on level surfaces: 30° flexion, 10° extension, 5° abduction, 5° adduction, 5° medial rotation, 5° lateral rotation Ascending stairs: 65° flexion, 5° extension Descending stairs: 65° flexion, 5° extension Sitting: 90° flexion Tying shoelaces: 50° flexion.

However, some patients show greater restriction in movement than those mentioned above, without indi cating large limitations of their daily life activities. Com pensatory mechanisms from the lumbar spine, pelvis and knee still may allow an acceptable level of function. Nevertheless, the whole lower quadrant movement sys tem may become more vulnerable to symptoms and additional restrictions if further impairment of joint mobility occurs.

develop hypotheses regarding the source(s) of the patient's disorder and the degree to which the daily life activities are limited. Some patients may present with pain as the main problem. This may be in combination with significant limitation of daily life activities and thus be indicative of the severity or irritability of the disorder. Additionally, it may also be an aspect of the perceived disability as a psychosocial risk factor hindering recovery to full func tion (Chapters 5 and 6). Some patients report restrictions of daily life func tions but hardly any pain or discomfort. In physical examination they may present with large restrictions of range of motion. Although these patients may have some pain or discomfort after functional activities such as walking, gardening or driving a car for longer periods of time, this does not appear to be a significant limiting factor in the level of activities or participation.

Areas of symptoms (body cha rt) Precise localization of the symptoms may aid in the gen eration of the possible sources of the symptoms. Typical pain patterns associated with disorders of the hip are delineated in Figure 14.3. However, it should be empha sized that other sources such as the sacroiliac joint, lum bar spine, the neurodynamic system and at times the thoracic spine may refer symptoms in the same or simi lar body areas. Furthermore, especially in cases of direct contact, the physiotherapist needs to consider possible visceral or vascular sources of the symptoms which may require the attention of a medical practitioner. Note: It has been stated that many hip disorders may present predominantly with symptoms in the knee area (Cyriax 1978, Wroblewski 1978) and therefore detailed questioning on the behaviour of the symptoms and history is necessary. Additionally, precise differen tiation procedures are required during physical exam ination to distinguish symptoms deriving from movement disorders of the hip or the knee joint.

Behaviour of symptoms If the hip is compromised, functions related to hip move ments may aggravate or ease the patient's symptoms. Aggravating factors associated with movement dysfunctions of the hip include: •

M a i n problem ('Question ,') Information from the subjective examination will help to establish the kind of disorder being presented, to

•

• oil

sitting starting to walk after long periods in sitting or squat positions crossing the legs getting into lout of a car

The h i p region

Figu re 1 4.3

• • • • •

Possible symptom areas associated with movement d i sorders of the hip.

putting on socks lying on the side in bed ascending or descending stairs gardening getting onto/off a bicycle.

These movements mostly involve combinations of flexion with adduction, abduction or rotation or some combinations of extension movements, all of which need to be assessed in physical examination procedures. Furthermore, many of these activities mainly involve hip movement in which a degree of pelvic, lumbar and neurodynamic movement is always included. There fore the principle of 'making features fit' as described in Chapters 5 and 6 may not easily apply in determining the main source of the movement dysfunction based on information from the body chart and 'behaviour of symptoms'. Physical examination procedures, differen tiation tests and treatment followed by reassessment

may provide confirmation of the sources involved in the patient's movement disorder. As essential as the aggravating factors in the devel opment of hypotheses regarding sources of the symp toms is the establishment of easingfactors: what has the patient learned so far or what does the patient instinct ively do to relieve the symptoms? The patient may, for example, grasp around the leg, shake it or rub it, which may be indicative of a movement disorder stemming from the hip. If the patient intuitively grasps the back or shifts the body weight to the other buttock during sitting, a lumbar spine or sacroiliac movement dis order may be present. With those patients who have few symptoms or lit tle discomfort after prolonged activities such as walk ing, gardening or driving a car, it may be difficult to find useful parameters which can be used in reassess ment procedures. However, if asked, the patient may become aware that certain movement functions have

449

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MAITLAN D'S PERI P H ERAL M A N I PULAT I O N

not been performed for a long time, for example sitting with crossed legs, squatting, or getting on a bicycle while moving the leg backwards towards extension. These activities may serve as subjective parameters ('asterisks') in reassessment procedures and may be used in functional demonstration tests during physical examination procedures. If symptoms seem more constant in their behaviour, are perceived as deeply localized and more restricting in daily life activities, and regular changes in resting positions are needed, an intra-articular movement dis order with a certain degree of inflammation may be present (Maitland et aI2001). Hypotheses regarding muscular disorders may be generated if the symptoms can be clearly pinpointed by the patient, especially if they seem to occur in rela tion with stretching or contracting the muscle.

History •

•

•

•

Symptoms in the hip area may be related to overuse and misuse of the structures, as for example when performing activities such as gardening without repeated compensatory movements, or walking without sufficient motor control. The development of symptoms may be gradual over a long period of time with little interference with daily life activities initially. Symptoms of a relatively sudden onset due to twist ing movements on one leg, as for example when playing soccer, may be indicative of labrum tears (Sims 1999a), local muscular or ligamentous lesions. The course of symptoms over time may not be indicative of the current primary source of symp toms, as a patient with a history of low back pain and a degree of radicular symptoms may develop symptoms and signs of a hip movement disorder over time (Gunn 1980, Weinstein 1992). It may be expected that an originally one-component movement disorder in the lumbar spine, pelvic or hip region may develop easily in a multicomponent dis order over the course of years. This needs to be taken into consideration when planning the procedures of physical examination in the first 1-3 sessions.

Speci a l questions •

As well as routine information about the patient's general health, weight loss, radiographic findings, medication intake, etc., particular attention needs to be given to screening questions regarding urogeni tal and intestinal functions (Boissonnault 1995, Goodman & Snyder 2000).

•

In those cases in which the symptoms do not seem to be directly related to movement functions these screening procedures must be taken into considera tion (see also Chapters 5 and 6).

PH Y S I CAL EXAM I N AT I O N Box 14.2 provides an overview of examination proced ures of the hip and related structures. Detailed infor mation on some test procedures is given below.

Observation Present pain

•

+Fu nctional demonstration /tests, including differentiation of movement components Brief a ppraisal Active movements • Gait ana lysis • Squatting • Going up and down steps • In sta nding: - weight-bea ring: F, E, Ab, Ad, MR, LR - swing movemen s: F, E, Ab, Ad, MR, LR • I n sitting: - flexing knee to chest - flexing knee to opposite shoulder (F/ Ad) - flexion trunk to feet - MR, LR • In prone and supine lying, including overpressure: - in supine: F, Ab, Ad, in 90' F: MR and LR - in prone: E, MR, LR Muscle tests Isometric tests • Recruitment patterns (also during active test movements)

•

Screening of other structures in 'plan' • Lumbar spine • Sacroi liac joint provocation tests • Thoracic spine • If applicable: neurodynamic testing (or in later stage during passive testing) Palpation Tenderness of i nsertions of periarticu lar muscle g roups

•

The h i p reg ion

•

•

Nerves (e.g. lateral femoral cutaneous nerve in a rea of inguinal l igament) Bursae

Passive movements If applicable, including subsequent reassessment procedures • Neurodynamic test procedu res: - SLR - PKB - Slump - modified PKB i n side lying ('side lying slum p'), including modifications for lateral femoral cutaneous nerve, obturator nerve • Movement d iagram of relevant active tests: F, in gO°F; MR or LR, Ab, Ad • Physiologica l movements: - FIAd (if a l l tests negative so fa r: add MR, LR; compression through femur shaft; compression through coll u m femoris) - in F: do Ab; FlAb as part of passive circumduction movement - in E: do Ab, Ad, MR or LR; or combinations of three directions (esp. E + Ad + MR) • Accessory movements As applicable:

•

...... ceph and caud; ; , �,--++, -- , C:,:J in various hip positions Add compression (cephalad and medial), where applicable Muscle length tests (e.g. hip flexors, adductors, tensor fasciae latae, hamstrings)

Check case records etc. Highlight main findings with asterisks

Any asymmetry in posture needs to be corrected to determine if a protective deformity is present. If symp toms are being reproduced, the asymmetry is associ ated with the patient's disorder. An ideal alignment of the pelvis is present when the anterior superior iliac spine is in the same vertical plane as the symphysis pubis (Klein-Vogelbach 1983, Kendall & McCreary 1993). As described in Chapter 11 (Fig. 11 . 13) an ideal alignment from the side takes place if a plumb line fol lows a line from approximately midway through the trunk, the greater trochanter, slightly anterior to a mid line through the knee and slightly anterior to the lateral malleolus (Kendall & McCreary 1993). A pelvic tilt needs to be assessed with the angle between the anterior and posterior superior iliac spines, as well as the lumbar spine curves and the rela tionship between the hip joint angle and the knee joint alignment (Sahrmann 2002). Alignment variations may be structural or acquired (Sahrmann 2002). Structural variations include ante torsion of the hip and genu valgum. Acquired varia tions include: • • • • • • •

Fu nctional demonstration tests

Present pain

•

Functional demonstration - the patient is asked to demonstrate an activity which provokes the pain as described in the subjective examination. This activ ity may serve as an asterisk. Furthermore, differentia tion procedures, in which more stress is added to the individual movement components, may be per formed to decide upon the individual contribution of the components to the symptoms (see 'Differentiation tests', Chapter 6). This is an essential principle of this concept of manipulative physiotherapy.

Observation The physical examination from posterior, both sides and anterior usually starts with a general observation of:

• •

•

•

posture - alignments and any asymmetries, be they adaptive or protective pelvic and joint positions muscle contours - indication of visible wasting, in particular gluteal muscles, quadriceps, abdominal muscles observation of the skin and local soft tissues for possible changes in swelling, thickening or colour structural impairments.

- before performing any tests to repro duce symptoms, it needs to be determined if the patient has any pain.

•

I nstructions to patient at end of session

•

swayback posture posterior pelvic tilt poor definition of the gluteal muscles hip medial rotation hip extension hyperextended knees pronated foot.

•

Brief appraisal - after differentiation tests, frequently a brief appraisal or reflection on the findings so far is necessary to determine if the test procedures may be continued as planned, or if an adaptation of the examination is necessary.

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M AI TLA N D 'S PERI P H ERAL M A N I PULAT I O N

Active movements During active tests various parameters are being assessed and recorded: • •

• •

Willingness and ability to move Quality of movement, including muscular recruitment patterns Range of active movement Any symptom response.

If movement dysfunctions of the hip are suspected, special attention needs to be given to the following aspects: •

•

•

Gait analysis Gait analysis is an essential test procedure with every patient presenting with symptoms in the hip, knee or foot. Any deviations need to be corrected to determine if a direct relationship with the patient's symptoms is present. Observation should take place from the side, from anterior and from posterior. Precise observation of the different phases of the stance and swing phase is frequently necessary (Whittle 199 1 ): •

•

Stance phase: - heel contact - foot flat - mid stance - heel off - toe off (phase between heel off and toe off 'terminal rocker ') Swing phase: - mid swing - end swing.

Depending on the symptoms and the functional demonstration tests, the patient may be asked to walk in a different manner, for example: • • • • • • •

walking forwards, sideways, backwards speed small steps, large steps walking with crossed legs walking on toes, heels walking on medial or lateral borders of the feet walking in internal or external rotation of the legs.

Careful observation of any asymmetries of the various determinants of gait is essential (Whittle 1991, Rose & Gamble 1994): • • • • • • •

transfer of centre of gravity of body pelvis, trunk, foot, knee and hip movements stride length, stride width foot position cadence of movement, frequency of steps stance time and stride time average walking speed.

During stance - Duchenne sign, Trendelenburg sign, transfer of the pelvis over the leg, especially rotation, adduction and extension movements. At the end of the stance phase - extension, adduction and medial rotation movements (Klein-Vogelbach 1983). If forward walking seems normal, walking backwards, or variations of gait with big steps or with crossed legs may give a more detailed indication of gait deviations due to pain, stiffness or muscular impairments.

Squat The patient may be asked to hold onto the treatment plinth to maintain balance and to squat down either until the onset of pain or as far as the patient feels capable of squatting. Careful observation and correction of any devi ations during the movement is essential, especially abduction and lateral rotation of the leg, and retraction rotation of the pelviS. Observe if the patient is reaching the end position on the toes or on the heels. Progression of the exami nation Rocking over may be used as a progression of the examination. The physio therapist stands behind the patient to give support to the trunk and guides the patient back and forth from toes to heels, while holding the patient's knees. Reproduction of symptoms may be indicative of an intra-articular movement disorder which may require mobilization techniques under compression. As another progression of examination procedures, the patient may be asked to oscillate in the end-of range squat position.

Getting up and down steps Assess height of steps, distance to step s, quality and range of the movement.

Active testing in standing This may be very informative and undertaken before any tests in supine or in prone lying. Quality of movement and the ability to move may be more eaSily determined from the patient's normal functional movements than from those that can be demonstrated when lying down.

(Fig. 14.4) The physiotherapist guides the patient in the pelvic movements over the leg,

Weight-bearing

The h i p region

•

Application offorces: Therapist guides the patient's pelvis in F /E direction, Ab / Ad direction and MR/LR direction.

Swing movement Similar to the tests in weight bearing, the physiotherapist supports the patient's hands to maintain balance. The patient produces active swinging movements of the affected leg towards flex ion, extension, abduction, adduction, medial and lateral rotation. These tests are particularly indicative of any changes in range or quality of movement and may guide the physiotherapist towards more detailed active or passive testing in prone or supine positions.

Active testing in sitting Many patients may have difficulties with movements of the leg while sitting (e.g. putting on socks, getting out of a car). Active tests in sitting may therefore be very informative both to the patient and the physio therapist before undertaking any active tests in prone or supine lying. The following variations may be considered: • •

• • •

Figure 1 4.4

Active movements in weight-bearing.

producing flexion/extension movements, adduction/ abduction movements, internal and external rotation movements or any combinations of these. These movements may frequently reproduce the symptoms or produce impaired movements, for exam ple, discomfort with medial rotation in combination with extension; loss of range of motion with adduc tion; difficulties with balance; a diminished recruit ment pattern of gluteus medius and minimus muscles during abduction movements. Technique: •

•

•

Patient starting position: Standing on the affected leg, holding the physiotherapist's shoulder to maintain balance. Therapist starting position: Standing in front of the patient. Localization of forces: Physiotherapist holds onto the left and right crista iliaca of the patient's pelvis.

Flexing the knee to the chest Flexing the knee to the opposite shoulder (F/Ad movement) Flexion of the trunk to the feet Abduction of the leg Medial rotation, lateral rotation of the leg.

Active testing in supine and prone positions, including overpressure Frequently it is useful to examine in more detail the main physiological movements of the hip and add overpressure to the end of the active range of move ment if no symptoms have been reproduced with the active tests so far. In supine the following tests may be performed: • •

• •

Flexion (Fig. 14.5) flexion: lateral and medial rotation (Fig. 14.6) (alternative position: sitting) Abduction (Fig. 14.7) Adduction (Fig. 14.8).

In 90°

In the prone position the following tests may be performed: •

Extension (alternative position: side lying) (Fig. 14.9)

- Note: Next to the observation of range, general quality and symptom reaction, this test allows for an observation of the recruitment patterns of the

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M A I T LA N D ' S P E R I P H E R A L M A N I P U LAT I O N

Figure

• •

14.5

Active flexion, including overpressure.

gluteus maximus, hamstrings and lumbar erector trUIlci muscles. - If symptoms are reproduced, a differentiation may take place if overpressure is applied subsequently to the hip, sacroiliac joint and lumbar spine. Medial rotation (Fig. 14.10) Lateral rotation - performed as medial rotation, the therapist standing on the contralateral side.

M uscle tests

Isometric tests •

Isometric tests are performed if muscular lesions are suspected. The tests frequently need to be com bined with palpation to localize the tender spots during the tests. For further reading see Cyriax (1 978) and Kendall and McCreary (1993).

Figure 14.6 rotation.

In 90' flexion: (a) medial rotation; (b) lateral

Note: If muscles signs are present in conjUIlction with joint signs, it is often useful first to treat the joint signs and then utilize those isometric tests that reproduce the symptoms as reassessment parameters. •

Examination of recruitment patterns of the trunk and leg muscles becomes essential once the treatment of contributing factors is a relevant objective in treat ment. Therefore these tests are not necessarily a compulsory procedure in a first examination ses sion of a patient with pain. However, many active

test procedures will have already given an indica tion of the recruitment patterns (e.g. active testing in prone, guided abduction and adduction move ment in one-leg standing, active flexion in supine).

Muscle length tests These tests may be performed after establishment of the status of joint movements. Frequently it is essential to first develop an impression of the mechanosensitivity to

The h i p reg ion

Figure 1 4.7

Hip abduction, i ncluding overpressure.

Figure 14.8

Hip adduction, i ncluding overpressure.

neurodynamlc test procedures before testing of muscle length (Edgar et al 1994).

Screening of other structures in 'pl an' It is essential to examine the possible involvement of other components to the patient's symptoms and movement disorder. These components may be exam ined in the first session; however, as they also include passive test procedures with subsequent reassessment tests of the main physical asterisks, it is suggested that these screening tests be considered in the planning of the second and third treatment sessions. •

•

Lumbar spine: flexion, extension, rotations. If indi cated, lumbar quadrant. PAIVMs, including subse quent reassessment of the main physical asterisks so far. Sacroiliac provocation tests as F / Ad with compres sion, Patrick test (Faber sign), anterior and posterior tilts, passive accessory movements including subse quent reassessment.

Figure 1 4.9 Extension including overpressure: (a) hip; (b) sacroiliac joint; (c) lumbar spine.

Note: As F/ Ad with compression is also an impor tant procedure for hip movement disorders, it is often useful to complete the hip examination with the relevant passive tests prior to the screening pro cedures of the sacroiliac joints. •

•

Thoracic spine: extension, rotations, PAlVMs includ ing subsequent reassessment. Neurodynamic tests: SLR, PKB, slump, slump in side lying (Fig. 14.11), including modifications to assess obturator or lateral femoral cutaneous nerves.

455

I

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M A ITLAN D'S P E R I P H E R A L M A N I P U LATIO N

Figure 1 4. 1 1

Slump i n side-lying.

indicated if inflammatory signs are being investi gated. The findings can be monitored during the subsequent active and passive test procedures as a precautionary measure. •

•

Before passive examination tests, when the findings can be used as comparable signs in reassessment procedures. After passive examination tests.

The following aspects may be palpated: Figure 1 4.10

Medial rotation, including overpressure.

May be performed during the passive test proce dures and, if indicated, followed by reassessment procedures.

•

•

For a detailed description of the screening tests see Butler (2000) and Maitland et al (2001). As possible contributing factors to the movement disorder of the hip and pelvis region, the knee joint and foot complex frequently need quick screening of their alignment, mobility and recruitment patterns.

Pa lpation Palpation of the periarticular structures may take place in various phases of the examination process: •

At the beginning of the physical examination, as one of the first test procedures. This may be particularly

• •

Bony landmarks such as the iliac crest, anterior superior iliac spine, greater trochanter, ischial tuberosity and tuberculum pubis. The hip joint may be palpated deeply just below the inguinal ligament lateral to the femoral artery. Temperature and swelling. As the hip joint is placed deeply under the muscles, synovial swelling may be appreciated as a vague sensation of fullness or tenderness. A synovial cyst may track anteriorly to present as a swelling in the groin and needs to be differentiated from, for example, a femoral hernia, a saphenous varix, an arteriovenous fistula, a psoas abscess and an iliopsoas bursitis (Corrigan & Maitland 1983). Femoral artery and inguinal lymph nodes. Tenderness of the greater trochanter, as for example in trochanteric bursitis; over the adductor origin in adductor tendinitis; lesser trochanter or a point deep lateral from the femoral artery in the groin as

The h i p region

in psoas tendinitis; symphysis pubis with the abdominal insertions. •

Nerves. The sciatic nerve midway between the greater trochanter and the ischial tuberosity in the buttock; the femoral nerve lateral from the femoral artery over the joint; the lateral femoral cutaneous nerve medially from the anterior superior iliac spine under the inguinal ligament.

Test procedures under compression may need to be added to the test movements if no symptoms have been reproduced, particularly in those cases where an intra-articular movement disorder is suspected. Neurodynamic testing and muscle length tests may be included in this section of passive test procedures. A selection of passive examination techniques are described in detail in the following sections: •

Passive test procedu res

•

Passives test" movements are essential in the examin ation of movement disorders of the hip.

flexion/adduction, including differentiation procedures accessory movements and test procedures under compression.

Physiological movements and accessory movements need to be examined on the behaviour and relation ship of symptoms (P), resistance (R) and motor responses ('spasm' - S). The findings of the tests will guide the therapist in the selection and application of treatment techniques (Chapters 7 and 8). As many of the passive test procedures may also be used as treatment procedures, frequently the test pro cedures need to befollowed by a reassessment of the main physical parameters found so far. Often it will be useful to establish a movement dia gram of the most comparable active test movement in order to obtain more detailed parameters regarding the behaviour of symptoms, and the range and quality of movement by the establishment of the behaviour and the interrelationship of pain, resistance and motor responses. For example, flexion, rotation movements, adduction, abduction or extension may be examined in more detail and the findings may be expressed in a movement diagram (see Appendix 1 ) . Physiological movements o f the hip may include: • • • •

positions of the joint and may encompass:

•

• • •

•

• •

•

• •

•

Direction : Movement of the hip into the arc of flexion/ adduction at various points from 80 to 1400 of flexion. Symbol: F / Ad. Patient starting position: Supine, lying near the right-hand edge of the couch with the hip flexed to 900 and the knee comfortably flexed. Therapist starting position: Standing by the patient's right thigh facing across the patient's body.

flexion/adduction and variations flexion/abduction and variations extension/adduction/medial rotation extension/abduction/lateral rotation.

Accessory movements may be performed in various •

Flexion/add uction (Figs 14.12-14.19)

posteroanterior movement (on femur, on greater trochanter) anteroposterior movement (on femur, on greater trochanter) transverse lateral movement (on femur) transverse medial movement longitudinal distal movement (parallel to femur shaft) longitudinal proximal movement (parallel to femur shaft) medial rotation lateral rotation movement, including inclination.

Figure 1 4. 1 2

Flexion I adduction.

140' F (towards ipsilateral shoulder)

r·).<

F ("""d, ,h;'1

..125'

/"* \, c. 110' F (towards opposite shoulder) .

�\ ----+

Figure 1 4. 1 3 movements.

:

c. 95' F (towards opposite waist) 80' F (towards opposite iliac crest)

Flexion I adduction - d i rection of examination

457

458

M A I T LA N D'S P E R I PHE RAL M A N I P U LAT I O N

(a)

(b)

\ Figure 1 4.1 6 Diagra mmatic representation of: (a) hip flexion/adduction; (b) hip adduction.

Figure 1 4. 1 4 Flexion/adduction with compression through the shaft of the femur (longitudinal cepha lad movement).

Figure 14.15 Flexion /add uction with com pression through the neck of the femur (transverse medial movement, i nclined cephalad).

Loca/ization o f forces (position o f therapist's hands) •

Fingers of both hands are interlocked and lightly cupped over the top of the patient's flexed knee (if the patient has a very painful knee the therapist can support under the knee with one hand to

Figure 1 4. 1 7 leg raise.

•

•

Hipjoint: flexion/adduction with straight

bring the leg out of the painful knee flexion position) (Fig. 14.12). The therapist's right knee is placed on the couch, level with the patient's knee to maintain balance. The left thigh is pressed firmly against the edge of the couch at the level of the patient's hip to give added control to the pelvis movement and to

The hip region

459

] Figure 1 4. 1 8 Circumduction of the hip. Reproduced by kind permission from Kapandji (1987).

Eq

/

/ / / / /

(a) L..-

Figure 1 4. 1 9

---I

_ _

prevent the therapist's bodyweight falling fully against the patient's right thigh.

Application of forces by therapist (method) •

•

•

The patient's hip is fully adducted until the right ileum begins to lift from the couch. The therapist leans against the lateral surface of the patient's femur so that the therapist's chin and hands are close together. The hip is adducted further using small oscillatory movements. Release the movement and flex the hip a further few degrees so that the adduction can be repeated at a different point of hip flexion until the whole range (80-140°) has been assessed (Fig. 14.13).

•

Changes i n F/Ad.

First series: the patient's hip is adducted until the therapist feels a first increase in resistance ('Rl')' Then a second series of oscillatory F / Ad movements is performed over the whole range and the therapist examines the behaviour of resistance and the possi ble behaviour of pain until the limit of the range.

Variations of F/Ad as an examination technique Progression of examination If F / Ad is thought to be normal, medial or lateral rotation and/ or compression through the shaft of the femur or through the neck of the femur should be added as a grade IV to IV ++ in several positions before judging the movement as normal or ideal (Figs 14.14, 14.15). -

M A I T LAN D'S P E R I P H E R A L M A N I P U LAT I O N

460

Different combinations are possible, for example, in MR: do F / Ad; in compression through femur shaft do F/ Ad, etc. To find the position of painful limitation the hip can be moved in adduction, through the arc of flexion/ adduction from 80 to 140° to the point where the patient's knee is pointing towards the left shoulder from a starting position of the hip in less than 90° of flexion. A constant pressure is maintained through the knee along the shaft of the femur in both the flexion and adduction directions while at the same time moving the patient's thigh through a further 60-70° of flexion. The femur should lie midway between medial and lateral rotation. If movement is normal or ideal, the knee will follow an arc of a circle (Fig. 14.16a); any small abnormality will be felt as a bump on the smooth arc of the circle (Fig. 14.16b).This point may also be painful. The move ment should always be compared with that of the normal hip. Adduct the hip further so that the right ilium lifts off the table. Increase the hip adduction by applying pressure through the patient's knee downwards in line with the shaft of the femur, therefore pushing the patient's right ilium down onto the couch again. If the shaft of the femur has been retained in its relationship to the vertical, the pelvis will have adducted under the femur at the hip. This method drives the head of the femur posteriorly in the acetabulum. This technique can produce groin pain in the normal hip. However, if a patient's main problem is groin pain, the pain will be reproduced earlier in the range when compared with the normal hip. D ifferentiation tests Flexion/adduction may be con sidered as a dominant test and treatment technique of the hip joint; however, other movement components may also be responsible for impairments of the test. While maintaining the leg in the pain-provoking pos ition or slightly short of the painful position, various differentiation tests may be performed to determine the possible contribution of other movement compon ents to the painful movement. •

•

•

•

Neurodynarnic system: add knee extension and dor siflexion of the foot; may add neck flexion (Fig. 14.17). Lumbar spine: add rotation towards or away from the hip; alternative: patient may put an arm under the waist to prevent further flexion. Sacroiliac joint: tilting pelvis posteriorly or anteriorly; alternative: may add lateral traction to the ilium. While tilting the ilium posteriorly the sacroiliac joint increases the movement, while the stress in the

hip joint is slightly decreased. If symptoms increase, a sacroiliac movement disorder may be responsible; if symptoms decrease, the hip may be suspected. (Note: If symptoms increase, the lumbar spine may be differentiated by repeating the same manoeuvre but the patient extends the lower lumbar spine by putting an arm under the spine.) While tilting ante riorly the opposite may occur. •

Hip joint: add accessory movements.

Uses offlexion/adduction and its variations F / Ad is probably the most useful technique for both examination and treatment. It is as important to the hip as the quadrant is to the shoulder. F/ Ad may be considered as one of the 'functional corners' as described in Chapter 1 . The curve of F / ad may easily be recognized in the circumduction move ment as described by Kapandji ( 1987) (Fig. 14.18). Full mobility of this functional corner permits rotation movements of the trunk while walking and running and is essential in many hip functions such as moving the body or trunk in sitting, putting on socks and so forth. When all other movements are pain free this movement can be painful and restricted. The test manoeuvre may detect minimal impair ments such as local pain and little change in resistance and joint mobility. As described earlier, it is essential to treat impairments leading to degenerative changes in a phase as early as possible. Hence the examination and treatment using F / Ad may play an essential role in the treatment of degenerative osteoarthritis. Figure 14.19 gives some indication of the progression of impair ments as they may happen in some pathologies or if maintenance of joint mobility is being neglected.

T R EATM E N T -

•

•

•

•

Detailed informa tion on the selection and progres sion of treatment techniques has been described in Chapters 7 and 8. Both physiological and accessory movements may be suitable for treatment, depending on the clinical indications and their effects. In many cases flexion/adduction techniques or accessory movements performed in end-of-range flexion/adduction positions may be particularly suitable in treatment.

'The technique is the brainchild of ingenuity' is a core principle of this concept. Accessory movements may be adapted to the patient's limitations of activity and

The h i p region

may be carried out in various physiological and func tional positions. For example, the techniques may be performed in mid- or end-of-range positions of flex ion/ adduction, extension, flexion/ abduction, etc. In some cases the techniques may be performed in functional positions (e.g. sitting with crossed legs or in half-standing positions). •

It is emphasized that every technique and position of treatment may be adapted to the needs of the patient and the specific constitution of the therapist.

• •

Symbol: -+ Patient starting position: - in side lying (grades I and II): side lying with pillows placed between the legs for comfort, legs flexed for comfort - in supine (grades ill and IV): supine, lying with the hip flexed to the chosen angle and the knee flexed comfortably.

•

Therapist starting position: - in side lying: standing behind the patient facing in line with the line of the femoral shaft

- in supine: standing alongside the patient, level with the hip, faCing across the patient's body.

ACCESSORY M OVE M E NTS Lateral movement (Figs 14.20, 14.21) •

Direction: Movement of the head of the femur in a lateral direction in relation to the acetabulum.

Localization of forces (position of therapist's hands) I n side lying •

•

•

Both hands grasp around the patient's thigh anteriorly and posteriorly as near to the hip as possible. The fingers of both hands spread around the inner thigh. The thumbs of both hands spread around the outer thigh.

In supine • •

•

The sternum is pressed against the patient's knee. The fingers of both hands interlock and hold round the medial surface of the patient's thigh as near to the hip joint as is practicable. The arms and chest stabilize the patient's lower leg.

Application of forces by therapist (method) Fi gu re 1 4.20

Lateral movement, grades I and II.

In side lying •

The very gentle oscillatory lateral movement is pro duced by the therapist's body movement through the whole of the palmar surfaces of all the fingers against the inner thigh.

In supine •

•

•

Figure 1 4.21

Lateral movement grades III and IV.

this starting position the oscillatory lateral movement of the head of the femur in the acetabulum is produced by the therapist moving the femur laterally while ensuring that the angle of Ab / Ad does not alter. This may require considerable movement of the patient's knee position to avoid the tendency of the patient's pelvis to roll as the therapist's hands help to pull the head of the femur laterally. The patient's whole limb and the therapist's hands, arms and thorax should move as one solid entity while the therapist rocks back and forth (grades ill and IV especially).

In

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M A I T LA N D ' S P E R i P H E R AL M A N i P U LAT I O N

Variations i n the application of forces •

•

•

•

The same movement can be performed with the hip in any degree of flexion or extension, and in different angles of abduction and adduction or in varying degrees of rotation. While producing lateral movement of the hip the therapist may also: 1. stabilize the patient's knee, preventing its lateral movement so that the lateral movement of the hip is combined with a small degree of hip horizontal adduction 2. carry the knee in parallel with the hip so that a small degree of hip horizontal abduction takes place. To increase range using accessory lateral movement at the limit of physiological range (e.g. medial rotation), the therapist can first of all flex and rotate the hip to its limit; the therapist's trunk must then be turned to face the patient's feet while simultaneously producing the lateral movement. In this way the patient's whole limb and the therapist's hands, arms and trunk move as an entity as the required movement is produced by the rocking action of the therapist's body. Straps and belts can be used but the therapist may then lose the feedback information on the quality and range of movement available. However, a small therapist treating a large patient may require a strong grade IV + movement in treatment and is therefore justified in using such equipment.

Fi g u re 1 4.22

- in flexion: supine, lying with hip flexed to 90° or at the limit, knee fully flexed. •

• •

Recovery of range following fracture of the femur or acetabular region. Capsular tightness or a medially migrated OA hip. Painful hip conditions or stiff ranges of movement.

Longitu d i n a l movement caudad (Figs 14.22-14.25) •

Direction: Movement of the head of the femur in a longitudinal caudad direction in relation to the acetabulum.

• •

Symbol: +-+-+ Patient starting position: - in supine: supine, lying in the middle of the couch, knee slightly flexed, heel on the couch - in side lying: lying on the left side with pillows between the legs and the hips positioned in mid flexion/ extension, knees comfortably flexed

Therapist starting position: - in supine: standing level with tl1e patient's right knee facing the patient's head. The therapist's right knee is placed on the couch supporting under the patient's slightly flexed hip and knee (Fig. 14.23) - in side lying: if thumb contact is to be used the therapist stands behind the patient in line with the femur (Fig. 14.22). If the patient's femur is to be used as leverage the therapist stands behind the patient and leans across the patient's body so that the pelvis is cradled in the therapist's left axilla (Fig. 14.24) - in flexion: standing by the patient's side facing the patient's head (Fig. 14.25).

Uses •

Longitudinal movement caudad, grades I and II.

Localization of forces (position of therapist's hands) i n supine • •

•

The therapist kneels (right shin on couch). The right thigh is placed diagonally under the patient's knee. Alternatively, the therapist sits on the edge of the couch.

The h i p r eg i on

Figure 1 4.25 Longitudinal movement ca udad in flexion, grades III and IV.

•

•

The right leg, fully flexed at the knee and laterally rotated at the hip, placed under the patient's thigh. Both hands encircle the distal end of the patient's femur.

In side lying • • • •

Figure 1 4.23

Longitudinal movement caudad.

Both thumbs are placed on the greater trochanter. Fingers spread widely to help stabilize the thumbs. Forearms are directed in line with patient's femur. If the leg is to be used as leverage, both hands grasp the lower end of the patient's femur just proximal to the femoral condyles.

In flexion •

•

The fingers of both hands interlock and grasp around the anterior surface of the patient's thigh as far proximal as is practicable. The head and shoulders cradle the patient's knee to stabilize the hip and knee angle.

Application of forces by therapist (method) In supine •

•

•

Figure 1 4.24 Longitudinal movement ca udad, a l ternative method, grades I and II.

The oscillatory longitudinal movement is produced by pulling gently on the patient's femur. This technique can be assisted by a rolling or sliding movement of the therapist's supporting thigh under the patient's leg in the direction of the treatment movement. The technique should be performed gently with no discomfort for very painful disorders and in varying degrees of flexion.

463

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M A I TLAN D ' S P E R I P H E R A L M A N I P U LAT I O N

I n side lying •

•

•

•

•

•

•

If the therapist's thumbs are to be used, extremely gentle and comfortable longitudinal movement can be produced. The therapist's thumbs should not be the prime movers but should act as spring-like contact points, feeling the movement that is taking place. The therapist's arms and body gently rock back and forth in line with the patient's femur. If the patient's femur is to be used the therapist's left axilla must stabilize the patient's pelvis to prevent it moving while the technique is being performed. In this way the longitudinal movement is produced as an oscillatory movement through the therapist's hands which clasp the distal end of the patient's femur. The movement should be produced by the therapist's arms. The therapist's body cannot be used because loss of control of the patient's pelvis would occur.

•

Therapist starting position: PA standing behind the patient; AP standing in front of the patient (if leg is used as leverage: next to patient). -

-

Localization of forces (position of therapist's hands) Posteroanterior •

The pads of both thumbs, pointing towards each other are placed against the posterior surface of the greater trochanter (grades I and II).

In flexion •

The therapist's grasp of the patient's leg is such that the therapist's feet can rock back and forth as the leg rocks in the same direction.

Variations in the application of forces •

•

The longitudinal movement performed in flexion can be adapted so that it can be performed in any chosen angle of abduction or adduction. In flexion, more flexion can be added as the longitudinal movement is produced (group 2) or flexion can be reduced a few degrees during the technique (group 3b). Flexion may also be combined in flexion/adduction or flexion/ abduction positions (group 2).

Figure 1 4.26

Posteroanterior movement.

Uses • •

Very soothing for painful hip disorders. Superior migrating OA and capsular tightness.

Posteroanterior and a nteroposterior movements (Figs 14.26, 14.27) •

• •

Direction : Movement of the head of femur in posteroanterior and anteroposterior directions in relation to the acetabulum.

Symbols: ; , t Patient starting position: Side lying with the upper

leg supported by pillows in the neutral position or at the limit of the stiff range (if leg is used a leverage: supine or side lying).

Figure 1 4.27 Anteroposterior movement.

The h i p region

465

] •

•

The fingers are spread around the thumbs which should be in direct bone-on-bone contact with the trochanter. Alternatively, the heel of the hand is placed against the posterior surface of the greater trochanter (grades III and IV).

•

•

these movements may be useful as a treatment for very painful hip disorders (grades I and IT). Can be used as an accessory movement at the limit of stiff physiological range (grades III and IV). May be a technique to consider in disorders such as subtrochanteric bursitis or piriformis syndrome.

Anteroposterior •

•

•

The pads of both thumbs pointing towards each other are placed against the anterior surface of the greater trochanter (grades I and IT). The fingers are spread around the thumbs which should be 'in direct bone-on-bone contact with the trochanter. Alternatively, the heel of the hand can be placed against the anterior surface of the greater trochanter (grades III and IV).

TR EATM ENT TEC H N I Q U ES U N DER CO M PR ESS I O N Along t h e femoral l i n e (longitudinal movement cephal ad) (Fig. 14.28) •

Direction: Compression of the head of the femur into the acetabulum along the line of the femur (longitudinal cephalad movement).

Application offorces by therapist (method): PA and AP •

•

•

For grades I and IT soft, gentle, small oscillatory movements are produced by the therapist's body and arms through the thumbs stabilized against the trochanter. The movement should not be produced by the thumb intrinsic muscles as the movement needs to be both discomfort- and pain-free. For grades III and IV the heel of the hand, via the body and arms, produces the stretching movement while the other hand needs to stabilize the patient's pelvis via the anterior superior iliac crest.

Variations in the application of forces •

•

•

•

The thumbs can be used to produce the PA and AP movements in the same way as described above but with the patient lying supine. With the patient lying prone the heel of one hand can be used to produce a PA movement on the posterior surface of the greater trochanter while the therapist's other hand is used to take the patient's hip and leg into more extension. The point of contact around the greater trochanter can be changed to explore a variety of inclinations to the technique. Supine: both hands around the leg - one palm of the hand just below the ischial tubercle, the other hand just below the joint in the inguinal fold. Produce the movement with gentle movements of the trunk.

Uses •

Very little PA and AP movement of the head of the femur takes place in the acetabulum. However,

Figure 1 4.28 Rotation added to longitudinal cephalad compression : (a) medial rotation; (b) latera l rotation.

466

M A I T LA N D ' S P E R I P H E R AL M A N I P U LAT I O N

• • •

Symbol: >---< femur, o r ....... ceph. Patient starting position: Supine, lying on the couch. Therapist starting position: Standing beyond the

•

Patient starting position : Lying on the pain-free side (in this case the left side).

•

patient's slightly flexed right knee facing the patient's head.

Therapist starting position: Leaning across the patient from in front.

Localization of forces (position of therapist's hands) Localization of forces (position of therapist's hands) •

•

•

The therapist's thigh supports under the patient's slightly flexed knee. The right hand cups over the patient's tibial tuberosity. The left hand adds to the support under the patient's knee.

•

•

•

The heel of the right hand is cupped over the patient's left greater trochanter. The right shoulder is positioned directly over the right hand. The left hand and forearm hold round and support the patient's lower leg medially, making maximum contact.

Application of forces by therapist (method) Application of forces by therapist (method) •

•

•

•

The oscillatory movement of pushing of the head of the femur into the acetabulum is performed by the therapist's right hand thrusting against the front of the patient's tibia in the line of the femur. The return oscillation is guided by the therapist's left hand against the back of the patient's knee. Stronger techniques will produce associated pelvic movement. The technique, generally, should be performed into slight pain or discomfort or short of the onset of severe irritable pain.

•

•

•

•

Variations in the application of forces •

•

•

This compression technique can be performed with other movements such as rotation or flexion and extension. While compression is maintained, other movements can be added. While compression is maintained along the shaft of the femur through the knee, the hip can be medially or laterally rotated via the patient's lower leg and foot.

Uses • •

Mild aching in the hip with weight-bearing. To reproduce and treat joint surface pain.

•

•

•

Uses •

•

Compression med i a l ly (with tra nsverse medial movements) (Fig. 1 4.29) •

Direction: Compression of the head of the femur

•

into the acetabulum in a medial direction. Symbol: >---< neck, or --++ medial.

The therapist produces a sustained squeezing together of the head of the femur medially into the laterally facing articular surface of the acetabulum. Via the therapist's right shoulder the head of the femur is then squashed towards the floor in an oscillatory overpressure fashion. The time needed to apply the pressure and reproduce the patient's symptoms should be related to the time the patient is able to lie on the painful hip before becoming aware of the symptoms (Fig. 14.29a). While the pressure is sustained the therapist's body and right hand pivot around the patient's right hip to produce extension (Fig. 14.29b) and flexion (Fig. 14.29c). The therapist's trunk is side flexed to produce abduction at the patient's hip (Fig. 14.29d). For lateral rotation, the therapist's body is curved forwards over the patient's right hip resulting in the patient's left foot being lowered towards the floor while the knee is retained in mid flexion and extension, abduction and adduction (Fig. 14.2ge). For medial rotation the reverse action of the therapist's body will produce medial. rotation (Fig. 14.29f).

Chronic hip symptoms which make it uncomfortable for the patient to lie on the painful hip. OA hip which is painful when the patient's lies on the affected side.

F/ AD AS A TREATM ENT TECH N I QUE F / Ad as a treatment technique can be carried out in grades II, III and IV (Fig. 14.30).

The h i p region

Figure 1 4.29 Compression medially: (a) in neutra l ; (b) producing extension; (c) producing flexion; (d) producing abduction ; (e) producing lateral rotation ; (f) producing medial rotation. Grade IV Small oscillations at end of range (grade N) can be directed against the painful limit as treatment in one of three ways: 1. With a F / Ad movement directed towards the limitation (single headed arrow) (Fig. 14.30c).

By moving through an arc of F / Ad backwards and forwards over the limitation (double-headed arrow) ('rolling over') (Fig. 14.30d). 3. Using small oscillatory movements in an arc, back and forth at either side of the limitation (two double-headed arrows) ('scooping') (Fig. 14.30e). 2.

467

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M A I T LA N D ' S P E R I P H E R A L M A N I P U LATI O N

(a)

\ (b)

(d )

(e)

Figure 1 4.31

Flexion /adduction grade III.

Figure 1 4.32

Flexion I adduction grade II.

(e)

Figure 1 4.30

Diagrammatic representations of different hip flexion ladduction movements.

If the patient has a very painful knee the therapist can support under the knee with one hand to bring it out of the painful knee flexion position.

Uses •

•

•

•

Probably the most useful hip technique for both examination and treatment. As important to the hip as the quadrant is to the shoulder. When all other movements are pain free, this movement can be painful and restricted when the hip is a source of minor symptoms. Hip flexion and adduction are not described separately as F I Ad serves the purpose of both. The technique can be used in clinical groups 3b and 2 and group 4 in combination with medial rotation and compression.

- grade III: standing at the level of the patient's right thigh facing the left shoulder. The right knee rests on the couch and the left thigh leans against the edge of the couch.

Localization of forces (position of therapist's hands) Grade II • •

Grades II and I I I (Figs 14.3 1, 14.32) •

•

Patient starting position: Supine, lying with the hip flexed accordingly and the knee flexed to approximately 90°.

•

Grade III •

Therapist starting position: - grade II: standing at the level of the patient's right thigh facing the left shoulder. The therapist's body is positioned as a stop at the lateral extent of the F I Ad movement (this would be further away for a grade III)

The left hand holds the patient's right knee. The right hand holds the patient's foot. The body position is adjusted to face the appropriate direction of F I Ad.

•

Both hands first hold the patient's flexed knee in order to flex and adduct the hip to the limit of the range at the chosen point in the arc. The grip is then altered so that: - the left hand supports the patient's knee - the right hand supports the patient's foot so as to maintain the mid rotation position.

The h i p region

Application of forces by therapist (method) Grade I I •

•

•

The large amplitude oscillatory movement should not reach the limit of the range and is performed back and forth by the therapist's arms. The depth to which the movement reaches is determined by the onset and increase of pain, and is performed short of any resistance. The return movement and therefore the arc of oscillation is determined by the therapist's body position which acts as a stop.

Grade I I I •

•

•

•

The large amplitude oScillatory movement of approximately 30° (to 90°) is directed towards the limit in a straight line. The amplitude of the patient's foot must equal that of the knee. The therapist's body is positioned to form a stop at the outer limit of the movement. The therapist swings the patient's knee towards the limit of F / Ad to where the patient's pelvis starts to lift off the couch and into a degree of resistance. The discipline is to perform the technique smoothly and without any hip rotation.

Figure 1 4.33

Medial rotation, g rades I and II.

Uses • •

• •

Clinical group 3a (grade II), 3b (grade ill). Resolving hip pain or to help restore range of movement after injury . To help settle an exacerbation of osteoarthritis. As a technique to ease off treatment soreness (Chapter 7).

OTHER TREATM ENT TECH N I QU ES Med i a l rotation (Figs 14.33-14.38) Medial rotation is frequently restricted and painful, and may be more restricted in hip flexion than in extension or vice versa, and such variations should be sought during examination. As a treatment technique medial rotation can be performed in grades I, II, ill and IV and may be varied in different positions. •

• •

Direction: Medial rotation of the hip joint in various physiological positions. Symbol: :J Patient starting position : - i n supine (grades I and II): supine, lying near to the right edge of the couch (Fig. 14.33)

Figure 1 4.34 Medial rotation, alternative method for grade I and II.

- in side lying (grades I and II): left side lying with a pillow between the legs to support the hip in the neutral pain-free position (Fig. 14.34) - in extension supine (grades III and W): supine, lying near the right side of the couch at a slight angle to bring the patient's left foot near the edge of the couch and so that the right knee is free of the edge (Fig. 14.35) - in extension prone (grades III and IV): prone, lying with the knee flexed to a right angle (Figs 14.36, 14.37)

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M A I TLA N D ' S P E R I P H E R A L M A N I PU LAT I O N

Figure 1 4.36 Medial rotation i n extension prone for grades III and IV.

Localization of forces (position of therapist's hands) Figure 1 4.35 Medial rotation i n extension supine for grades III and IV.

I n supine •

Both hands grasp around the patient's right knee.

In side lying •

III and IV): supine, lying near to the right edge of the couch with the hip and knee flexed to right angles (Fig. 14.38).

- in flexion (grades

•

Therapist starting position: - in supine: standing at the level of the patient's

-

knee facing across the patient's body. Right knee placed on the couch with the thigh carefully positioned so as to support the patient's thigh and cali for comfort and to allow the patient's hip and knee to flex a few degrees so that the patient's heel rests on the couch (Fig. 14.33) in side lying: leaning across the patient's hip from behind (Fig. 14.34) in extension supine: kneeling by the patient's right thigh facing the left knee (Fig. 14.35) in extension prone: standing by the patient's right knee facing the hip (Figs 14.36, 14.37) in flexion : standing by the patient's right hip facing the left knee (Fig. 14.38).

•

•

The left axilla is positioned so as to support the patient's hip. The left hand holds round and under the patient's knee to stabilize it and to feel for the hip rotation. The right hand holds under the patient's right ankle and foot to stabilize it.

In extension supine •

• •

The left forearm supports under the patient's knee. The right hand holds the patient's right foot. The left forearm stabilizes the patient's knee.

In extension prone • •

• • •

The left knee rests on the couch. The left thigh forms a comfortable stop to the patient's leg at the limit of hip medial rotation. The right hand holds the patient's heel. The left hand holds the patient's forefoot. The left leg is adjusted to the height required to prevent further medial rotation.

The h i p region

I n flexion • •

The left hand supports' the patient's knee. The right hand supports the patient's heel.

Application of forces by therapist (method) In s u p i n e (grades I and I I) •

Small or large oscillatory movements of the patient's femur are produced by light pressure against the lateral surface of the patient's knee.

In side lying (grades I and II) •

•

•

•

The therapist holds around the patient's knee using the left hand. A constant position of Ab and Ad and flexion/ extension must be maintained. Small or large oscillatory movements are produced by raising and lowering the patient's foot using the right hand. No pain or discomfort should be felt in the hip.

In extension supine (grades I I I and IV) •

•

•

Figure 1 4.37 Medial rotation, grade IV, left i l i u m pushed back towards the couch.

•

The therapist medially rotates the patient's hip by raising the heel laterally. Grade IV movements are produced by moving the patient's foot laterally to the limit of the range while maintaining an equal and opposite counter pressure against the lateral side of the patient's knee using the left forearm. OScillatory movements of medial rotation are controlled by the therapist's left hand; the pressure with the left arm should be quite firm. Grade III large amplitude movements are produced by lowering the patient's right foot, which releases the pressure against the therapist's left forearm. While lowering the foot, the therapist must take care to maintain the patient's thigh in a constant position so that only medial rotation is produced.

In extension prone (grades I I I and IV) •

•

•

Figure 14.38

Medial rotation in flexion, g rades III and IV.

Medial rotation is produced by the drawing of the patient's foot towards the therapist until it reaches the therapist's thigh as a stop. The patient's foot and leg are then oscillated back and forth by the therapist's arms. The use of inversion of the patient's foot, while it is being drawn towards the therapist, makes for a better action. The therapist may need to have the right hand positioned against the lateral side of the patient's thigh during medial rotation to prevent hip abduction.

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M A I TLAN D ' S P E R I P H E RA L M A N I P U LATI O N

I n flexion (grades I I I a n d IV) •

•

The therapist medially rotates the patient's hip and at the same time prevents the hip abducting by using the left hand to apply pressure against the lateral side of the patient's knee. The therapist's right hand then moves the patient's foot in an arc around the patient's knee.

•

Therapist starting position: - in flexion supine: standing by the patient's right hip facing the left knee

- in extension prone: standing by the patient's left knee facing the right hip. The therapist's right knee is placed on the couch using the thigh positioned so as to provide a stop at the limit of lateral rotation of the patient's hip.

Variations in the application of forces I n extension prone •

•

•

As with nearly all passive movement treatment techniques the movement of the joint can be produced from either of the bones forming the joint. In the case of medial rotation of the hip (grade IV) the same starting position as for medial rotation in extension prone (Figs 14.36, 14.37) can be adopted but with sufficient medial rotation to allow the patient's ilium to be raised a few centimetres from the couch. By stabilizing the patient's lower leg the therapist can produce medial rotation of the patient's right hip by oscillatory pressure on the patient's left buttock, moving the left ilium back towards the couch (Fig. 14.37).

Uses •

•

•

• •

Very painful disorders of the hip (clinical groups 1 and 3a). Stiff hips which require mobilization to improve range (clinical groups 2 and 3b). Frequently restricted movement in many hip disorders. Osteoarthritic hips. As a shaft rotation technique to incorporate roll and slide of the femoral head in the acetabulum, including a small degree of Ab and Ad due to the roll of the leg.

Figure 1 4.39

Lateral rotation in 90· flexion, supine.

Figure 1 4.40

Lateral rotation i n extension, prone.

Lateral rotation (Figs 14.39, 14.40) •

• •

Direction: Lateral rotation of the head of the femur in the acetabulum. SymboL: c: Patient starting position: - in flexion supine: supine, lying with the hip and knee flexed to 90°

- in extension prone: prone, lying with the knee flexed to 90°.

-�-

-

�-�-----

The h i p reg ion

Localization of forces (position of therapist's hands)

Abductio n (Fig. 1 4.41 )

I n flexion supine

•

Direction : Movement of the hip into abduction

•

(either in flexion or extension). SymboLs: Ab, AblE, AblE

•

• •

The left hand holds the patient's flexed knee and stabilizes it. The right hand holds the patient's foot. The therapist's body is adjusted to face the patient's left shoulder when the hip is at the limit of lateral rotation.

•

for very painful disorders or into more degrees of flexion (all positions possible) - in extension: supine, lying with the hip and knee in extension and the legs abducted comfortably.

In extension prone • •

The right hand holds the patient's forefoot. The left hand holds the patient's heeL

•

Application of forces by therapist (method)

•

•

The oscillatory movements are produced by moving the patient's foot back and forth in an arc around the knee. The therapist's left hand and trunk maintain the position of the knee as the centre of the arc of movement. If the hip is flexed a few degrees during the medial rotation phase of the oscillation and then extended back through those few degrees during the lateral rotation phase, the technique is sometimes easier to perform. This action lessens the amount of work required by the right hand.

In extension prone •

•

•

Hip lateral rotation is produced by lowering the foot towards the stop until the limit of the range is reached. The oscillatory lateral rotation is then performed by a back and forth action of the therapist's arms. The movement can be enhanced by flicking the foot into eversion as the hip is laterally rotated.

Therapist starting position: - in flexion: standing by the patient's flexed hip and knee, level with the knee and close to the patient's leg to form a stop - in extension: standing by the patient's right lower leg facing the hip, right shin placed on the couch, sit back on the right heeL

In flexion supine (grades I I I and IV) •

Patient starting position: - in flexion: supine, lying with the hip flexed to 20°

Localization of forces (position of therapist's hands) I n flexion •

• •

The left hand is placed over the femur to support the patient's knee. The right hand is placed over the patient's tibia. The patient's leg is abducted to the point in range intended for treatment.

In extension • •

(Fig. 14.41)

The left hand supports under the patient's knee. The right hand supports under the patient's ankle.

Variations in the application of forces •

In side Lying: lateral rotation in side lying can be performed in a similar way to that described for medial rotation (Fig. 14.34) except that the patient's foot is pushed into the pillow to perform oscillatory grade I and IT lateral rotation.

Uses •

• •

•

Used less often than medial rotation and flexion I adduction. Usually best performed in flexion. May be useful as a pain-modulating technique, such as medial rotation in supine and in side lying. Best used to treat stiffness in flexion or in extension prone.

Figure 1 4.41

Abduction i n extension.

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M A I TLAN D ' S P E R I P H E R A L M A N I P U LAT I O N

Application of forces b y therapist (method)

•

In flexion •

•

Small and large amplitude oscillatory movements are produced by the action of the hands on the patient's knee. Watch that the movement is not taken beyond the point where the patient's pelvis starts to move.

In extension •

•

The oscillatory movements usually do not exceed 10-15° and are produced by the therapist's arms and hands with the patient's leg just free of the couch. The therapist's right leg acts as a stop at the limit of the abduction range required.

Variations in the application of forces •

In extension the range can be increased by placing a towel under the patient's buttock.

Uses •

•

•

To increase the range of hip abduction limited by pain or stiffness. OA hip where abduction has become stiff and painful. Groin strain where abduction is the painful hip movement.

If the hip disorder is very painful the therapist's thigh can support under the patient's knee to provide a stop.

Variations in the application of forces •

•

A towel under the patient's buttock can increase the range of the limit of extension. The patient's left hip and knee may be flexed for comfort.

Uses •

•

Where patients are having difficulty with hip extension as in walking. Particularly limited in OA hips.

Extension I abduction •

• •

•

Direction: Movement of the hip into extension/ abduction. SymboL: E/ Ab Patient starting position: Supine, lying with the hip and knee in extension. Therapist starting position: Standing by the patient beyond the knee and faCing the patient's opposite shoulder.

Localization of forces (position of therapist's hands) Extension • • •

•

Direction: Extension of the hip. SymboL: E Patient starting position: Supine near the edge of the couch with the hip and knee in extension. Therapist starting position: Standing by the patient's side beyond the knee faCing the left knee.

• •

Application of forces by therapist (method) •

•

Localization of forces (position of therapist's hands) •

•

The left hand holds laterally around and under the patient's knee. The right hand holds under the patient's heel from the medial side.

The left hand supports under the patient's knee. The right hand supports under the patient's ankle.

The therapist rocks backwards to lower the patient's leg into E/ Ab. A grade II amplitude of 20-40° is performed using the therapist's arms and body, with the hip positioned in mid rotation.

Uses •

When hip extension and abduction are limited by pain or stiffness.

Application of forces by therapist (method) •

•

•

The therapist's left hand raises the patient's knee 15-20 cm from the couch. The right hand keeps the patient's heel off the couch and moves it towards the patient's buttock 7-10 cm. The therapist then carries the patient's heel away from the buttock and allows the knee to lower to the limit of extension.

Clinical profiles are presented for the following com mon disorders related to hip movement dysfunctions: • • • • •

osteoarthritis (Box 14.3) athletic groin pain (Box 14.4) torn acetabular labrum (Box 14.5) trochanteric bursitis (Box 14.6) meralgia paraesthetica (Box 14.7)

The h i p reg ion

Box

1 4.3

Clin ical profile: osteoarthritis

.

Examination

Clin ical evidence/'brick wall' thinking

Kind of disorder

Pain and restricted mobil ity i n various daily l ife activities

Body chart features

As described in Figure 1 4.3

Activity limitations/ 24-hour behaviour of symptoms

May incl ude activities such as driving, gardening, wal king. Stiffness especia l ly in the morning when rising from bed and getting u p after prolonged periods or sitting or squatting. Easi ng factors: rotation movements of the leg. Patients may indicate that the disorder needs a balance between rest and activity (but not too m uch of both)

Present/ past history

Gradual onset of symptoms in a prolonged history of constant awareness of discomfort studded with exacerbations. Some patients indicate that the pa i n and disability increased over t i m e and they m a y n o t be symptom free a n y more. With those patients, symptoms m a y have prog ressed from occurring during weight-bearing activities towards symptoms at rest (especia l ly at night). However, other patients may say that they have im proved over the years, as for exa mple after retirement from sedenta ry work, more activities (e.g. wa lking) a re being performed

Special questions Sou rce / mechan isms of symptom production

Pa i n originating from the subchon d ra l bone exposed by fu l l th ickness a rticu lar defects. Furthermore, capsular and ligamentous structures may cause nociceptive activity. Neurogenic mechanisms and i ntraosseous vascu l a r mechan isms m a y a lso play a role i n symptom production

Cause of the sou rce Contributing factors

Habitual gait patterns, lack of m uscu lar control, loss of joint mobil ity and reduced aerobic condition as neuromuscu loskeletal contributing factors

Observations

No loca l changes (e.g. bony or synovia l thicke n i ng) visible. Postu ral changes, especia lly pelvic position l eading to h i p fl exion. M uscu lar wasti ng possible: g lutea l m uscles, quadriceps. Underactivity of abdominal muscles

Fu nctional demonstration of active movements

Pa i nful l eg movements (e.g. putting on socks, squatting, crossing legs in sitti ng). Many movements, especially F, Ad, MR, E may be restricted and pain provoking. Crepitus is rare. Gait ana lysis is essential. If symptoms are difficult to reproduce, crossing the legs may be particu larly ind icative. Tests i n weight bea ring, especia lly Ad, MR and E may provoke symptoms with 'through-ra nge' fi ndings

If necessary tests

Symptoms may increase when the tests movements a re performed u n der compression

Other structures in plan

Essential : screening of l u mbar spine, sacroiliac joint. Furthermore: m uscu lar recruitment and m uscle length.

Isometric/ muscle l ength tests

Mostly inconcl usive with regards to symptom reproduction

Neurological exa mination Neurodynamic testing

Neurodynamic testi ng needs to be performed as a routi ne procedu re ; however, may not be involved in the movement disorder

47 5

476

M A I TLA N D ' S P E R I P H E R A L M A N I P U LAT I O N

Pa l pation findings Passive movement, accessory / physiolog ical combined movements

Pai n and stiffness through range. In particular, F/ Ad, MR and E may be restricted and pai nfu l. Accessory movements will react accordingly with changes in through-range resistance and pain. The friction-free feel of passive movement may be lost with the joint surfaces compressed together

Mobi lization / manipu lation techniques preferred

Accessory movements at end-of-range and in-range positions, if sufficient range of motion is present: F/ Ad. Large a mplitude treatments shoul d be used in variation with end-of-range ampl itudes. Minor symptoms may also respond to passive mobilization with the addition of intermittent joint compression

Other management strateg ies

NSAI Ds and pai n-relieving medication may be necessary. Consider joint replacement in severe cases. Restoration of m uscu lar control by coord ination, aerobic condition ing, a utomobil izations of joints and muscle stretching, pain coping strategies. Advice to take regular, moderate activity (e.g. walking, biking, swimming)

Prog nosis/ natura l history

As discussed in Chapter 1 0, osteoa rthritis ca n be classified as a mechan ical, degenerative, tra u matic or systemic disease. In the mechanical type, if pain and dysfu nction are due to a mechan ical d isorder within the joi nt and if passive mobilization and exercises can alleviate the mechan ical factors, the patient's symptoms should resolve according ly. The traumatic and degenerative types may have some residual impairments of restricted mobil ity, but with appropriate management and advice patients ca n rema in symptom free for long periods. The disease type relates to the systemic type of osteoarthritis which genera l ly fol lows a progressive natura l history. In such instances mobilization can be a means of a l leviating symptoms but total rheumatolog ical management of this type of osteoarthritis is essential

Evidence base

See Chapter 7 for evidence of passive movement and a rticular cartilage repair; Va n Baar et al ( 1 998) ; Hoekstra (2004)

Examination

Clinical evidence/'brick wall' t h inking

Kind of d isorder

Symptoms i n groin and pubic a rea related to certain sports activities

Body chart features

Local symptoms in groin and pubic a rea

Activity lim itations / 24-hour behaviour of symptoms

In a l l sports where sudden rotation and acceleration are required (e.g. rugby, soccer). Symptoms may occur with activities such as kicking a ball, twisting movements of the leg. Occurs in long distance running, usually during speed or hill work. If of muscular origin, symptoms may occur d uring contraction or stretching of muscles (e.g. adductor tendinitis: squeezing knees together; i liopsoas tendinitis: lifting leg in sitting)

Present/ past history

Acute: related to certain sports activities and frequently contracting or stretching affected m uscle groups (e.g. add uctor tendinitis: for example in kicking a ba l l at the same moment as the opposition / throug h a block tackle)

The hip region

Special questions Source/ mechanisms of symptom production

The fol lowing structures /pathological processes need to be considered as a possible source of symptoms: Referred symptoms: l umbar spine, thoracic spine, sacroi liac joint; neurodynamic system. Local, other than hip joint: • • • • • • •

• • •

Adductor tendi nopathy, adductor longus m uscle I liopsoas tendi nopathy Rectus femoris tendi nopathy Rectus a bdominis tendi nopathy Osteitis pubis Pelvic stress fractures Pubic i nstabil ity (especially if adductor tendi nitis seems to occur in conj unction with rectus a bdominis tendi n itis) Nerve entra pment: i l ioinguinal nerve, obturator nerve Hernia inguina lis Gen itou rinary pathology (e.g. prostatitis)

Cause of the source Contributing factors

Repetitive overuse activity

Observations

Swe l l i ng or promi nence at i nsertions

Functional demonstration of active movements

Twisting movements, kicki ng ball. I n cases of tend in itis, m inor restrictions of h i p movements

If necessary tests Other structures in plan

Screening of l u mbar spine, sacroil iac joints, thoracic spine

Isometric! m uscle length tests

Isometric testing may provoke the symptoms. Exact loca lization of the source may be possible if careful pa lpation is carried out d uring the isometric testing

Neurological examination Neurodynamic testing

In cases of entra pment neuropathy, modified femora l nerve tests may reproduce symptoms

Palpation findings

In cases of tendin itis: tenderness over i nsertions, m uscle

Passive movement, accessory / physiological combined movements

In cases of tendinitis: often u n revealing

Mobil ization / mani pu lation techniques preferred

Soft tissue techniques, modal ities

Other management strategies

In acute phases: rest, ice, com pression for c. 48 hours. Gently increase stretching and contraction within pain-free l i mits. M uscu lar recru itment, instruction regarding warm ing up /cool ing down and self-management (pain-coping strategies - e.g. gentle stretching, soft tissue treatment) essential

Prog nosis/ natura l history

Depends on the identification of the i nterrelationshi p between the actual components and mechanisms. I n cases of local ized tendinitis with a short and clear h istory - good prognosis

Evidence base

'There is no consensus on diagnosis, pathophysiology or management' (Orchard et al 2000)

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M A I TLA N D ' S P E R I P H E R AL M A N I P U LATI O N

Exa m ination

C l i nical evidence/ 'brick wall' thinking

Kind of d isorder

Pai n in groin a rea with twisting movements while weight-bearing

Body cha rt featu res

Sharp 'catching' pain in the g roin which may radiate into the thigh. Usually at the front of the joi nt. Over time pain may become diffuse and d ifficult to localize

Activity lim itations/ 24-hour behaviour of symptoms

Often provoked by pivoting movements. I n itia l ly lasts only for a few min utes; may become more freq uent and longer lasting. Associated click may be present. Frequently during soccer or other sporting activities

Present /past h istory

Symptoms may be acute but more com monly occur over a nu mber of months. Related to sports activities such as soccer; can also occur by overuse or by acute trauma from a violent blow to the hip

Special q uestions Sou rce / mechan isms of symptom production

Acetabular labrum

Cause of the source Contri buting factors

Overuse with repeated twisting movements

Observations Functional demonstration of active movements

Twisting movements in weight-bearing positions may provoke the pain and /or click. Symptoms may be provoked on axial compression. Pinching sensation during hip flexion, add uction, m edial rotation and combinations

If necessary tests Other structures in plan

Differentiate from other movement com ponents which may refer symptoms into the same a rea

Isometric/ m uscle length tests

Frequently inconcl usive

Neurologica l exa mination Neurodynamic testing Pa l pation fi ndings Passive movement, accessory / physiological combined movements

Pa in and apprehension on im pingement provocation tests i nvolvi ng flexion, adduction and internal rotation (anterosuperior tea rs) ; hyperextension, ab.d uction and external rotation (posteroinferior tears). Moving the hip from fu l l flexion, external rotation and a bduction to extension with internal rotation and adduction - pa in reproduction and / or clicking may be an ind ication of a labrum tear

Mobi lization /manipu lation techniques preferred

Depending on the pain, gentle passive movements with accessory movements short of the pai nfu l position may influence the pain

Other management strategies

Depending on other im pairments and habitual movement patterns found in physical exa m i nation

Prog nosis /natura l history

I n minor cases restoration of function may be expected. However, in some persistent cases arthroscopy should be considered. Postoperative management: restoration of ful l range o f motion, muscu lar control and gu idance t o normal level of activities a n d sports

Evidence base

Fitzgerald (1 995)

The h i p

region

Examination

Clin ical

Kind of disorder

Pa i n local ized over local a rea of g reater trochanter

Body chart features

Usua l ly local pain, may radiate down latera l or posterolatera l aspect of the thigh

Activity limitations/ 24-hour behaviour of symptoms

Symptoms with climbing stairs, sleeping on affected side, crossing legs. Pa in particu larly i n lying on the side, wa lking for longer periods of time

Present/past h istory

Gradual onset of symptoms; tends to run a protracted cou rse that is punctuated by exacerbations and remissions, often related to activity

evidence/ 'brick wall' th i n king

Special questions Source /mecha nisms of symptom production

May be loca l structu re. May be referred symptoms from lower l u m ba r spine, sacroiliac joi nt, hip

Cause of the sou rce Contributing factors

This overuse lesion tends to occur i n two groups of patients: those i nvolved in activities (e.g. extensive run n ing) or in middle-aged (usually female), often overweight patients with associated degenerative changes in the lower l u mbar spine

Observations

Muscle wasting ; tight i l iotibial band

Functional demonstration of active movements

Crossing l egs, lying on affected side may reproduce symptoms. Add uction, extension may reproduce symptoms. Local symptoms with l u mbar active tests

If necessary tests Other structures in plan

Screening of l u mbar spine, sacroiliac joi nt, neurodyna mic structures essential

Isometric/ muscle length tests

Hip abductors may reproduce the symptoms partially

Neurolog ica l examination Neurodynamic testing

May be symptomatic if l u mbar spine is i nvolved

Pa l pation fi ndi ngs

I ncreased temperature in local a rea possible

Passive movement, accessory /physiolog ica l combined movements

Hip movements freq uently concom itantly pa infu l , e.g. F/Ad; in particular L4-5 accessory movements may partially provoke the symptoms

Mobil ization / man i pu lation tech niques preferred

Treatment of concomitant l u mbar and hip joint signs is essential

Other management strategies

Soft tissue techniques and appl ication ; treat m uscle imbalance, especially of g luteal m uscles, quad riceps and abdominal m uscles, stretching of tensor fasciae latae and iliotibial band. I nstruct patients i n self-management strategies. Sports people: advice on warm ing up /cooling down prog rammes

Prog nosis/ natura l history

Depending on the interrelationship of contributing components to the movement disorder

Evidence base

479

480

M A IT LAN D'S P E R I P H E R A L M A N I P U LAT I O N

Examination

Clinical evidence/ 'brick wal l ' thinking

Kind of disorder

Burning pain at lateral side of thigh

Body cha rt featu res

Qual ity of symptoms: burning, sti nging, numbness, paresthesia down the proximal lateral aspect of the thigh. Other symptoms may be present in knee area, buttock and lower back

Activity lim itations/ 24-hour behaviour of symptoms

Symptoms with longer periods of sitting with i nvolved leg under body, prolonged sitting, squatting, increased walking, sta nding

Present/past history

Gradual, spontaneous onset of symptoms associated with, for example, obesity, wide belts, tight jeans, pregnancy, d iabetes mell itus and prior i nguinal surgery. At times may be the resu It of tra u ma

Special questions Sou rce /mecha nisms of symptom production

Symptoms typical of peripheral neurogenic mechanisms. May be associated with movement disorders of lu mbar spine, hip

Cause of the source Contributing factors

Overweight, clothing

Observations Fu nctiona I demonstration of active movements

Frequently inconcl usive, as symptoms may develop after remaining for long periods in the sa me position. Lumbar spine, hip movements need to be routinely exami ned

If necessary tests Other structu res in plan Isometric/muscle length tests Neurolog ica l examination

Motor function ful ly intact. Hyperaesthesia over lateral thigh, increased light touch sensation, i ncreased pin-prick sensation

Neurodynamic testing

Slump test in side lying (including hip extension and adduction) may provoke the symptoms. Variation of the test: patient may lie on the affected side (Butler 2000)

Palpation fi ndings

Deep palpation just below the anterior superior i l iac crest may reproduce the symptoms

Passive movement. accessory / physiologica I combi ned movements

Hip movements frequently concomitantly painful or restricted (e.g. F/ Ad)

Mobil ization / manipu lation techniques preferred

Treatment of concomitant lu mbar and hip joint signs is essential. Neurodynamic treatment respecting the symptoms (Progression of treatment: see Chs 7, 8)

Other management strategies

I nfiltration of the nerve at it course at the inguinal ligament. Recommendation on clothi ng, weight loss. Surgery is rarely considered

Prognosis /natura l history

Some authors state that in many cases a spontaneous resol ution may occur within 2 years. However, the results may be dependent on the interrelationsh ip of all other contributing components in the disorder

Evidence base

See for example Butler (2000)

The h i p region

CASE STU DY 1 4 . 1 A M OVE M E N T D I S O R D E R R E LAT E D TO D E G E N E RATI V E OSTEOART H R I T I S I N C O M B I N ATI O N W ITH A M I N O R L U M BAR M OV E M E N T DISORDER

Mr B is a 67-year-old retired construction worker whose hobbies i nclude gardening, biking (2-3x weekly for 2-3 hours), h i king in mountains (at least l x / week). skii ng i n wi nter. Kind of disorder

Symptoms in leg, especia lly during walking, getting up from sitting, gardening. Activities i n daily l ife: 'annoying', but carries on with them as usual. Body chart

'CD i Squatting (e.g. when playi ng on floor with g ra ndchi ld). after 5" CD 'annoying' ! Changes position on floor CD ! quickly 'CD i Putting on socks (in sitti ng) - crosses rio leg over Ie. leg, 'hard to do', CD little bit ! CD ! immediately, once leg straight again '@@ i Currently only after driving a ca r for 2-3 h ; sitting i n a cinema after 2-3 h ! Gets u p and wa l ks a round: settles q uickly Night: ./ Morn ing at getting out of bed stiff' CD, esp. in walking - settles after 30'; then ./ Day: as above; pm:a m : no d ifference; in genera l : needs movement more than resting Present/past h i story

Short-term (present) history is i l l ustrated in Fig u re 1 4.43.

As pointed out in Figure 1 4.42, the symptoms in the buttock and the groin a rea do not appea r to have a relationship.

Past history • •

Activity l i m itations/ 24-hour behaviour of symptoms

'CD i Gardening (esp. pulling weeds), after c. 2 h ! Gets u p and 'shakes' leg a bit; after c. 1 5' ./ 1 00%

Never had CDCDa, nor restricted movements.

@@ since C. 20 years. 5 years ago: @@++ went to Dr and PT for 1 st time; passive mobil izations and self-managements. Good effects; did not continue with exercises.

CD @ Together 0 0 Together CD � @0 Separate Figure 1 4.42 Body chart of Mr B.

48 1

482

M AI T LA N D ' S P E R I P H ERAL M A N I P U LATI O N

Short term Hx

I

l Since when I

l

,

CD started ca. 3 months ago

Figure 1 4.43

•

I

I

I Details on onset

.J

I

Noticed it 1 st in the morning stiff CD ; Lx CD G) were unchanged; Did a lot of skiing in that period; fell 2-3x; felt a bit stiff in legs at D1 but DLA incl. skiing were normal

I

I Course over time

.J

I

I

I

Gradually CDCDa (CD G)remained isq) - Noticed difficulties with squat, putting on socks and shoes, gardening -+GP -+ PT

Now: onset

.J

I

Now: DLA not limited; however

CDCDa isq since

ca. 2 months

Short term history.

Better now than 4-5 years ago: attributes this to increased l evel of activity (is retired): reg u l a r biking, hiking, and skiing.

Passive tests hip F/AD

1

Special questions

G H : ./; Medic. none; no history of accidents or i l l n esses; X-ray Ie. and ri. hips: degenerative changes in both hi ps (no difference leftl rig ht).

)) < "'

I d;"�O",

� "..

Pla n n i n g of physical exam i nation

Hypotheses •

•

Symptom mechanisms: nociceptive mechanisms (stim u l us-response related symptoms). Tissue mechanisms: degenerative cha nges with OA, however symptoms developed only after fa l l on right h ip. Main sou rce of symptoms: h i p CD ; Lx @@; neura l system CD@@; (later: screen SIJ).

Procedures of examination •

•

No specific CI I precautions (not severe I irritable; no specific 'nature' factors) -+ routine testing possible: until l (resp. Pl. Test h i p and Lx movements; after active testing decide : Continuation P I E hip OR contin uation P I E Lx.

Physical exa m i n ation (D l ) • •

•

•

PP ./ Inspectio n : noth ing particular; a nt. tilt pelvis: correction ./ Functional demonstration and differentiation : *Putting on socks (sitting; R l eg crossed over l) CD Lx, SI stress: ISO Diff: NS (Neck flexion): pulls in buttock @ H i p (ri. leg) CD i * *Squat: ./, deviates in Ab / lat Rot, CD act EOR Corr. deviation : ./, CDCDa++ Gait: forwards, backwards, sma l l steps, l a rge steps: *Crossing Ie. leg over rio leg: ! ! , CD

Figure 1 4.44 Passive tests: hip flexion I adduction.

•

Active tests Active tests on 1 -leg : F, E, Ab, Ad, MR, LR all '/, ./ *F 10 cm, @ act + NF @ i Lx: E 20°, L 1 -5 stiff, loc. P Lx-area *LF I e : ./, @ act EOR; ri : '/, ./ Rot Ie ri ! , ./ Lx 0 Ie ! , ! (Ioc. P) ; ri ./, ./ (Ioc. P) =

Hip supine

F 1 20°, CD IVI n 90° F: MR U , CD IV I n 90° F: lR ./ Ab 40°, ./ Ad 25°, ./

Hip prone

E 10° (ri. 20°), ./ IV++ MR ! , ./ ; LR '/, ./

}

Decision: Screening neurodynamics; then continue PIE hip. Neurodynamic tests

SLR rio 80°, + DF; + NF SLR Ie. 60°, + DF PKB side lying : Ie. ri.

C / O : ISO P I E : Fct. Demo (socks) Squat

(Decision: do quick reassessment as rio seemed to change during tests)

Gait (crossing Ie. leg) Hip F, in 90° F, do MR Lx: F 5 cm, @ act. + NF @ i ©

=

LF Ie. ISO

all ISO

The hip region

p' CD a (a)

R,

R2 (IV++)

Figure 1 4.46

P,

Left hip: in flexion / adduction.

Plan (D4,Rx2j •

P' CD

•

•

•

Consideration of hypotheses: movement dysfu nction of hip CD, with restricted mobil ity Plan session 2: screen Lx - effects of PAIVMs on hip function and Lx function Decide: continue Rx Lx? OR continue Rx h i p? (F/Ad ; in EaR F/Ad: acc. mvt; a utomob. F/Ad) (Screening SIJ : Rx 3)

(b) D4,Rx2 •

•

PIE:

•

Pa lpation and P I E PAIVMs TlO- LS / S 1 (Fig. 1 4.47) :

(c)

Figure 1 4.4S Left hip: restricted.

Passive tests hip F/Ad

Ri. hip: a l l directions .I, .I (Fig. 1 4.44) Le. hip: restricted, CD (Fig. 1 4.4S) LE. hip: in FI Ad (pos. c) before P 1 (Fig. 1 4.46) : do PIE accessory movements: * t femur, -- lat, -- latl caud, ; fem u r, ; troch, t troch, ....... ca ud: .I, .I

cIa: 'lig hter', 'more comfortable to move' P I E : F 1 2S·, CD IV+ © In 90· F: MR range j, CD IV-© Squat: deviation t Lx: F, LF Ie.: ISO Warned patient: P may be more localized and and intense - expo CD Should observe AND compare:"stiffness a.m.; "squat; "sitting on floor; "gardening;

c I a : Felt lig hter in a rea CD for C. 4 h , then ISO Gardening, squat: ISO Putting on socks: seemed less stiff CD Morning: seemed less stiff CD - sti l l C. 30' Lx: no change (did not bother at a l l ; did not sit for longer periods)

*Lx F S cm *Lx LF left *Putting on socks CD l ittle (overpressure: CD j ) *Sq uat: l ittl e dev in Ab / LR, CD l ittle *Gait sideways: ISO as after Rx 1 *In supine: hip F 1 2S·, CD IV*In supi ne, in 90· F: do M R C. 20·, CD IV-

Temp, sweating, skin tone, bony alignment, m uscle tone : .I I nterspin. space (ISS) L2-S, laminae Ie. and ri. L2-S: 'thick', 'full'

C I a : ISO P I E : Lx: F, LF: range j, @ ISO Hip: Squat, putting on socks, ga it, F, M R : ISO

; TlO- L2; � TlO-LS; r Tl O-L2 .I .I ' ; L3-LS; r �3- �S (Fig. 1 4.47) Decision : continue Rx hip, as described in plan Rx 2.

483

484

M A I T LA N D ' S P E R I P H E RA L M A N I P U LATI O N

R2 (IV++)

•

•

p', loc.

P

R1 P1 Figure 1 4.47 Palpation and physical examination PAIVMs, TlO-L5/S1. Summ ary o f rem a i n i n g treatment sessions •

•

The hip was treated and cleared with F/Ad techniques (grades IV, IV+ , slightly before the onset of pain) as well as with accessory movements i n EOR positions of F / Ad. Those accessory movements which were impaired in Rx 1 were selected as treatment i ntervention . Automobil izations for F/AD were given : - F/ Ad i n sitti ng

•

- F/Ad i n standing, with the leg on the seat of a chair; trunk flexion and automobil ization with AP pressures on the femur. These exercises were performed 2-3x/ day and when symptoms CD were i ncreased. Screening of the sacroil iac joint with provocation tests and passive movements: no effect. Althoug h the l u mbar spine was not fu l ly impairment free, it was decided to repeat some of the self management strateg ies that the patient learned c. 5 years ago. The patient indicated beneficial effects of these after longer periods of sitting. I n a retrospective assessment in the eig hth session, left side flexion was sti l l slig htly restricted; however, it was symptom free with overpressure. Lu mbar flexion was cleared with rega rd to the symptoms. The patient was encouraged as a 'joint care' to mainta i n the l u mbar and hip self-management strategies (ma i n ly automobil izations) after completion of the treatment. To enha nce long-term com plia nce, it was determi ned col laboratively with the patient where possible difficulties regarding the execution of the exercises may occur and adaptations to the exercises were performed (Appendix 2).

References Arnoldi, C, Linderholm, H., Mussbichler, H . 1972. Venous engorgement and intraosseous hypertension in osteo arthritis of the hip. Journal of Bone and Joint Surgery, 54B, 409-421

Boissonnault, W. 1995. Examination in Physical Therapy Practice - Screening for Medical Disease. New York: Churchill Livingstone Bullough, P. 1984. Osteoarthritis: pathogenesis and aetiology. British Jou mal of Rheumatologtj, 23, 166-169

Butler, D. S. 2000. The Sensitive Nervous System. Adelaide: NOI Group Corrigan, B. & Maitland, G. D. 1983. Practical Orthopaedic Medicine. London: Butterworth-Heinemann Corrigan, B. & Maitland, G. D. 1994. Musculoskeletal and Sports Injuries. Oxford: Butterworth-Heinemann Cyriax, J. 1978. Textbook of Orthopaedic Medicine. London: Bailliere Tindall Dieppe, P. 1984. Osteoarthritis: are we asking the wrong questions? British Journal of Rheumatologtj, 23, 161-165 Dieppe, P. 1998. Osteoarthritis: time to shift the paradigm. BMt 318, 1 299-1300

Edgar, D., Jull, G. & Sutton, S. 1994. The relationship between upper trapezius muscle length and upper quadrant neural tissue extensibility. Australian Journal of Physiotherapy, 40, 99-103

Fitzgerald, R. 1995. Acetabular labral tears. Clinical Orthopaedics and Related Research, 311, 60-68

Goodman, C C & Snyder, T. E. K. 2000. Differential Diagnosis in Physical Therapy. Philadelphia: W. B. Saunders Gunn, C C 1980. Prespondylosis and some pain syndromes following denervation supersensitivity. Spine, 5, 185-192 Hoekstra, H. 2004. Manual Therapy in Osteoarthritis of the Hip. Amsterdam: Vrije Universiteit Kapandji, 1. 1987. The Physiology of Joints - Lower Limb. Edinburgh: Churchill Livingstone Kendall, F. P. & McCreary, E. K. 1993. Muscles, Testing and Function. Baltimore: Williams and Wilkins Klein-Vogelbach, S. 1983. Funktionelle Bewegungslehre. Berlin: Springer-Verlag Maitland, G. D. 199 1 . Peripheral Manipulation; 3rd edn. London: Butterworth-Heinemann Maitland, G. D., Hengeveld, E., Banks, K. & English, K., eds. 2001. Maitland's Vertebral Manipulation, 6th edn. Oxford: Butterworth-Heinemann Moncur, C 1996. Physical therapy management of the patient with osteoarthritis. In Physical Therapy in Arthritis, ed. J. M. Walker & A. Helewa. Philadelphia: W. B. Saunders Orchard, J., Read, J., Verall, G. & Siavotinek, J. 2000. Pathophysiology of chronic groin pain in the athlete. International Sports Medicine Journal, 1(1) (abstract) Palastanga, N., Field, D. & Soames, R. 1994. Anatomy and Human Movemen t. Structure and Function. Oxford: Butterworth-Heinemann

The h i p region

Rose, J. & Gamble, J. 1 994. Human Walking. Baltimore: Williams and Wilkins 5ahrmaru1, 5. 2002. Diagnosis and Treatment of Movement Impairment Syndromes. 5t. Louis: Mosby 5ims, K. 1999a. Assessment and treatment of hip osteoarthritis. Manual Therapy, 4, 136-144 5ims, K. 1999b. The development of hip-osteoarthritis: implications for conservative management. Manual Therapy, 4 1 27-135 50ames, R. 2003. Joint Motion. Clinical Measurement and Evaluation. Edinburgh: Churchill Livingstone Van Baar, M., Dekker, J., Oostendorp, R. A. et al. 1998. The effectiveness of exercise therapy in patients ,

with osteoarthritis of the hip or knee: a randomized clinical trial. Journal of Rheumatology, 25, 2432-2439 Weinstein, J. 1992. The role of neurogenic and non neurogenic mediators as they relate to pain and the development of osteoarthritis. Spine, 17(105), 5356-5361 . Whittle, M. 1 99 1 . Gait Analysis - An Introduction. Oxford: Butterworth-Heinemann Williams, P. L. & Warwick, R., eds. 1980. Gray's Anatomy, 36th edn. London: Churchill Livingstone Wroblewski, B. 1978. Pain in osteoarthrosis of the hip. The Practitioner, 1 315, 1 40-141

485

487

Chapter

15

The knee complex

TH IS CHAPTER I N CLU DES: • • •

•

Key words for this cha pter Glossary of terms for this cha pter Presentation of the knee complex as a source of movement dysfu nctions Subjective examination principles related to knee movement disorders

KEY WORDS

• •

•

Physical exa mination princi ples Exa mi nation and treatment techniques Clinica l profiles of common disorders related to knee movement dysfu nctions - osteoarth ritis

•

- a nterior knee pain (patellofemoral syndrome) - subl uxating patella A case exa mple of a patient with anterior knee pain.

joint. su perior tibiofibular joi nt.

Tiblofemoral joint. patel lofemora l

GLOSSARY O F TERMS

Anterior knee pai n - a cond ition with symptoms in the area of the anterior aspect of the knee. Movements of the patellofemoral joints a re freq uently involved. Treatment often consists of passive mobilization and normal ization of the patella tracking throug h the

femoral g roove by activation of the vastus medialis oblique (VMO) in relation to the vastus latera lis and the overa l l muscle chain of the pelvis and foot (McConnell 1 996). Extension / abduction, extension / adduction, flexion/abduction, flexion/adduction - functional movements of the joint ('functional

I N TRODUCTIO N

The knee joint, the largest synovial joint in the body, combines considerable mobility and strength with the stability necessary to lock the knee in the upright pos ition. A bicondylar hinge joint, the knee is made up of three functional units: the medial and lateral tibio femoral compartments and the patellofemoral joint. The superior tibiofibular joint is included in the knee complex. It is often forgotten as a source of lateral

corners') which can be used in the examination and treatment of minor or less obvious painful restrictions. Joi n t stabil ity - provided by the ligamentous structures (passive sta bility) and the surrounding m uscles (dynamic sta bil ity).

leg and knee pain. It needs to be examined routinely in movement disorders of both the foot and the knee (Corrigan & Maitland 1983).

Stabil ity and mobility Stability (particularly in extension) and mobility are essential for the knee joint to fulfil the requirements of a weight-bearing joint. Both functions are secured by the interplay of ligaments, menisci, muscles and

488

MAITLAND'S PE RIPHE RAL MANIPULATION

complex gliding and rolling movements at the articular surfaces (Palastanga et al 1994, Nordin & Frankel 2001). Nevertheless the joint is quite vulnerable to disloca tions and strains to the ligaments, muscles and intra articular structures, including the menisci, as the articular surfaces have a relatively poor degree of interlocking (Palastanga et aI1994). In locomotion the knee joint plays an important role in shortening and lengthening the leg, and - in conjunction with the ankle - in the propulsion of the body and transmission of forceful stresses including lateral and rotation movements of the joint (Palastanga et aI1994). Motion occurs simultaneously along three axes, although flexion and extension predominate (Nordin & Frankel 2001). However, many functional movements and symptom-provoking activities concerning the knee joint need to be considered in the light of com bined movements, for example extension and adduc tion or abduction combinations, flexion and rotation combinations and so on, as these specific combinations frequently play an essential role in the delivery of successful treatment with passive movement.

Anatomy The femoral condyles rest on the tibia and the inter condylar femoral groove is slightly widened to the lateral side. The femoral condyles are convex from ante rior to posterior and from side to side. The medial condyle bulges out more than the lateral condyle. The tibial condyles are relatively flat with a slight posteroin ferior inclination of the condyles. The lateral condyle is smaller and rounded, concave from side to side, but concavo-convex from front to back. The articular sur faces of the tibia are deepened by the lateral and medial menisci (Palastanga et alI994). The anatomical shapes allow for a large amount of glide and roll movements on an intra-articular level. The instant centre of rotation of the joint ranges from c. 30 to 60° of flexion in a normal joint, indicating a large amount of gliding movement. However, rotation movements also play an essential role in intra-articular movement behaviour, in particular to allow an optimal stability in extension movements in weight-bearing (Kapandji 1987, Nordin & Frankel 2001). The articular surface of the patella is oval and a ver tical ridge divides the joint surface into a smaller medial area and a larger lateral area. In flexion the medial side has more contact with the medial condyle. The articular cartilage, having to transmit large stresses, is probably the thickest cartilage of the body (Palastanga et al 1994).

Movement patterns During flexion/extension movements of the knee the patella follows a complex three-dimensional movement pattern, with a large amount of gliding over the femoral condyle in combination with rotation movements and laterally and medially directed movements (Kapandji 1987, Van Eijden 1990). The patella may glide approxi mately 7 cm in relation to the femoral condyles when the knee moves from full extension to 140° of flexion, in which the patella rotates laterally beyond 90° of flexion (Nordin & Frankel 2001). It has been stated that, particularly in the last degrees of extension/first 20° of flexion, a balance in the recruitment patterns of the vastus medialis oblique and lateralis is essential to permit optimum tracking of the patella in the femoral groove (McConnell 1996), in which the vastus medialis oblique should react earlier and faster than the vastus lateralis during the move ment (Witvrouw et alI996).

Range of motion The following ranges of motion have been described (Soames 2003): •

•

Active range of flexion to extension: 140° with the hip flexed and 120° witl1 the hip extended. PaSSively the range may increase to 160°, allowing the heel to touch the buttock. Medial and lateral rotation are influenced by the degree of flexion of the joint. In extension rotation is minimal. In 90° of flexion active medial rotation is 30° and lateral rotation is 45°. Beyond 90° of flexion the range of rotation decreases again.

N erve supply The knee joint is innervated by fibres of the lum bosacral plexus originating from the levels L2-3 (front of the knee) to S3 (back of the knee). The femoral nerve and saphenous nerve, the posterior branch of the obtur ator nerve and tibial and common tibial nerves send branches into the joint (Pa1astanga et a1 1994).

Pathological d isorders Corrigan and Maitland (1983, 1994) described the fol lowing classification of knee lesions contributing to movement disorders of the knee: 1.

Soft tissue injuries (Fig. 15.1): a. Ligamentous injuries: i. Collateral ligaments ii. Anterior cruciate iii. Posterior cruciate

The knee complex

(including peri- and intra-articular structures - range of motion, pain-free movement, stability) at various times during examination and treatment of soft tissues and neurodynamic function and in almost all cases of restoration of muscular control with proprioceptive feedback mechanisms. SU BJECTIVE EXAMI NATIO N

Figure 15.1

Areas of soft tissue lesions of the knee.

b. Musculotendinous lesions: 1. Quadriceps, tendon, expansion, muscle ii. Gastrocnemius tendinitis iii. Bicipital tendinitis iv. Popliteal tendinitis v. Iliotibial tract c. Bursitis: i. Prepa tellar ii. Infrapatellar iii. Anserine iv. Semimembranosus v. Bicipital 2. Lesions of the tibiofemoral joint: a. Menisci (tears, cysts, discoid meniscus) b. Chondral injuries c. Osteochondral lesion, osteochondral fractures, osteochondritis dissecans d. Osteonecrosis e. Loose bodies f. Osteoarthritis 3. Patellofemoral joint: a. Chondromalacia patellae b. Osteochondral injuries c. Instability d. Osteoarthritis e. Lesions of the infrapatellar mechanism Some aspects on the contributing factors to osteoarthritis and its treatment have been described in Chapter 14. In minor symptoms compression may be added to the examination and integrated in the progression of treatment. In the rehabilitation of movement disorders it is essential to consider the normalization of joint function

Subjective examination, as in all other areas of move ment dysfunctions as described in this book, is essen tial to determine the possible sources of symptoms, contributing factors, precautions and contraindica tions to examination and treatment procedures and the overall level of disability, leading to treatment object ives in activity and participation levels as described in the International Classification of Functioning, Disabilities and Health (ICF) (WHO 2001). The main movement components to be analysed during the subjective and the physical examination are: •

•

•

•

tibiofemoral joint, including peri- and intra articular structures patellofemoral joint, including peri- and intra articular structures soft tissues (if not to be localized as periarticular structures of the above-mentioned joints) and musculotendinous structures superior tibiofibular joint (often needs to be examined in foot and ankle disorders as well).

However, if symptoms appear vague and difficult to localize or the symptoms have not developed based on a clear incident, other contributing components (e.g. hip joint, lumbar spine, neurodynamic system) to the movement disorder also have to be taken into consider ation. This may also be the case in those circumstances where an injury has led to the symptoms but recupera tion of function seems to take longer than would be expected. Important points in the subjective examination include (Corrigan & Maitland 1994): • •

•

• • • •

•

whether the onset of pain is gradual or sudden the relationship of pain to any trauma and the mechanism of such trauma the presence of any swelling and how rapidly or gradually it developed a feeling of instability or 'giving way' during use any locking of the knee clicking or catching, especially if it reproduces pain whether the knee problem is stable, progressive, recurrent or intermittent, or brought on by certain activities the presence of any stiffness

489

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MAITLAND'S PE RIPHE RAL MANIPULATION

• •

whether other joints are involved the effects of any previous treatments.

M a i n problem ('Question 1') Next to pain, the patient may describe various other complaints as the main problem (Corrigan & Maitland 1994).

Locking A careful evaluation of this symptom is essential. Locking may result from a torn meniscus, a loose bony fragment (e.g. from osteochondritis dissecans), a torn cruciate ligament or avulsed anterior tibial spine, chon dromalacia patellae, a dislocated patella or a medial plica. Locking is not an appropriate term as it implies that no movement at all should be possible. Locking usually means a sudden complete block to full exten sion of the knee which is nevertheless able to flex fully. The knee usually lacks 30° of extension and the screw home mechanism is lost. The end-feel extension in a locked knee provides a characteristic rubbery sensation with an associated motor response (spasm).

extremely painful, warm, tender and held in some degree of flexion. The most common cause of a haemar throsis is a ruptured anterior cruciate ligament. Less common causes are tears in the capsular ligament or an osteochondral fracture. Non-traumatic causes are rare and include blood dyscrasias, anticoagulant ther apy, pigmented villonodular synovitis or neoplasms. Haemarthrosis may need to be differentiated from crystal deposition diseases, inflammatory arthritis and septic arthritis. Diagnosis is then made after aspirating the knee of synovial fluid.

Areas of symptoms (body chart) The localization of symptoms may be indicative of the movement component causing the symptoms. •

•

Catching Catching is a sensation which indicates that something is getting in the way of joint movement and it may be painfuL Its mechanism of production is similar to locking.

•

Instability - 'giving way' Stability is provided by the ligamentous structures (passive stability) and the surrounding muscles (dynamic stability). A feeling of instability, giving way or 'buckling' of the knee on use is a common symptom. It may be produced in chondromalacia patellae, a torn meniscus, a loose bone foreign body or arthritis. A feel ing of instability may also arise after cruciate ligament tear with true rotatory instability. The knee usually gives way suddenly without any warning or pain, but often with a feeling that one bone has moved or slipped on the other. This tends to occur on walking down stairs or on uneven ground when the leg supports the body weight. It is particularly common when a runner changes direction or steps off the involved leg.

Swelling Swelling indicates the presence of some intra-articular damage. Haemarthrosis comes on more rapidly after injury than synovitis so that its onset is measured in minutes rather than in hours. The knee is usually

Disorders from the tibiofemoral joint usually pro duce pain within the knee itself. The patient may grasp around the knee and indicate that 'it' is deep within. The pain may be associated with stiffness, especially after sitting for a time. Disorders of the patellofemoral joint usually pro duce pain in the retropatellar area or the anterior side of the knee, more superficially indicated than disorders from the tibiofemoral joint. Occasionally some symptoms may be felt deep in the knee fold on the posterior side. Soft tissue lesions (e.g. of ligamentous structures or tendons and their insertions) are often felt locally and the patient may be able to pinpoint the painful spot by touching it.

Pain may also be felt in the knee area as a result of dys functions in more proximal structures. Frequently this type of pain is more vague, dull and more difficult to localize. In particular, the hip joint may refer to ventro medial areas of the knee, while the lumbar spine may radiate to the dorsal side. In certain circumstances dys functions of neurodynamic structures may contribute to the symptoms.

Behaviour of symptoms - activity lim itations While hypotheses with regard to the sources of the symptoms may already have been generated during the first phase of the subjective examination, the behaviour of the symptoms and the concomitant activ ity limitations may serve to modulate or confirm some of these hypotheses (principle: 'make features fit'). •

Symptoms arising from the tibiofemoral joint are often worse when the patient first stands up to walk or after walking for some distance, are often worse

The knee complex

with weight-bearing on the affected leg and are worse on going up or down stairs. Pain may also be associated with stiffness, particularly after sitting for a time. •

•

Disorders of the patellofemoral joint are usually made worse by activities such as walking, running, riding a bicycle, going up stairs or walking down hill for some time. The symptoms may also occur after a prolonged period of sitting, for example in a car or at the theatre. Local ligamentous lesions may be provoked with activities which involve stretching the ligament concerned. Furthermore, tendinous lesions may be provoked with activities involving contraction of the muscle or stretching or compression the tendon.

History If the symptoms are of traumatic onset, information on the injuring movement is essential. In acute cases it may give an indication of the structures involved. If total ligamentous ruptures, torn menisci or fractures are suspected, the physiotherapist may need to consult a medical practitioner before continuation of treat ment. If symptoms are more minor, or the disorder has recuperated to a degree, and it no longer limits most daily life activities, the injuring movement may become an essential element of physical examination and may be used in treatment with passive mobilization (Maitland 1991). If symptoms are of spontaneous onset, it is necessary to investigate if any overuse or misuse of the structures or reduced capability to bear stress (e.g. due to muscular imbalances or lack of aerobic condition) has contributed to the development of the nociceptive processes (see Chapters 6 and 10). In cases of pain in the inferior patellar area the activ ities leading to the symptoms may give an indication of the possible structures involved: •

•

eccentric loading (e.g. jumping in ball sports or increased hill work during running) mainly provokes the patellar tendon

disease such as varicosis, deep venous thrombosis or polyneuropathy. PHYSICAL EXAMINATION

Depending on the plan after the subjective examination, the physiotherapist may decide to focus the examina tion on one of the main components of the joint, be they tibiofemoral, patellofemoral or superior tibiofibu lar movements. First, active movements will provide the therapist and patient with parameters for reassess ment procedures. The components may be examined passively, with subsequent reassessment of the active parameters to confirm the possible involvement of one or more components in the movement disorder. If soft tissue lesions are suspected, it is often recom mended that the joint components be examined first, as they frequently constitute a part of the periarticular structures which may be influenced by mobilizations with accessory and physiological movements. In many cases screening of movement functions of hip, lumbar spine and neurodynamic structures is necessary. Box 15.1 provides an overview of examination pro cedures of the knee complex and its related structures. Detailed information on some test procedures is given below.

Observation Some details on the essentials of observation in weight bearing joints have been described in Chapter 14. The following aspects may be of particular relevance in the examination of the knee complex. •

•

Next to the routine information regarding the patient's health, weight loss, radiographic findings, medication intake and so on, screening questions may be posed with regard to vascular and neurogenic

Alignment of the knee joint, including valgus/varus positions, hyperextension of the knee (distinguish from bowing of the tibia) and position of the tibia in relation to the femur and different positions of the knee.

symptoms developed after tumble turning or vigor ous kicking in a swimming pool may indicate the presence of an irritated fat pad (McConnell 1996).

Special questions

In some cases, especially if inflammatory processes are suspected, it may be important to commence the observation with a quick palpation of temperature and swelling. If found positive, as a precautionary meas ure the tests should be repeated regularly during the steps of physical examination to ensure that the temperature and swelling do not increase due to the testing procedures (see 'Palpation' below).

•

Alignment of the patella in different positions of

•

Foot positions (pronation, rigid high longitudinal arc).

•

Pelvic position (especially rotated posteriorly -

the knee.

leading to relative medial rotation of the hip and

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MAITLAND'S PE RIPHERAL MANIPULATION

Observation First pa lpation of tem perature, swel l ing or effusion • Present pain •

*Fu nctional demonstration / tests, i ncl ud i ng d ifferentiation of movement components Brief appraisal Active movements Gait ana lysis: forwards, backwards, on heels (esp. backwards), on toes; may assess: sprint, running • Squat: on toes, on heels, bouncing Height of step • • Quadrupedal positio n : sit towards heels • Getting up or down a step (forwards, backwards, sideways) • Hopping, jumping • Extension of knee in standing • I n supi ne, lying, including overpressure: - F, E, i n 90° F, MR and LR - 'If necessary' tests: FlAb, F/Ad, incl. combinations in rotation ; F + Ab, F + Ad E l M E /Ab (= E with t on tibia) I n different positions of F or E: MR, LR Ab/Ad (in E and 20° F) 'Inj u ring movement' •

Muscle tests Isometric tests: symptom reproduction. Quadriceps, biceps femoris, semitendi nosus, semimembranous, add uctors • Recruitment patterns: VMO, VL in d ifferent positions of F in standing • Muscle length tests (mostly at end of passive testing after neurodyna mic testing)

Pal pation Temperature, swel ling, effusion • Tenderness •

Passive movem ents Neurodynamic test procedures • Movement diagra m of relevant active tests: F, E, in 90° F, MR or LR • Meniscus tests, ligamentous tests (stability testi ng) • Tibiofemoral joint: - Physiological movements: F combinations; E/Ab, E/Ad as treatment technique - Accessory movements: Ab, Ad (in E and 20° F), ; , t, -++ , +-,"""" caud and ceph, C,:J - Test procedures under compression • Patellofemoral joint: - Accessory movements: ...... caud and ceph, -++, +-, >-+-<, distraction, C, :J longitudinal and sagittal - I n different positions - Test procedures under com pression • Su perior tibiofibular joint: - Accessory movements: ; , t, ...... caud and ceph,

•

C,:J,>-+-<

- In different positions, incl. SLR and inversion of foot (common peroneal nerve) - Test procedures under compression

•

Screening of other structures in 'plan' H ip, lumba r spine, sacroi liac joi nt, neurodynamic structures

•

underactivity of the stabilizing hip abductors and vastus medialis oblique). •

Any indication of muscular wasting (e.g. contours of vastus medialis, hip abductors) and shortened ili otibial band.

•

Present pain: before performing any tests to repro duce symptoms, it is necessary to determine if the patient has any pain at rest.

Check case records etc. Highlight main findings with asterisks

I nstructions to patient at end of session Warning: possible exacerbations • I nstructions: observe and compare symptoms and activities • Other recommendations: self-management strategies etc. •

Functional demonstration tests The patient is asked to demonstrate a functional activity which provokes the pain as described in the subjective examination. This activity may serve as a functional reassessment parameter ('physical asterisk'). Differentiation procedures may also be performed, which add or subtract stress to the movement compon ents involved in the activity. For example, the patient

The knee complex

may demonstrate symptoms at the medial side of the knee during the demonstration of a tennis movement (forehand). The patellofemoral joint may be examined, when medial or lateral gliding movements, including compression, are added to the activity. The tibiofemoral joint may be additionally stressed by increasing, for example, the medial rotation of the femur over the tibia, and the hip joint may be put under more stress (while at the same time the therapist controls the knee joint to control its position) by rotatory movements of the pelvis over the femur. Changes in symptoms during the manoeuvres· indicate the movement component(s) responsible for the symptoms. After the differentiation tests a brief appraisal or reflection is necessary in which the physiotherapist determines if the test procedures may be continued as planned, or if an adaptation of the examination sequences seems necessary.

Active movements Gait analysis Some aspects on gait analysis have been described in Chapter 14. In the examination of movement disorders of the knee, particular attention should be given to walking forwards, backwards, walking on heels (espe cially backwards) and walking on toes. Getting up and down a small step with the affected leg should also be assessed. If this is symptom free, testing may progress to: •

•

•

Squat

on toes, heels; bouncing - if symptom free may progress to bouncing sideways with the pelvis laterally and medially from the affected knee. -

Sitting on heels - moving from the quadrupedal position, gradually move the buttock towards the heels. If range is normal, the patient should be able to sit at least on the heels or past them.

Figure 1 5.2 Extension overp ressure app lied: (a) to th e tib ia; (b) to th e femur; (c) over the joint l ine.

Hopping, jumping on both legs, on affected leg. Extension (supine)

Active knee extension in standing The patient should place both feet next to each other and lightly bounce into extension. Some symptoms may be reproduced, but mostly the therapist gains an impression of the range of motion and the recruitment of the quadriceps muscle groups.

Supine, active tests of the knee, including overpressure The standard tests include extension, flexion and, in 90° of flexion, medial and lateral rotation.

•

•

•

The patient actively extends the knee. Observe range, quality (including muscle recruitment patterns) and symptom reaction. Overpressure should be applied in three different ways: 1. towards the proximal aspect of the tibia (Fig. lS.2a) 2. over the distal aspect of the femur (Fig. lS.2b) 3. over the joint line (Fig. lS.2c). The end-feel may be appreciated in a different way, i.e. with the knee fully extended and relaxed. Passively flex the knee approximately 20° and then allow it to drop back into full extension. A normal

493

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MAITLAND'S PE RIPHE RAL MANIPULATIO N

physiological movements are performed, either pas sively or assisted actively, as follows: •

•

•

•

•

Produce medial and/or lateral rotation in different positions of flexion and extension. (Passive) Abduction, adduction (see 'Description of techniques' below). Extension/adduction, extension/abduction (including anteroposterior movement on tibia) (Fig. 15.5). Flexion/abduction, flexion/adduction, including combinations in rotation (see 'Passive test procedures' below) (see Fig. 15.10). Test movements may be produced under compression (see 'Passive test procedures' below).

M uscle tests Isometric tests Isometric tests are carried out if muscle or tendon lesions are suspected. The tests frequently need to be combined with palpation of the tender spot(s) to con firm the structure at fault. The following structures may frequently cause symptoms and require soft tis sue treatment: • •

Figure 1 5.3

Flexion overp ressure.

knee can fall into full extension with a typical pain less hard end-feel. In patients with osteoarthritis a similar end-feel may be found, but the joint lacks full extension. A meniscus lesion may produce a softer end-feel and the leg may bounce slightly more once dropped from flexion to extension. Flexion (Fig. 15.3) •

•

The patient is asked to pull the knee towards the buttock. Observe range, quality and symptom response. Mobility may be measured with a goniometer, but as an alternative the distance between the heel and the ischial tubercle may be measured in centimetres.

In 90° of flexi o n : medial rotation , lateral rotation •

The test may be performed in supine (Fig. 15.4), as well as in sitting.

'Ifnecessary' tests These need to be performed if the 'standard' tests insuf ficiently produce symptoms. Usually combinations of

•

biceps femoris with the insertion at the fibular head quadriceps, with the patellar ligament adductors as part of the pes anserinus.

Note: If soft tissue lesions occur in conjunction with joint dysfunctions, it is recommended that joint signs are treated first, with the isometric pain-provoking tests used as one of the parameters in reassessment procedures.

Recruitment patterns, patellar alignment and symptom reproduction The recruitment of vastus medialis oblique (VMO) in weight-bearing positions merits particular attention in movement disorders of both the tibiofemoral and the patellofemoral joints. In different positions of high sit ting (e.g. 0°, 20-30°, 60°, 90°) the following factors may be observed (Hilyard 1990): • •

•

Symptom reproduction. Patellar movement: Does correction of the patella (manually or with tape) reduce the symptoms? Quadriceps activity within the overall muscle chain: Is the patient capable of maintaining the position without pronatory movements of the foot or internal rotary movements of the femur/ backward rotation of the pelvis? Especially in c. 20° and 0° it should be observed if the VMO reacts quicker than the vastus

The knee complex

Figure 15.4

Active rotation, including overpressu re : (a) med i a l ; (b) latera l.

Figure 1 5.5

If necessary tests: (a) extension/add uctio n ; (b) extension/abductio n.

495

496

MAITLAND'S PE RIPHERAL MANIPULATION

include: flexion/adduction, including combina tions and subsequent reassessment. •

Lumbar spine: extension, rotations, quadrant (if pos sible). PAIVMs, including subsequent reassessment.

•

•

Figu re 1 5.6 Examination of recruitment patterns of vastus medialis oblique.

lateralis (McConnell 1996, Witvrouw et al 1996). Furthermore, in 20° of flexion the patella should be aligned in a mid position between the two femoral condyles and be positioned parallel to the femur in a frontal and sagittal plane (McConnell 1996) (Fig. 15.6).

Compare the temperature of various areas around the knee with the non-affected side.

Temperature

E ffusion •

•

Screening of other structures in 'plan' Screening tests are performed to determine if other movement components contribute to the movement disorder of the knee. It is also necessary to establish whether these components should be included in the treatment. The mentioned test procedures are minimum requirements. If some of the tests are not impairment free, the movement components need to be examined in more detail. •

Place the thumb and index finger of one hand on either side of the patella. The other hand places the web space over the suprapatellar pouch and squeezes fluid distally. A large effusion may be appreciated if the finger and thumb at the side of the patella are separated and a fluctuant feeling is produced. A small effusion may be found with the bulge sign: 1. Fluid is stroked out of the medial gutter next to the patella. 2. The suprapatellar pouch is compressed in the same way as described under (1). 3. Fluid bulges out into the medial gutter as a result of (2). 4. Alternative: step (1), then tl1e lateral gutter of the patella is compressed.

Most swellings are best appreciated by inspection, but palpation is necessary to confirm their presence, for example:

Swe l l i ng

•

•

•

Hip joint: should be performed routinely in most movement disorders of a spontaneous onset. Active movements include: flexion, in 90° of flexion: medial and lateral rotation, extension. Passive tests

Neurodynamic system: SLR and modifications (tibial, common peroneal nerve). PKB and slump in side lying, including modifications (femoral nerve, saphe nous nerve, obturator nerve) (see Butler 2000).

Palpation

Muscle length tests Tests of adductors, hamstrings, rectus femoris, tensor fasciae latae (including iliotibial band), gastrocnemius and soleus may be performed in this stage of examin ation. However, it is often recommended that an impres sion of the mechanosensitivity of the neurodynamic system be obtained first (Edgar et al 1994) and that muscle length tests be performed during the sequence of passive movement testing.

Sacroiliac joint: sacroiliac provocation tests as F/Ad with compression, Patrick test (Faber sign), anterior and posterior tilts, passive accessory movements including subsequent reassessment. (Note: As F/Ad with compression is also an impor tant procedure in the examination of hip movement disorders, frequently it is useful to complete the hip examination with the relevant passive tests prior to the screening procedures of the sacroiliac joints.)

•

A tender swelling of the tibial tubercle may be present in Osgood-Schlatter's disease. Cyst of the menisci, involving the lateral meniscus, with a tender swelling over the joint line. Prepatellar bursitis: soft tissue swelling anterior to the patella. Chronic synovial thickening: along the suprapatellar pouch with a characteristic doughy sensation when rolled under the fingers; over the medial joint

The knee complex

compartment in the gutter at the medial side of the patella, just cephalad of the joint line. Tenderness •

•

•

•

Tenderness may occur at times in combination with local swelling of ligaments, insertions and muscles (see Fig. 15.1). Positive findings serve as a compa rable sign in reassessment procedures and may indi cate the necessity of soft tissue treatment. Tenderness is best palpated in supine with the knee in flexion. Meniscus injuries may produce tenderness over the anterior, middle or posterior third of the joint line. The points of tenderness may displace if the knee is moved towards extension. Ligament sprains frequently are tender over the upper and lower attachments. If tender over the joint line, this may be difficult to distinguish from tenderness stemming from a meniscus lesion. Tenderness or symptom provocation of nerves (e.g. infrapatellar branches of saphenous nerve, tibial nerve, common peroneal nerve at the medial side of the head of the fibula).

•

• • •

Passive test movements of the various knee components As described previously, in some cases the test proced ures may need to be performed under compression. Many of the passive test procedures can also be used as therapeutic techniques and therefore these test procedures frequently need to be followed by a reassess ment of the main physical parameters (,asterisks') identified so far. Tibiofemoral joi nt

Physiological movements may include: •

Passive test procedures Movement diagram The establishment of a movement diagram of the most comparable active movements gives more detailed information on the behaviour and interrelationship of pain, resistance and possible motor responses ('spasm'). Such information may guide the therapist in the deter mination of treatment techniques by passive move ment; additionally the test(s) may be used as physical asterisks in reassessment procedures (see Chapters 7 and 8 and Appendix 1).

Stability and meniscus testing In acute lesions with a traumatic onset, stability and meniscus tests may need to be carried out. However, it is emphasized that many active and passive test proced ures may have already provided indications as to whether lesions in the above-mentioned structures are present. The following structures may need to be examined a description of the test procedures may be found in most orthopaedic standard textbooks as well as in Corrigan and Maitland (1983, 1994): • • •

Anterior cruciate ligament Posterior cruciate ligament Medial collateral ligament, e.g. abduction movements in 30 and 0° of flexion

Lateral collateral ligament, adduction movements in 30 and 0° of flexion' Medial meniscus Lateral meniscus Anteromedial, anterolateral and posterolateral rotatory instability.

•

Extension variations: - extension (Figs 15.2a, 15.5) - extension/adduction (Fig. 15.9b) - extension/abduction (Fig. 15.9a) - extension/adduction, including anteroposterior movement (Figs 15.2b, 15.5a) - extension/abduction, including anteroposterior movement (Figs 15.2c, 15.5b) Flexion variations: - flexion (Fig. 15.3) - flexion/adduction, including rotations (Fig. 15.10b) - flexion/abduction, including rotations (Fig. 15.lOa) - medial rotation, lateral rotation (Figs 15.4, 15.11-15.14) (may also be carried out as accessory movements).

Accessory movements may include: • •

• • •

abduction, adduction posteroanterior movement, anteroposterior movement longitudinal caudad, longitudinal cephalad transverse medially, transverse laterally medial rotation, lateral rotation.

The accessory movements are most frequently applied to the tibia; however, they can be carried out on the femur as well. The patellofemoral joint needs to be examined with accessory movements which may include (Fig. 15.7):

Patel lofemoral joint

•

longitudinal movement caudad and cephalad, including inclinations (Fig. 15.21)

497

498

MAITLAND'S PERIPHERAL MANIPULATION

A

A\ I� '

A __ caud B __ cep h C -..- med

•

V7:- I-

D

•

'+I B

F

t c:::J\

�

Rotation

Gcb �

Distraction

Figure 15.7 Accessory movements of the patel la. •

• • •

transverse movement medially and laterally, including inclinations (Fig. 15.20) distraction (Fig. 15.19) compression (Fig. 15.18) rotation around the sagittal axis (Fig. 15.22) and around the longitudinal axis.

The examination (and treatment) procedures frequently need to be carried out in various positions of flexion or flexion/abduction. Furthermore, it may be necessary to add a certain degree of compression to the movements and in some cases movements may need to be per formed in weight-bearing positions (see Fig. 15.23). Crepitus is best appreciated by palpating the patello femoral joint while flexing and extending the knee. A fine crepitus may be present in chondromalacia of the patella (sensation of fine sand or glass) whereas a coarse crepitus (sensation of 'dry wood') may indicate osteoarthritis. If the crepitus occurs in combination with pain, it is an important comparable sign which has to be assessed during the application of treatment and in reassessment procedures. Clinical tip: if during the application of passive movement the crepitus seems to become less, immediate reassessment of the main test procedures may show beneficial changes. In certain cases of recurrent subluxation of the patella, lateral movement of the patella may provoke pain. The patient may then become acutely aware that the patella is about to dislocate and any further attempts to move the patella are actively resisted by contractions of the quadriceps, i.e. apprehension (see Clinical profile of subluxating patella, Box 15.4). The superior tibiofibular joint is often forgotten when seeking the source of lateral leg and knee pain. Although not a frequent cause of pain, it is sufficiently common to warrant inclusion in routine examination. The joint needs to be examined with accessory movements.

Frequently these procedures with their different positions are easiest to perform in side lying, with the affected leg above and the tibia well supported by the plinth in front of the tmaffected leg.

Examination and treatment of the superior tibiofibular joint may include: • • • •

• •

anteroposterior movement (Fig. 15.24) posteroanterior movement (Fig. 15.25) longitudinal movement caudad (Fig. 15.26) longitudinal movement cephalad (may be carried out with the lever of the foot or directly to the head of the fibula) compression rotary movements (with the lever of the foot).

TREATM ENT

Many painful movement disorders of the knee need to be treated with passive mobilization, be they accessory or physiological movements. However, treatment often needs to be complemented with automobilizations exercises to regain muscular control, restoration of pro prioceptive feedback, normalization of gait patterns or guidance towards the full level of activities (including sport).

T i biofemoral joint When the knee is very painful, worse when walking or with the first few steps following rest, the treatment techniques are directed towards treating pain (group I). Although all accessory movements may be considered, frequently rotary movements may be the. most successful as an initial treatment. •

Superior tibiofibular joint

•

Test (and treatment) procedures may need to be carried out in various foot positions and different positions of knee flexion. Additionally, it may be necessary to add compression to the test and treat ment procedures.

•

•

The knee may be positioned comfortably in a neu tral, pain-free position on an easily moulded pillow. The therapist palpates the joint line with one hand and the other hand grasps around the malleoli and performs the rotation movements of the tibiofemoral joint with the latter hand. For minor symptoms, extension/abduction, extension/adduction, flexion/adduction and flexion/abduction may be used in treatment. If movements are very restricted but provoke only minor symptoms, physiological movements (e.g.

The knee complex

extension or flexion combinations in abduction and adduction) need to be taken into consideration. •

If, for example, flexion is very restricted, both the tibiofemoral joint and the patellofemoral joint need to be treated while holding the leg at the end of the limited range.

Patellofemoral joint The treatment of patellofemoral disorders calls for a high degree of skill and considerable delicacy. When patellofemoral movement is painful, the initial ses sion(s) need to be carried out extremely gently. It is far better to perform movements too gently and for too short a time than to find out at the following session that they had been performed too excessively, even to the smallest degree. •

•

•

Oscillatory distraction may be the first choice for treatment if any other movement of tl1e patella seems to be too vigorous for the current condition of the patient. A slow progression of treatment can take place once it is established how the patient reacts to this gentle treatment. On the other hand, there are times when maximum amplitude movement should be performed in one or more directions, at the same time maintaining a strong compressive force on the patella.

If, for example, it is found that the patient is able to squat fully without pain and all examination tests have revealed only minimal signs, it may be neces sary to move the patella quite forcibly while the tibiofemoral joint is flexed approximately 40° and compression applied by the physiotherapist's hand.

Next to passive mobilizations of the patella, it has been stated that rehabilitation of muscular control should take place as early as possible to allow optimum track ing of the patella in the femoral groove during the first 20-30° of flexion. In particular, the recruitment of the vastus medialis oblique in relation to the vastus lateralis within the overall muscular chain of the foot and pelvis merits special attention. Corrective tape may be applied to the patella if movements would be too painful to start in an early phase (Hilyard 1990, McConnell 1996).

performing stronger techniques with compression and comparing these with the unaffected leg. •

•

•

•

When a comparable sign is found this movement should be used in treatment. Initially it should be performed firmly but not vigorously. Posteroanterior and anteroposterior movements can be performed. In the progression of treatment they may be carried out under firm compression. However, it needs to be emphasized that if symp toms are being produced during the treatment technique, they should occur in the rhythm of the movement and they should settle fairly quickly once the treatment has stopped. When the superior tibiofibular joint is responsible for symptoms, frequently it responds very readily and rapidly to massive mobilizing techniques.

D ESCR I PT I ON O F T EC HN I Q U ES PHYSIOLOGICAL MOVEMENTS O F T H E T l BIO FEMORAL JO INT : EXAMINAT IO N AND TREATM ENT T ECHNIQUES

Extension (Fig. 1 5.8) • • •

Direction: Extension of the tibia on the femur. Symbol: E Patient starting position: Supine, lying in the middle of the couch.

•

Therapist starting position: Standing by the patient's right thigh facing the feet, kneeling on own left shin to support under the lower end of the patient's femur with the left thigh. When the patient's knee is flexed, the therapist's left thigh also moves to the patient's calf.

Superior tibiofibular joint Often it may not be easy to determine whether the superior tibiofibular joint is responsible for a patient's symptoms. Frequently this needs be ascertained by

Figure 1 5.8

Extension of the tibia on the fem u r.

499

500

MAITLAND'S PERIPHERAL MANIPULATION

Localization of forces (position of therapist's hands) •

•

Both hands hold distally around the patient's lower leg from behind. The left elbow is placed by the side of the patient's knee so that the axis of the therapist's left arm coincides with the axis of the knee movement.

Application of forces by therapist (method) •

The lower leg is moved through a range of 25-30° by the therapist lowering and raising the patient's leg through an arc of movement. The therapist's arms are used to achieve this.

Variations in the application of forces •

•

Adduction and abduction can be added to this move ment as required. This will require firm but comfort able control of femoral rotation with the insides of both elbows and distal parts of the upper arms. Alternatively, perform extension as described below in extension/ abduction and extension/adduction.

Uses • •

•

Most useful as a grade ill movement. For through-range pain and stiffness, especially in OA. To help recovery of range after injury, immobilization or disuse.

Extension I abduction, extension I adduction (extension) (Fig. 1 5. 1 9) An example of this concept's approach Some manipulative therapist authors argue the axiom that all examination and treatment passive movements must be performed in the directions (roll spin, slide) in which they occur actively. This is anathema to the con cept propounded in this book: in fact the concept says the opposite, on the basis of the very positive import ance of the 'pain provoked with movement' principle. The 'comparable', 'appropriate' pain response is nearly always found with the non-physiological rather than the physiological movement. •

• •

•

Direction: Extension/abduction, extension/ adduction (and extension) of the tibiofemoral joint. Symbols: E/Ab, E/Ad (E) Patient starting position: Supine, lying in the middle of the couch. Therapist starting position: - for grades III and IV (Fig. 15.9): standing by the patient's right ankle facing the left hip; the

Figure 15.9 Tibiofemoral movements in extension: (a) extension labduction; (b) extension ladduction.

The knee complex

therapist's right knee and lower leg rest on the couch at right angles to the patient's leg; the patient's heel is supported across the therapist's thigh adjacent to the ASIS - for grades IV and IV+ (see Figs 15.2, 15.5): standing by the patient's right knee.

Application offorces by therapist (method) Grades III and IV •

•

Localization of forces (position of therapist's hands) Grades III and IV •

•

• •

• •

•

Grades III and IV •

•

• •

• •

•

-

-

•

•

•

•

E /Ad

The left hand supports the patient's knee laterally around the lateral aspect of the joint. The fingers of the left hand reach the lateral condyle of the tibia posterolaterally. The thenar eminence is anterolateral. The heel of the right hand is placed: (1) over the medial epicondyle of the femur; (2) on the medial condyle of the tibia; (3) over the joint line medially. The fingers of the right hand reach posteriorly. The thenar eminence of the right hand is placed slightly anteriorly. The right forearm is directed at right angles to the shaft of the femur and tibia so that the adduction component can be produced.

Grades IV and IV+ •

E /Ab

The right hand supports the patient's knee medially around the medial aspect of the joint. The fingers reach the medial condyle of the tibia posteromedially. The thenar eminence is anteromedial. The heel of the left hand is placed: (1) over the lateral epicondyle of the femur; (2) on the lateral condyle of the tibia; (3) over the joint line laterally. The fingers of the left hand reach posteriorly. The thenar eminence of the left hand is placed slightly anterior. The left forearm is directed at right angles to the shaft of the femur and tibia so that the abduction component can be produced.

-

Grades III and IV •

Grades IV and IV+ • •

•

-

E/ Ad (Figs 1 5.2, 1 5.5)

With the patient's leg laterally rotated. The right hand holds under the patient's heel from the medial side. The left hand is placed anteromedially: (1) on the femur; (2) on the tibia; (3) on the joint line.

-

E /Ad

-

E /Ab

With the patient's leg medially rotated, support under the patient's heel and contact against the anterolateral aspect of the knee (with left elbow only slightly flexed), the therapist's trunk is rotated to the left and back again to produce the small oscillatory movements in the direction of extension/abduction.

Grades IV and IV+ •

E /Ab

The same application of forces applies to extension/ adduction as for extension/abduction with the exception that the left hand becomes the right hand, the medial movement of the tibia and femur becomes lateral movement, extension/abduction becomes extension/adduction, abduction becomes adduction, and the left shoulder becomes the right shoulder.

Grades IV and IV+ •

E /Ab (Figs 1 5.2, 1 5.5)

With the patient's leg medially rotated. The right hand holds under the patient's heel from the lateral side. The left hand is placed anterolaterally: (1) on the femur; (2) on the tibia; (3) on the joint line.

-

The patient's knee is raised and lowered through a distance of approximately 13-15cm by the therapist's hands. A constant pressure is maintained against the lateral surface of the patient's knee by the heel of the left hand placed in one of three positions as described above. Each of the three positions will produce a different movement of the tibiofemoral joint: 1. when the heel of the left hand is against the femur with a strong abduction force (abduction of the tibial shaft), the femur will tend to move slightly medially on the tibia during extension/ abduction 2. when the heel of the left hand is against the tibia, the tibia will tend to move medially on the femur during the extension/abduction movement 3. when the heel of the left hand is over the joint line the whole movement will simply be extension/abduction. Note that the stronger the abduction pressure required the more the therapist needs to crouch over to bring the left shoulder closer to the patient's knee.

-

E/Ad

With the patient's leg laterally rotated, support under the patient's heel and contact against the anteromedial aspect of the knee (with the left elbow straight), the therapist's trunk is side flexed to the left and back again to produce the small oscillatory movements in the direction of extension/ adduction.

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Variations in the application offorces: extension (E) •

•

•

The above methods can be adjusted so that movement of the tibiofemoral joint is produced into extension only. For grade III, for example, the left hand is placed laterally around the joint and the right hand is placed medially around the joint during the movement of raising and lowering the knee. In this way the movement will be into tibiofemoral extension only. For grade IV, the patient's leg is not rotated for convenience, the right hand supports the heel and the left hand is placed either directly anterior on the femur, anteriorly over the joint line (around the patella) or anteriorly on the tibial tubercle. In this way with the hand on the upper leg, the femur will move anteroposteriorly in relation to the tibia. With the hand over the joint line the tibiofemoral joint movement will be extension only and with the hand on the tibia, the tibia will move anteroposteriorly in relation to the femur during extension.

Uses •

•

• •

As special examination tests when knee symptoms are minimal and there is a full painless range of flexion and extension. As ftmctional corners to be examined and treated to ensure the joint regains its ideal movement capacity after injury or disuse. As excluding or screening tests for the knee. To confirm ligamentous injury or internal mechanical derangement.

Flexion / abduction. flexion / add uction (Fig. 1 5. 1 0) •

• •

•

Direction: Abduction or adduction of the tibia on the femur at the limit of full flexion of the knee. Symbols: FI Ab, FI Ad Patient starting position: Supine, lying at the edge of the couch with the hip flexed to 90° or beyond, and the knee fully flexed (see Fig. 15.3). Therapist starting position: Standing beside the patient's right knee facing the patient's head.

Localization of forces (position of therapist 's hands) • •

The left hand supports the patient's thigh. The right hand grasps anteriorly around the patient's ankle.

Figure 1 5. 10 Tibiofemoral movements in flexion : (a) flexion labduction ; (b) flexion ladduction.

The knee complex

for FlAb •

•

•

The fingers of the right hand push laterally against the medial surface of the patient's calcaneum posteriorly. The right thumb is hooked around the patient's lateral malleolus.

•

Counterpressure needs to be applied to the thigh so that rotation of the hip is prevented (either over the soft tissues of the thigh or by blocking the greater trochanter with the physiotherapist's leg). The therapist needs to keep close to the patient's lower leg to enable control of the pressure through the patient's ankle.

for F/Ad •

•

The fingers of the right hand hook around the patient's medial malleolus. The thumb and metacarpophalangeal joint of the index finger of the right hand apply pressure in a posterior d.irection on the anterior surface of the tibia.

Application of forces by therapist (method) •

•

Small or large amplitude oscillatory movements can be performed as diagonal movements into F / Ab and F / Ad while strongly maintaining medial rotation of the tibia (Jar F/Ab) or lateral rotation of the tibia (Jar F /Ad). The patient's heel should then move lateral to the ischial tuberosity (Jar F /Ab) and medial to the ischial tuberosity (Jar F /Ad).

Figure 1 5. 1 1

Tibiofemoral rotation prone: (a) media l ; (b) lateral.

Uses •

•

• •

Examination technique as an 'if necessary' procedure. To restore the range of movement into F / Ab and F / Ad in cases of minor intermittent knee symptoms. To help to thoroughly screen the knee. To remobilize the knee after injury, immobilization or disuse.

Medial rotation, latera l rotation (Fig. 1 5. 1 1 , see a lso Figs 1 5.4, 1 5. 1 2- 1 5. 1 4) •

•

Direction: Medial and lateral rotation of the tibia in relation to the femoral condyles. Symbols: :J , c:

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MAITLAND'S PE RIPHE RAL MANIPULATION

•

Patient starting position: - inflexion supine: supine, hip and knee flexed to

90°, foot in the air (Fig. 15.4)

Varia tions in the application of forces •

- inflexion prone: prone with the knee flexed to 90° (Fig. 15.11). •

Therapist starting position: - in flexion supine: standing by the patient's right hip facing the patient's foot (Fig. 15.4)

- in flexion prone: standing by the patient's right

•

•

thigh facing the patient's foot (Fig. 15.11).

Localiza tion offorces (position of therapis t's hands) In flexion supine • •

•

The left arm and side hold the patient's knee. The left hand, pronated, holds the patient's forefoot from the lateral side. The right hand holds the patient's heel posteriorly and medially.

In flexion prone •

•

•

•

• •

The heel of the right hand holds the medial surface of the patient's heel. The fingers spread over the sole of the heel with the tips of the fingers reaching the lateral surface. The left hand grasps the dorsum of the patient's forefoot. The heel of the left hand holds against the foot's lateral border. The thumb is placed over the sole of the foot. The forearms are directed opposite each other.

Application offorces by therapis t (method)

•

Uses •

• •

•

In flexion supine •

•

•

•

The rotation (medial or lateral) is produced by a pulling action of both hands while the therapist's body stabilizes the patient's knee. Large amplitude movements involving 30° of movement can be performed easily. Small amplitude grade IV stretching movements can also be performed easily in this position. Foot and ankle movement will also occur during the knee rotation.

In flexion prone •

•

•

Small and large amplitude movements can be produced by a pulling and pushing action of both hands in opposite directions. It is essential to prevent the forefoot from inverting (jor medial rotation) and everting (jor lateral rotation) when pressure is applied to its lateral surface by the left hand (MR) or its medial surface by the left hand (LR). Movement takes place at the foot and ankle as well as the knee. This does not make the technique any less effective in producing knee rotation.

If the foot and ankle are very painful, the knee rotation may need to be produced by grasping the malleoli. The techniques of AP and PA in slight flexion can be adapted so that grades I and II medial and lateral rotation are produced (Figs 15.13, 15.14). For grades I and II medial rotation of the tibia in this position, an AP pressure through the therapist's thumbs can be applied to the medial tibial condyle near the joint at the same time as a PA pressure is applied by the therapist's fingertips against the lateral condyle of the tibia posteriorly and near the joint line. Lateral rotation will be produced if the thumbs apply pressure to the lateral tibial condyle anteriorly at the same time as the fingertips apply pressure to the medial tibial condyle posteriorly. Grades I and II: supine, knee over a soft pillow. One of the therapist's hands palpates the joint line, the other hand grasps around the distal part of the tibia around the malleoli. Rotation is applied by gently rotating the malleoli and fixating the knee and femur.

•

• • •

Most useful as a grade IV stretching movement in flexion. Very painful joints (variation, grades I and II). Medial rotation is usually more valuable in treatment than lateral rotation. Tibial medial rotation corresponds to anterior cruciate restraint; tibial lateral rotation corresponds to medial ligament and posterior cruciate restraint. Where functional demonstration indicates knee rotation is stiff or painful. As part of postmeniscectomy rehabilitation. As part of posttibial plateau fracture rehabilitation. Encourage restoration of proprioceptive function.

ACCESSORY MOVEMENTS OF THE TIBIOFEMORAL JOINT : EXAMINATION A N D TREATMENT T ECH N I QU ES

Abduction and adduction (see Fig. 1 5.9) •

• •

Direction: Abduction and adduction of the tibia in relation to the femur, best achieved with the knee held approximately 10° short of full extension. Symbol: Ab, Ad Patient starting position, therapist starting position, localization of forces: - the position adopted is identical to that described for extension/ abduction

The knee complex

- the therapist maintains 10-20° of flexion by finger support under the patient's knee.

Application of forces by therapist (method) •

•

Abduction movement is produced by the pressure of the therapist's left hand against the lateral surface of the patient's knee. Adduction is produced by pressure against the medial side of the patient's knee from the therapist's right hand.

Uses •

•

Examination of end-feel on adduction and abduction: in extension only minimal range of movement should take place with a characteristic end-feel to the movement. If a collateral ligament is ruptured, the range of movement may be excessive and this end-feel becomes 'mushy' (Corrigan & Maitland 1994). To recover lost range of abduction and adduction in 10° of flexion.

Longitud inal movement caudad and cephalad (Fig. 1 5. 1 2) •

• •

•

Direction: Movement of the tibial plateau in a longitudinal caudad direction in relation to the femoral condyles and femoral joint surfaces. Symbol: +-++ Patient starting position: Supine, lying near the right hand edge of the couch with the knee supported in a few degrees of flexion with a soft pillow. Therapist starting position: Standing by the patient's right foot facing the knee (Fig. lS.12a)

Figure 15. 1 2 Tibiofemoral longitudinal movements: (a) caudad; (b) caudad - alternative.

Localization of forces (position of therapist's hands) •

•

•

Both hands grasp around the tibia as close to the joint line as is possible. The thumbs overlap to reach the opposite side of the tibial tubercle. The fingers reach around the medial and lateral borders of the tibia to the posterior surface.

Application of forces by therapist (method) •

Small or large amplitude oscillatory movements are produced by pulling lightly or strongly on the tibia near to the joint line and in line with the shaft of the femur.

Variations in the application of forces •

Therapist stands by patient's right knee facing the foot; both hands grasp around the malleoli and the

therapist's forearms support the tibia. Oscillatory movements are produced by the therapist's arms and upper body (Fig. lS.12b). Longitudinal movement cephalad •

•

•

Occasionally compression of the joint surfaces becomes important when combined with other accessory or phYSiolOgical movements in the treatment of joint surface pain (Chapter 8). This compression can be produced as described above with the exception that the tibia is moved towards the femoral condyles in line with the shaft of the femur. While the joint surfaces are held together (which may serve the purpose of reproducing the ache emanating from the joint surfaces) other movements may be carried out such as AP, PA or flexion/extension with abduction/ adduction or rotation.

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MAITLAND'S PE RIPHERAL MANIPULATION

Uses • • •

•

Very painful joints (caudad). Minor aching with joint surface loading (cephalad). In conjunction with other accessory or physiological movements. Stretching stiff collateral ligaments or reducing the loading on very painful joint surface disorders

(caudad). •

Adding to (for example) extension/abduction to reproduce momentary pain - clinical group 4

(cephalad).

Posteroanterior movement (Fig. 1 5. 1 3) •

Direction: Movement of the tibial plateau in relation to the femoral condyles in a posterior to anterior direction.

• •

Symbol: i Patient starting position: - for grades I and II: supine, lying with the knee

carefully supported in a few degrees of flexion by a soft pillow (Fig. 15.13a) - for grades III and IV: prone, lying with the knee flexed to approximately 70° or at the available limit (Fig. l S.13b,c). •

Therapist starting position: for grades I and II: standing by the patient's side facing the patient's head (Fig. 15.13a)

- for grades III and IV: standing by the side of the patient beyond the flexed knee and facing the patient's head; the left tibia rests on the couch, the therapist's knee is fully flexed so that the upper thigh supports across the patient's distal shin (Fig. 15.13b, c).

Localization of forces (position of therapist's hands) For grades I and II • •

• •

The hands grasp the patient's knee from both sides. The thumbs and heels of both hands are placed around the joint medially and laterally. The thumbs extend anteriorly over the joint line. The fingertips of both hands are placed along the posterior surface of the tibia adjacent to the joint line.

For grades III and IV •

•

As much of the thumb pads as possible are placed on the posterior surface of the medial and lateral condyles of the tibia with the fingers spread across the tibia laterally, medially and anteriorly. The left hand supports the patient's right shin, the heel of the right hand is placed on the posterior surface of the tibia as far proximally as possible, the fingers of the right hand lie over gastrocnemius.

Figure 1 5. 1 3 Tibiofemoral posteroanterior movement.

The knee complex

Application of forces by therapist (method) For grades I and II •

The gentle oscillatory posteroanterior movement is produced by the therapist's pressure transmitted through the fingertips against the posterior surface of the tibia proximally.

For grades III and IV •

•

•

The stretching oscillatory movements are produced by the therapist's arms and body acting through the thumbs (the thumb flexors should never be used as this may produce discomfort and the therapist will be unable to appreciate the extent and feel of the movement) or the heel of the hand. If the heel of the hand is to be used to produce the movement, the pressure against the tibia should originate from the therapist's arm and trunk. Three distinct movements can be produced in this case: 1. As the tibia is moved forwards the therapist can, with the right hand, carry the distal end of the tibia an equal distance so that the whole lower leg moves through a parallel line. 2. As the pressure is exerted posteroanteriorly through the therapist's left hand, the therapist can slightly lift the patient's distal tibia so that, combined with the PA movement, there will be a degree of knee flexion taking place. 3. As the PA movement of the tibia is taking place, the therapist's right hand can lower the distal end of the tibia so that there is a degree of tibiofemoral extension as the PA movement is taking place.

Uses

Figure 1 5.14 Tibiofemoral anteroposterior movement: (a) grade I; (b) grade II. posterior direction. The greatest range will be achieved in 10-70° of knee flexion.

Grades I and II • • • •

Painful joint movements. Clinical groups 1 and 3a. Acute injury/flare-up of OA. Commencement of mobilization after surgery or immobiliza tion.

• •

pillow carefully placed under the patient's knee supporting the femur more than the tibia and in not more than 10° of knee flexion - for grades III and IV: supine, lying with the foot resting on the couch so that the knee is flexed to approximately 70° or to its available limit.

Grades III and IV •

• •

To restore range in a stiff joint at the limit of flexion or other movements. Clinical groups 2 and 3b. Postinjury/ immobilization stiffness.

Anteroposterior movement (Fig. 1 5. 1 4) •

Direction: Movement of the tibial plateau in relation to the femoral condyles in an anterior to

Symbol: t Patient starting position: - for grades I and II: supine, lying with a soft

•

Therapist starting position: - for grades I and II: standing by the patient's right lower leg facing the patient's knee

- for grades III and IV: standing by the patient's right ankle, right lower leg resting across the patient's foot to stabilize the position.

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MAITLAND'S PE RIPHE RAL MANIPULATION

Localization of forces (position of therapist's hands) For grades I and II •

•

•

The pads of the thumbs are placed against the anterior surface of the tibia either side of the tibial tuberosity. The fingers rest against the adjacent surfaces of the tibia and fibula. The metacarpophalangeal joints of the thumbs are positioned almost vertically above the pads of the thumbs so that the pressure is directed through these joints.

For grades III and IV •

•

•

The heel of the right hand is positioned over the anterior surface of the tibia immediately adjacent to the joint line. The fingers spread over the front of the patient's knee. The left hand is placed behind the patient's knee and the palm over the upper calf posteriorly.

Lateral movement and medial movement (Fig. 1 5. 1 5) •

• •

•

Direction: Movement laterally or medially of the tibial plateau in relation to the femoral condyles, in any position of flexion or extension of the knee (900 of flexion in this case). Symbols: -++ , -Patient starting position: Supine, hip and knee flexed accordingly and the foot resting on the couch. Therapist starting position: Standing level with the patient's foot facing the patient's head.

Localization of forces (position of therapist's hands) Lateral movement (Fig. 15.15a) •

•

The heel of the right hand is placed on the medial condyle of the tibia. The heel of the left hand is placed on the lateral epicondylar area of the femur.

Applica tion of forces by therapis t (me thod) For grades I and II •

•

Small or large but gentle oscillatory movements are produced by the therapist's arms acting through the thumbs. These finely controlled movements should never be performed by the flexor muscles of the thumb.

For grades III and IV •

•

The AP movement of large or small amplitude is produced by pressure against the upper end of the tibia. The patient's hand posteriorly acts as a support and produces the return movement when a large amplitude is required.

Uses Grades I and II • • • • •

Extremely painful knees. Clinical groups 1 and 3a. Acute injury. Acute flare-up of OA. Commencement of mobilization after arthroplasty or other surgical interventions.

Grades III and IV •

• •

To restore range in a stiff joint at the limit of flexion (can be performed in other positions such as extension, rotation, abduction, adduction). Clinical groups 2 and 3b. Postinjury/immobilization stiffness.

Figure 1 5.15 Tibiofemora l movements: (a) latera l ; (b) medial.

The knee complex

•

•

The therapist leans forward and extends both wrists so that both forearms are directed parallel to each other. The right forearm is positioned in a slightly lower plane to the left hand.

Medial movement (Fig. 1 5. 1 5b) •

•

The heel of the right hand is placed on the medial epicondylar area of the femur. The heel of the left hand is placed on the lateral condyle of the tibia.

•

The left forearm will be positioned in a slightly lower plane than the right.

Application of forces by therapist (method) •

•

•

The technique is merely one of pushing the arms towards each other. For lateral movement it is essential to apply the pressure along the line of each forearm in the correct plane such that, if the patient's knee was not there, the therapist's right arm would pass parallel to but below the left arm. For medial movement the left arm would pass parallel to but below the right arm.

Uses •

•

•

•

Pain and stiffness of the knee in the lateral and medial directions. To complement the recovery of Ab or Ad or E/Ab, E/Ad, F/Ab, F/Ad. After knee debridement to help to regain natural shearing forces across the joint surfaces. To complement recovery after collateral ligament injury.

Tibiofemoral treatment tech niques under compression Figures 15.16 and 15.17 are examples of how treatment techniques may be adapted under compression.

Figure 15.16 Example of treatment under compression : flexion or accessory movement in flexion position. ACCESSORY MOVEMENTS OF T H E PATELLO FEMORAL JOINT : EXAM INATION AND TREATM ENT T ECHNIQU ES

Compression (Fig. 1 5. 1 8) •

• •

•

Direction: Compression of the posterior surface of the patella against the intercondylar articular surfaces of the femur. Symbol: >----< Patient starting position: Supine, lying with a pillow under the knee and the knee in a few degrees of flexion. Therapist starting position: Standing by the patient's right knee facing the patient's head.

Localization of forces (position of therapist 's hands) •

Figure 15.17 Example of treatment in weight-bearing position: flexion or PAl AP movements.

•

The left hand is placed under the posterior surface of the patient's femur distally. The heel of the right hand is placed over the patella.

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MAITLAND'S PE RIPHERAL MANIPULATION

Figure 1 5. 1 8

•

•

Patellofemoral compression.

The centre of the patella fits between the therapist's thenar and hyperthenar eminences. The right forearm should be directed vertically through the patient's knee.

Application offorces by therapist (method) •

•

•

•

The technique is produced by a gentle squeezing of the patella against the femur. Pressure should be applied gently and slowly against the patella. The patient should report any discomfort or pain as the pressure is applied. If no discomfort is felt, maximum pressure can be applied against the patella and a strong small amplitude grade IV+ movement produced.

Figure 1 5.19 Patel lofemoral movements: (a) distractio n ; ( b ) distraction - a lternative.

Uses •

Variations in the application of forces •

•

•

When this technique is painless or only minimally painful a technique can be used where the patella is hit sharply by the heel of the therapist's hand so as to knock the patella sharply against the femur. The first session should be very short (not exceeding 20 seconds) and an assessment made on the following day to guide whether stronger techniques can be used or whether, because an exacerbation has been caused, gentler techniques are included. Can be useful as a means of identifying patellofemoral pain by adding compression of the patella to functional activities such as squatting. This can also then serve as a progression of treatment.

•

•

•

Minimal pain emanating from the patellofemoral articulation during loaded activities such as squatting, descending stairs or sitting to standing. To reproduce pain originating from the patellofemoral joint surfaces. In combination with other patellar movement such as longitudinal movements. Patellofemoral OA.

Distraction (Fig. 1 5. 1 9) •

• •

•

Direction: Movement of the patella away from the femoral articular surfaces. SymboL: Distr. Patient starting position: Supine, knee in extension (or pain-free position). Therapist starting position: Standing level with the patient's knee, faCing across the patient's body.

The knee complex

Localization of forces (position of therapist 's hands) (Fig. 1 5. 1 9a) •

•

•

•

Both thumbs are placed in the space between the patella and femur medially (or laterally). Both index fingers are then placed in the space on the opposite side. The fingers and thumbs are then gently squeezed together to reach under the patella. At the same time the wrists are extended and radially deviated so that the fingers and thumbs lift against the undersurface of the patella.

Application of forces by therapist (method) •

•

•

The technique is a very gentle, slow oscillatory movement consisting of raising and lowering the patella. The patella should not be lowered to the extent whereby it comes into full contact with the femur. Care should be taken to avoid discomfort under the patella.

Variations in the application of forces •

•

The therapist places the bases of both hands lateral and medial to the patella, and performs the distraction movement by gently moving both elbows towards each other (Fig. 15.19b). As well as a tecluuque in its own right the distraction of the patella can then be accompanied by other patellar movements (e.g. medial, lateral, longitudinal, rotational and diagonal).

Figure 1 5.20 Patel lofemoral transverse movement med ially.

•

Localization of forces (position of therapist 's hands) •

Uses •

• •

•

Very painful patellofemoral joint surface disorders (clinical groups 1 and 3a). Pain relief in chondromalacia patellae. As a means of progressing pain-free movements of the patella in other directions. Stretching the retinaculum and soft tissue attachments of the patella (clinical groups 2 and 3b).

Therapist starting position: Standing by the patient's right knee, facing across the patient's body.

•

•

The pads of both thumbs are placed, pointing towards each other, against the lateral border of the patella. The fingers of the left and right hands point medially to rest across the distal end of the patient's femur and proximal end of the tibia, respectively. The thumbs are hyperextended at the inter phalangeal joints to bring as much of the pads as possible into contact with the lateral border of the patella.

Application of forces by therapist (method)

Transverse movement med i a l ly and l atera l ly (Fig. 1 5.20) •

• •

•

Direction: Movement of the patella in a transverse

•

medial direction in relation to the femoral intercondylar articular surfaces.

•

Symbols: --++ , ++Patient starting position: Supine, lying with knee in extension.

Oscillatory movements of the patella are produced by the therapist's arms acting through the thumbs. Grade I should produce 5 mm of movement of the patella from its resting position. For other grades of movement the patella is displaced more medially, reaching the limit of its excursion for grade III and grade IV movements.

51 1

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MAITLAND'S PERIPHERAL MANIPULATION

Variations in the application of forces •

•

•

•

Transverse laterally is merely the reverse of the transverse medial movement. The patella can also be mobilized in the transverse direction while the patient adopts a position of the knee which relates to a painful or stiff activity (e.g. squatting). Alternatively, the patient's patella can be realigned with a transverse pressure during an activity which is painful (e.g. stepping up). If the pain diminishes with the realigned transverse pressure the therapist can utilize this in treatment and rehabilitation.

Uses •

•

Painful or restricted transverse movement of the patella. In combination with pain-relieving distraction or discomfort-provoking compression.

Longitudinal movement caudad and cephalad (Fig. 1 5.21 ) •

Direction: Movement of the patella in a longitudinal caudad direction in relation to the femoral intercondylar articular surfaces.

• •

Symbol: ....... Patient starting position: Supine, lying with knee in

Figure 15.21 Patel iofemoral longitudinal movements: (a) caudad; (b) cephalad.

extension. •

Therapist starting position: Standing by the patient's right knee faCing across the patient's body, or facing the patient's feet for stronger grades of movement. •

Localization of forces (position of therapist's hands) •

• • •

•

•

The heel of the left hand, near to the pisiform bone, is placed against the superior margin of the patella. The left wrist is extended. The left forearm is directed distally. The right hand, pointing proximally, is placed over the patella. The fingers and thumb of the right hand pass either side of the heel of the left hand. The right hand serves three purposes: 1. providing stability for the left hand 2. guiding the patella during movement 3. applying compression to the patella if desired.

Application of forces by therapist (method) •

The caudad movement of the patella is produced by the heel of the therapist's left hand while

the direction of the movement is guided by the right hand. The therapist's two hands and the patient's patella should move as a single unit.

Variations in the application offorces •

•

•

Longitudinal cephalad movement: the same hand positions over the patella are used as for the caudad technique, but the movement is produced through the ulnar border of the therapist's right hand. To guide the direction of the movement the therapist uses the palm of the right hand (cupped over the patella) and the cupped base of the palm of the left hand. If compression is required during the movement, the patella can be pressed against the femur by the therapist's right hand. If the movement signs indicate, the movement described above can be combined with a medial inclination whereby the point of contact against the superior border of the patella is moved slightly

-------

-

- - ---------

The knee complex

laterally and the direction of the arms altered so that the diagonal movement direction can be performed. Likewise, a lateral inclination can be performed.

•

•

Patellofemoral OA (clinical group 3b). Pain with this or inclined longitudinal movement directions. In combination with compression or distraction as progressions of treatment.

•

•

•

Rotation around longitudinal axis /sag ittal axis

Rotation i n the coronal plane around a sagittal axis (Fig. 15.22).

Patellofemoral movements in knee flexion (exam ples of treatment) (Fig. 1 5.23) •

Uses •

•

Direction: Any direction of movement of the patella in relation to the femur with the patient's knee in flexion. Symbols: IN P IF F 60° DID ...... caud and ceph, -- med. Patient starting position: Sitting with the knee over the edge of the couch; alternatively, weight bearing. Therapist starting position: Standing by the side of the patient's knee.

Special testing The purpose of special tests is to move the patella through a full amplitude of movement by moving the patella in any radius of a circle while applying a compressive force against the anterior surface of the patella, thereby rubbing the posterior surface of the patella against the femur.

Two rotary movements (Figure 15.7 illustrates the directions of the movement.) •

Rotation of the patella about the anatomical longitudinal axis producing contact between the medial articular facet of the patella and the medial condyle of the femur.

Figure 1 5.23 Treatment example: in (c) transverse medial.

60'

Figure 15.22

Patellofemoral rotation (sagittal axis).

flexion, do longitudinal movements of patellofemoral joint: (a) caudad ; (b) cephalad;

513

51 4

MAITLAND'S PE RIPHERAL MAN IPULATION

Localization of forces (position of therapist's hands) • •

•

The right palm is cupped over the patella. The heel and ulnar border of the left hand is placed against the superior margin of the patella. The lower legs stabilize the patient's lower leg in the required degree of flexion.

Application of forces by therapist (method) •

•

From this starting position the therapist can produce a variety of oscillatory movement directions (cephalad, caudad, angled, rotary, medial, lateral, with the addition of compression). Movement is produced by arm movement acting through the hands.

Uses •

•

Stiff knee flexion after injury or prolonged periods of immobilization (Fig. lS.23a,b). Minor symptoms (group IV) (Fig. lS.23a-c).

ACCESSORY MOVEMENTS OF THE SU PERIOR T I B IOFI B U LAR JOINT: EXAMINATION AND TREATMENT T ECH N I QU ES

Examination and treatment techniques may be per formed in any position: supine, prone or side lying. Side lying permits many adaptations of the techniques to the knee and foot positions.

Anteroposterior movement (Fig. 1 5.24) •

• •

•

Direction: Movement of the head of the fibula in an anterior to posterior direction in relation to the fibular articular facet on the tibia. SymboL: t Patient starting position: Side lying with the right

hip and knee flexed and the lower leg resting on the couch. Therapist starting position: Standing in front of the patient's knee (if carried out in supine with knee flexion: sitting on the patient's foot to stabilize it, facing the patient's knee).

Figure 1 5.24 Superior tibiofibular joint: (a) anteroposterior movement; (b) anteroposterior movement with compression. Application of forces by therapist (method) •

•

Anteroposterior movements are exerted against the head of the fibula through stable thumbs. It is extremely difficult to differentiate between different grades of movement but they can be varied by altering the strength of the pressures.

Localization offorces (position of therapist 's hands) •

• •

The pads of both thumbs are placed against the anterior border of the head of the fibula. Both thumbs point posteriorly. The fingers of both hands spread around the patient's knee to help stabilize the thumbs.

Variations in the application offorces •

If the addition of compression is necessary, the heel of the left hand is placed over the head of the fibula laterally while the fingers lie over the knee. The right thumb maintains its contact against the

The knee complex

•

anterior margin of the fibula. The left forearm is directed so that it can apply a medially directed pressure against the head of the fibula as well as assisting the right thumb in its anteroposterior pressure (Fig. lS.24b). Anteroposterior movement without or with compression can be performed with the patient in side lying. The medial aspect of the lower leg should be fully supported on the couch and the patient's ankle must be in a loose neutral mid range position. The movement is then produced through the therapist's thumbs or cupped hands in much the same way as shown for the inferior tibiofibular joint.

Uses • •

•

Pain and stiffness of the superior tibiofibular joint. To help the recovery from peroneal nerve entrapment at the head of the fibula. To complement mobility of the inferior tibiofibular joint and thus the foot and ankle.

Posteroanterior movement (Fig. 1 5.25) •

• •

•

Direction: Movement of the head of the fibula in a posterior to anterior direction in relation to the fibular articular facet on the tibia.

Symbol: ; Patient starting position: Side lying, with right leg in hip and knee flexion, lower leg resting on plinth (if carried out in prone, lying near the right edge of the couch with the knee flexed approximately 30° for convenience). Therapist starting position: Standing behind the patient.

Localization of forces (position of therapist's hands) •

•

•

The pads of both thumbs are placed against the posterior border of the head of the fibula. The fingers of the left hand spread medially across the patient's upper calf. The fingers of the right hand reach anteriorly around the fibula.

Figure 1 5.25 Superior tibiofibular joint: (a) posteroanterior movement; (b) posteroanterior movement with compression. Variations in the application o f forces •

•

Application of forces by therapist (method) •

•

Posteroanterior mobilizing is performed by pressure from the therapist's arms through the thumbs against the head of the fibula. The movement must not be produced by the muscles of the thumbs as this immediately becomes uncomfortable for the patient.

The movement can be performed under

compression by changing the position of the

•

therapist's hands so that the heel of the hand is placed against the lateral surface of the head of the fibula while the thumb of the other hand produces the PA movement (Fig. l S.2Sb). The posteroanterior movement can also be performed with or without compression with the patient in side lying in the same way as that described for anteroposterior movement, apart from the thumbs or heel of the hand being placed against the anterior border of the head of the fibula. For examination purposes the posteroanterior movement can be tested with the patient lying supine with the hip and knee flexed. A pulling pressure is then applied behind the head of the fibula with the fingers of the left hand.

515

516

MAITLAND'S PERIPH E RAL MANIPU LATION

•

The PA mobilization can also be performed using the left thumb with the patient in supine and the leg in a degree of SLR in cases of nerve entrapment.

Uses •

Pain and stiffness of the superior tibiofibular joint

•

To help in the recovery of peroneal nerve

in this direction. entrapment at the head of the fibula. •

To complement mobility of the inferior tibiofibular

• •

•

Directions: Movement of the fibula in a longitudinal caudad and cephalad direction

Prone, lying with the knee

flexed to a right angle. •

Therapist starting position: Standing next to the patient's foot, facing across the patient's body.

Localization of forces (position of therapist 's hands) •

One hand holds the patient's foot, the other palpates movement of the fibula.

joint and therefore the foot and ankle.

longitudinal movement caudad and cephalad (Fig. 1 5.26)

Symbol: ...... Patient starting position:

Application offorces by therapist (method) •

Caudad movement is produced by strongly

•

Cephalad movement is produced by the therapist

inverting the patient's heel (Fig. 15.26a). everting the patient's heel, at the same time

in relation to the tibia.

pushing the inferior angle of the fibula cephalad with both thumb pads. •

This movement can readily be felt in the normal subject by palpating the head of the fibula with one hand while inverting and everting the patient's heel with the other hand.

Variations in the application offorces •

The longitudinal movements of the fibula can be produced with the addition of compression. One hand can be used to apply compression laterally to the head of the fibula while the other hand inverts and everts the patient's heel.

•

The longitudinal movements with or without compression can also be performed with the patient in side lying with the foot free of the edge of the couch so that the patient's heel can be inverted and everted readily.

•

Longitudinal movement caudad can be

locally to the head of the fibula

applied

(Fig. 1 5.26b).

Uses •

Stiffness of the fibula in the longitudinal directions principally in relation to inversion and eversion injuries or disorders of the foot and ankle.

Clinical profiles common

are presented for the following

disorders

related

to

knee

movement

dysfunctions:

Figure 1 5.26 Su perior tibiofibular joint: (a) longitudinal movement with lever of foot; (b) longitudinal movement applied loca lly to head of the fibula.

•

osteoarthritis (Box 1 5 .2)

•

anterior knee pain (patellofemoral syndrome)

•

subluxating patella (Box 15.4).

(Box 15.3)

The knee complex

Examination

Clinical evi dence/'brick wall' thinking

Kind of disorder Body chart features

Pa in and restricted mobi lity in various daily l ife activities The patient may g rasp around the knee and indicate that the pa in is felt deeply in the joint or in the bone. Pain which is felt more superficially at the a nterior side may indicate that movements of the patella a re pai nfu l as wel l Getting up from a deep chair, walking u p and down sta irs, walking for longer periods. Patient indicates that neither too much activity nor too l ittle a re beneficial - needs to find a balance between active and rest periods. Pain may be strong at night (vascular mechanisms?) Gradual onset of symptoms in a prolonged history of constant awareness of discomfort studded with exacerbations. Some patients indicate that the pa in and disability i ncreased over time and they may not be symptom free a nymore. With those patients symptoms may have progressed from occurring during weig ht-bearing activities towards symptoms at rest (especially at night). However, other patients may describe that they have improved over the years, as for example after retirement from sedentary work, more activities (e.g. wa lking) a re being performed

Activity limitations/24-hour behaviour of symptoms Present/past history

Special questions Source/mechan isms of symptom production Cause of the source Contributing factors Observations Functional demonstration of active movements

If necessary tests Other structures in plan Isometric/muscle length tests Neurological exami nation Neurodynamic testing Palpation findings Passive movement, accessory / physiological combined movements Mobil ization / mani pu lation techn iques preferred Other management strategies

Prognosis/natural history Evidence base

Pain originating from the subchondra l bone exposed by symptom production of fu l l thickness defects. Ca psular a n d ligamentous structures m a y cause nociceptive activity. Neurogenic and intraosseous vascu lar mechanisms may contribute to the pain Habitual gait patterns, loss of joint mobility (esp. in extension), loss of m uscle strength (e.g. coming u p from squatting not performed for years), reduced aerobic condition Genu varum, va lgus position possible. Wasting of quadriceps, g l utea l m uscles; tight iliotibial band Weight-bea ring activities (e.g. getting u p from a chair) and squatting may provoke symptoms. Differentiation testing of the tibiofemoral and patellofemoral joi nts is freq uently possible. Often, however, both joints involved. Flexion, extension, rotations (esp. under compression) may be pa in provoking. Often with throug h-range findings, crepitus may be present (may be deep in tibiofemoral joint or more superficial in patellofemoral joi nt) See a bove: compression Relation to lumba r movement dysfunction ; hip, neurodynamic structures Mostly inconclusive rega rd i ng symptom reproduction as contributing factors usually wea k Tenderness of soft tissues su rrou nding the joint Accessory and physiolog ica l movement of tibiofemoral (and perhaps patel lofemoral) joi nts may be pain provoking and restricted. Compression may el icit crepitus and increase pain Accessory movement at end of ra nge and through range positions. Large amplitudes, progression to compression may be necessary. If the problem is stable, physiological movements, particularly in extension combinations, may be uti lized NSAlDs and pain-relieving medication if necessary; improvem ent of aerobic conditioning (e.g. on ergometer without resistance), m uscle control, habitual (gait) movement patterns. Encouragement to exercise regularly, maintaining mobility, muscle strength, aerobic condition ; pain-coping strategies, e.g. with automobilizations, repeated movements See Cha pters 10 and 1 4 I t has been shown that active exercises have beneficial effects o n outcomes such as pain, mobility and function (Moncur 1 996, Van Baar et al 1 998)

51 7

518

M A ITLA N D ' S P E R I P H ERAL M A N I P U LATI O N

Exa m i nation

Clini cal evidence / 'brick wall' thinki n g

Kind of disorder Body chart features Activity limitations/24-hour behaviour of symptoms Present/past h istory

Symptoms in a nterior area o f knee, m a y li mit daily l ife activities strongly Symptoms may be felt superficia lly in area of patella or more deeply underneath patella Squat, getting u p / down stairs, bike riding, down hill ski ing, jumping may be mildly/severely restricted due to pain Symptoms may have developed gradual ly, usually in periods of g rowth spu rts and active integration in sports (e.g. running). May occur post-trau matic (e.g. after a fal l on the knee, as in vol leybal l)

Special questions Sou rce / m echanisms of symptom production Cause of the source Contributing factors

Observations Functional demonstration of active movements

If necessary tests Other structures in plan Isometric/m uscle l ength tests Neurological exa mination Neurodynamic testing Pa l pation findings Passive movement, accessory / physiological combined movements Mobi lization / ma n ipu lation techn iques preferred

Other management strategies

Prog nosis/natura l history

Evidence base

(Peri- and / or intra-a rticular oriented) patellofemoral movements or the soft tissues su rrou nding the joint may be causes of the nociceptive processes Muscle imbalance: recruitment pattern of VMO distu rbed. VMO activity to late responses. Abd uctors of h i p, pronation position of foot influence activity of VMO. Contribution of Q angle inconcl usive Postural ana lysis is essential - alignment of tibia to femur; pronation of foot? Medial rotation pelvis/retraction of pelvis? Squatting, getti ng down stai rs. Observe qual ity of the movement: leg may fa l l into adduction and medial rotation of the h i p. Pa in may occur especially between 0 and 60° of flexion. Pain provocation with hip extension and adduction or position of lateral tibial rotation -> indicative of short and tight tensor fasciae latae and i liotibial bands Relation to l u mbar movement dysfunction, h i p, neurodynamics Tests of quadriceps, VMO in particu lar may provoke pa i n ; coordination changes

Soft tissue tenderness. Patella position in 20° of flexion: para l l el to frontal and sagitta l pla nes? M idway between fem u r condyles? Accessory movements of patellofemoral joints may provoke symptoms, including crepitus, especially if compression is applied Accessory movements; if very pai nfu l (group I) gentle, large ampl itude techn iques short of Pl. Progressio n : in other positions of F and F/Ab of the knee; in later stages com pression may be added. Lateral retinacu lum may need to be stretched (e.g. in side lying and adding tra nsverse medial movements and rotary movements along a longitudinal axis) Normalize tracking of patella in femoral groove with recru itment exercises of VMO with in the m uscle chai n of foot and pelvis. Stretch tight il iotibial bands/tensor fasciae latae. Corrective ta ping of patella (medial ; rotary; tilting cephalad, medial ly) may be helpfu l, if weig ht-bea ring exercises are too painfu l. Condition : corrective tape hasto reduce the pain 'The need for surgery for patellofemoral pain has almost been elimi nated due to i mproved understanding of its aetiology, taping of the patella to reduce the symptoms, and specific training of the VMO and gl utea ls. However the patient needs to be aware that the symptoms are managed ... and the pain may recur, particu la rly when the activity level has increased and there has been a lapse in the exercise progra m' (McConnell 1 996, p. 65) McConnell 1 996, Stiene et al 1 996, Witvrouw et al 1 996, Herrington Et Payton 1 997, Ernst et a I 1 999

The knee complex

Exa mi nation

Cli n ical evidence/ 'brick wall' th i n king

Kind of disorder Body chart features Activity lim itations/24-hour behaviour of symptoms Present/ past history

Pa in and subl uxation of patel la Pa in in a nterior aspect of knee, locking, sensation of instabil ity All movements may be pai nfu l and restricted in acute cases. Burning pain freq uently felt during longer periods of sitting, walking and standing Acute onset during activities such as ru nning, q u ickly turning on the leg. Maybe recurrent

Special q uestions Source /mechanisms of symptom production Cause of the sou rce Contributing factors Observations

Patellofemoral structures provoke nociceptive processes

Fu nctional demonstration of active movements If necessary tests Other structures in plan Isometric/ muscle length tests Neurological exa mination Neu rodynamic testi ng Pa lpation findings Passive movement, accessory / physiological combined movements Mobil ization / ma ni pu lation techniques preferred Other ma nagement strategies Prognosis/natura l history Evidence base

CASE STU DY 1 5. 1

Knock-kneed teenage girls, athletes Genu valg u m ; medial rotation leg to pelvis; pronation position of the foot; VMO wasting Wa lking, ru nning (if possible). Flexion, extension movements pai nfu l and restricted

Differentiate from meniscus lesions

Tenderness around patella, retropatellar area Patella is excessively mobile, especially in c. 30° flexion. Apprehension with tra nsverse medial movements. Pa inful crepitus may be present Endeavour to make passive movements pain free; stretch lateral retinacu l u m Muscle recru itment, especia l ly VMO, gl uteals. Postu ra l correction (static and d u ring activities) of foot, knee and pelvis Su rgery in recurrent cases

ANTE R I O R K N E E PA I N

John D. is a 24-year-old student whose hobbies include volleyba l l, mou ntai n-biking, jogging and skitouring. Kind of disorder

Symptoms in knee a rea : stabbing pain. Had a rthroscopy nothing special revea led. After a series of treatments in open-chain quad riceps bench, symptoms i ncreased. Has difficu lties in walking and ru nning. No sports possible at the time. Body chart

As ill ustrated in Figure 1 5.27. Activity Iimitations/ 24-hour behaviour of symptoms

(!)(!)a i normal walking, after c. 50 m. Can continue, limps slightly.

� 1 00% immediately when sitting down. * (!)(!)a i when sitting with legs bent gets restless after c. 1 0' and sl ig htly pai nfu l. Needs to move leg conti nuously. *Ru nning, ju mping, volleyba l l training not possible because pain becomes too severe. Tried vol leyba l l training 2 weeks ago; symptoms increased for about 2 days. Past/ present history Present history

I n volleyba l l match c. 4 months ago fel l on knee; slight pain in (!) which i ncreased over the next few days (!)(!)a. Doctor advised quadriceps strengthening and stretching. Fitness studio (self-supported): pain increased after intense exercises on open-chain quadriceps bench. Orthopaedic su rgeon : X-ray, MRI, a rthroscopy - nothing revealed, no results. GP: sent to physiothera py.

519

520

M A ITLA N D'S P E R I P H ERAL M A N I P U LATI O N

Figure 1 5.27 Body chart of John D.

CD @ Always together

Past history

Never had problems with knee, hip or l u mbar spine (light backache in middle of spine after longer periods of sitting, never sought help). Special q uestions

G H .I ; no medicatio n ; X-ray, M RI norm a l ; a rthroscopy (6 weeks ago: norma l. Report: ca rtilage at spot of 00 can be dented l ightly).

• •

=

ooooa i • • • •

Pla n n i ng of physical examination •

•

•

Moderately severe symptoms - tests procedures until onset of Pl' Symptom mechanisms: nociceptive (stimulus-response related). Possible sources of dysfu nction : PF joint, TF joint (may refer from h i p, lumba r spine, neurodyna mics).

Physical examination •

Observation : wasting of medial aspect of quadriceps

PP .I Functional demonstration : getting up step taking weight of body on leg ( c. 30° knee flexion)

•

•

Knee active movements: F, F/Ad, E, E/Ad .l . .l F / Ab, E / Ab: slightly restricted, 00 IVVMO recruitment in weig ht-bearing in 20° F (moving from plinth to weig ht-bearing on both legs) 00; correction of patella medially: 00 slightly � Accessory movements of TF joint in EOR F as well as in EOR E : all .I, .I PF joint: in c. 1 5° F (no pain) PP: ISO Do: P / E accessory movements +-+ caud, ceph, ca ud/med, ceph / med (Fig. 1 5.28) __ med, med / caud (Fig. 1 5.28) All other P / F movements .I, .I

The knee complex

R2 (IV++)

p'C})

Rl

Figure 1 5.29 Flexion: in 90' F:MR; in 90' F:LR.

P1

Figure 1 5.28 P / E accessory movements. Decisio n : Treat P / F signs, short of Pl

•

0 1 ,Rx 1

In supine, 1 5° F (before P) do Rx: ....... caud, ceph, caud /med, ceph/ med --. med, med / caud 1 1 1-, rhythm smooth, reI. slow speed c. 5', alternating techn iques Assessment while: after c. 3-4' Pl later in range, after c. 5 ' : ISO

C / O : 'lighter' PIE: Fct. demo 00+, but can step up © EIAb .I, .I © FlAb .I, oo � © Warned patient: may increase; should compare walking, night. sitting

Plan (02,Rx2) •

•

Hypotheses reg. sources: PI F dysfunction confirmed ; T/ F impairment seems to improve with P / F treatment (hip, Lx, NS: probably not involved, however will need quick screening in next few sessions). Procedures PIE: Cave: may lose P I E ** ! Add i n squat, getting up from chair Screen: hip, screen Lx (both components IF no changes

in reassessment; if cha nges: screen only one component and leave other to Rx3) Rx:

•

•

P I E : "PP .I Fct. demo: getting u p step - is possible; ooooa 30-60° F "Squat (holds pl inth) : c. 50° F, ooooa *VMO test i n 20° F, take weight on both legs: 00 EIAb .I, .I "F/Ab .l, OO little Screening hip (Fig. 1 5.29) : F; in 90° F:MR; in C / O : PP .I (ISO) 90° F:LR: a l l .l, .I P I E : Fct. Demo Squat FIAd, a l l .l, .I VMO test FlAb Screening Lx : F, E, Ouadra nt left, rig ht: all .I, .I

r , ;, �

T10-L5: a l l .I, .I

as Rxl - grade I I I c . 5' (after c . 4 ' P l , Rl later i n range)

P / F (probably as in Rxl )

02,Rx2 •

C/O: Felt lighter after Rxl ; "wa l king was possible for a longer range - c. 500 m without pain "Sitting: pain intensity � (before c. 7/10, now c. 4/10). "Getting up stairs was possible, however became very painfu l ooooa after c. 6 steps.

} ISO

Rx2a

Self-management: objective - control P :

- 'stretch' rectus femoris? - automobil izations patel la? - may consider corrective tape to enhance VMO recru itment i n weight-bearing.

C / O : PP .I (ISO) P I E : Fct. Demo Squat VMO test FlAb

} ISO

C/O: PP 'lighter' P I E : Fct. Demo (get up stairs) 00 � � 30-60° F © Sq uat ooooa 50° (i ntensity �) © ' VMO test 00, 20° (i ntensity �) © F/Ab .l, .( ©

Rx2b

Stretch ing rectus femoris in standing Hip E 1 0°, knee F fu l l range Pu lls frontal side of thigh 5x, c. 10'

C / O : ISQ P I E : Fct. Demo (get up stai rs) 1 step .I, .I © 2nd step: Pl ooooa 3rd step ooooa++ Squat ooooa 70° (i ntensity .p ©

52 1

522

M A ITLA N D'S P E R I P H ERAL M A N I P U LATI O N

•

Info/lnstr. a t end o fsession: should perform R F exercise at least 3-4x/day; each time 1 series / 5x rep.; additionally should try exercise 3-5x if CDCDa t

Plan (Rx3) •

• • •

Continue Rx of PF joint; passive mobs may prog ress towards position of 30-40° F Check RF exercise Further automob. necessary? VMO exercise? (maybe with corrective tape?)

D5,Rx3 •

•

C I O : 'Better', 'Wa l king hard ly pai nfu l' 'Getting u p stai rs: 1 stairway (15 steps) possible without P; 2nd stairway ( 1 5 steps) CD increases, but may continue 'Getting down stai rs: CD+ after c. 10 steps 'Sq uat: seems easier Does not run or jump yet Effect of RF exercise: did it c. 3xl day; forgot to do it once on sta irs P t PIE: PP .I * Fct. Demo: Stairs up: after l Ox P, CD 30-60° F Stairs dow n : after 5x P, CD 30-60° F 'Sq uat: fu l l ra nge, CDCDa 70° F - EOR 'VMO in 20° F: takes on weight without pa i n ; after c. 3x P, CD

Rx3d

Automob. PF - large ampl itude ca udad movements Without pain. c. 2' Rx3e

VMO recru itment 5x, then P; did automob. PF: could continue with exercise After 5x VMO ex. P started agai n : tried RF ex -+ P decreased ; however felt that PF automob. hel ped better to i nfl uence pa i n End of session: info and instr. to patient • •

• •

•

•

•

•

•

Rx3b

C I O : .I PIE: Sta irs t 30x without pa in © Stairs � 20x without pai n © Squat: range ISQ, P i ntensity U (2/ 1 0) © Jump: small jump possible s P ©

•

•

•

Rx3c

Repetition of RF exercise; 5xl ca 10' without pain

Ju mping seems lighter Squat hardly painful

Patient feels m uch better: squat hardly painfu l ; getting up sta irs: a l most 2 stairs u p a n d down without pain. However, if movi ng qu icker, P may start. Tried to run for c. 1 km - then symptoms started; forgot to do exercises at moment of increase of pain. Overa l l level of activity has increased, especially normal walking and stai rs. However, did not continue running; did not start vol leybal l training and jumping. Would l i ke to start training ASAP. Patient felt that particularly passive mobilizations hel ped him best. Knows that exercises may control pain in daily life, however forgets it too often. P I E " rema ined as after Rx3.

Summary of remaining sessions •

As Rx3a Prog ress to 45° F

Continue treatment as in Rx3 May progress activities to jumping and running. If P increases: perform a utomob. and lor RF exercise

Rx4: Retrospective assessment

•

CIO: t PIE: Stairs t 20x without pain © Stairs � lOx without pain © Squat: range ISQ, P intensity U (51 1 0) © Jump: small jump possible s P ©

Should perform RF exercise/automob. if ever symptoms VMO exercise : series of 5x; if symptoms, perform either RF or PF a utomobilization ; should continue if possible in 3-4 series

Plan (Rx4)

Rx3a

As Rx2a: no symptoms D u ring Rx: progression : I n 30° F : d o R x ...... caud, ca ud / med ; -+ med ; __ latlcaud 1 1 1 -, short of P c. 5-6' After c. 4' P, later in ra nge; after c. 5' ISQ

Jumping a lso lig hter Squat: pain free

Overa l l treatment lasted 9 sessions. Passive mobil isations were continued as above until session 8 ; progression towards 60° F; after 6th session compression IV- was added to the passive movement series. VMO recruitment exercises contin ued as started in Rx3. Self-management to control pain incl uded RF stretches and light large ampl itude automobilizations of patella. Resu med vol leyba l l training after 4th session. However, jumping as in smash training was still pai nful and patient was not able to jump fu lly until about the 1 0th session.

---,-

-

-

-

-

-

-

-

--

-

--

----- - - --

- ----

- - _ .. ---- -

--

_ . . _ ._---

The knee com p l ex

•

•

After 9th session : DLA 1 00% symptom free; did not feel capable yet to fu l l explosive jumping d u ring volleyball. Stretch ing and PF automobil izations influenced pain directly and patient integrated these strategies in movement behaviour during warming-up and during volleybal l training. After 9th session : interruption of treatment; reassessment after 2 weeks: patient had continued

•

improving and felt c. 95% back to normal daily life and sports activities. . Reassessment after another 4 weeks: 1 00% normal daily life and sports activities. Patient contin ued with self-management exercises and with VMO training, especially during warming-up of voll eyball training (3x/ week) .

References Butler, D.

2000. The Sensitive Nervous System. Adelaide:

NOI Group

1983. Practical Orthopaedic Medicine. London: Butterworth-Heinemann Corrigan, B. & Maitland, G. D. 1994. Musculoskeletal and Sports Injuries. Oxford: Butterworth-Heinemann

Corrigan, B. & Maitland, G. D.

Edgar, D., Jull, G. & Sutton, S.

1994. The relationship between

upper trapezius muscle length and upper quadrant neural tissue extensibility. A ustralian Journal of Physiotherapy, 40,

99-103

Ernst, G., Kawaguchi, J., Sabila, E. et al.

1999. Effect of

Arthritis, ed.

J. M. Walker & A. Helewa. Philadelphia:

W. B. Saunders

2001 . Basic Biomechanics of the Musculoskeletal System. Philadelphia: Lippincott,

Nordin, M. & Frankel, V.

Williams and Wilkins

1994. A natomy and Human Movement. Structure and Function. Oxford:

Palastanga, N., Field, D. & Soames, R. Butterworth-Heinemann

2003. Joint Motion. Clinical Measurement and Evaluation. Edinburgh: Churchill Livingstone

Soames, R.

Stiene, H., Brosky, T., Reinking, M. F. et al.

1996. A comparison

patellar taping on knee kinetics of patient's with

of closed kinetic chain and isokinetic isolation exercise in

patellofemoral pain syndrome. Journal of Orthopaedic

patient's with patellofemoral dysfunction. Journal of

and Sports Physical Therapy, 29(11),

Herrington, 1. & Payton, C.

661-667

1997. Effects of corrective

taping of the patella on patients with patellofemoral pain.

Physiotherapy, 83, 566-572 Hilyard, A.

1990.

Physiotherapy, 76, 559-565 1987. The PhysiologJ) of Joints - Lower Limb.

Kapandji, r.

Edinburgh: Churchill Livingstone

1991. Peripheral Manipulation, 3rd edn.

London: Butterworth-Heinemann McConnell, J.

1996.

Management of patellofemoral

problems. Manual Therapy, 1, Moncur, C.

1996. Physical

136-141 1998.

The effectiveness of exercise therapy in patients with osteoarthritis of the hip or knee: a randomized clinical

Recent developments in the management

of patellofemoral pain: the McConnell Programme.

Maitland, G. D.

Orthopaedic and Sports Physical Therapy, 24,

Van Baar, M., Dekker, J., Oostendorp, R . A. et al.

60-66

therapy management of the

patient with osteoarthritis. In Physical Therapy in

25, 2432-2439 1990. Hoe werkt het patellofemoraJe gewricht. Nederlands Tijdschrift voor Manuele Therapie, 9, 67-72 WHO 2001 . ICF - International Classification of Functioning, trial. Journal of RheumatologJ),

Van Eijden, T.

Disability and Health. Geneva: World Health Organization

Witvrouw, E., Sneyders, c., Victor, J. et al.

1996.

Reflex

response times of vastus medialis oblique and vastus lateralis in normal subjects and in subjects with patellofemoral pain syndrome. Journal of Orthopaedic

and Sports Physical Therapy, 24,

160-165

523

525

Chapter 16

The ankle and foot complex

THIS CHAPTER INCLUDES: • • •

•

Key words for this chapter Glossary of terms for this chapter Presentation of the foot and ankle complex as a sou rce of movement dysfunctions Subjective exami nation principles related to foot and ankle d isorders

KEY WORDS I nferior tibiofibular, talocrural,

GLOSSARY O F TERMS Shin splint - this is a genera l term applied to a complex of conditions that lead to pain and irritation in the shin region of the lower leg. Shin splints can occur i n any sport and a re often associated with the untrained or u nconditioned athlete, a change in event or playing su rface, an increase in jumping activities or a change in footwear, as well as changes in tra i ning schedules. It is necessary to distinguish between anterior shin splints (involving the anterior muscle g roups such as m. tibialis anterior, extensor digitorum longus, extensor hallucis long us) and

• •

•

Physical examination principles Exa mination and treatment techn iq ues Clinical profi les of common d isorders related to the ankle and foot complex: - ankle distortion - Ach i l les ten d i n itis - shin splint

subtalar, tarsa l , ta rsometatarsa l, metatarsophalangea l ,

med ial shin spl i nts (i nvolving the posterior tibial m uscle, usually dorsal of the medial m a l leol us). Shin splint needs to be differentiated from an anterior compartment syndrome and stress fractures of the tibia or fibula (McPoil Et Culotta McGarvey 1 988). Tarsal tunnel syndrome - entrapment of the posterior tibial nerve as it passes in its neurovascular bundle behind and then below the med ial mal leolus to gain access i nto the foot. The nerve runs in a fibro osseous tarsal tunnel, roofed over by the flexor reti nacu l u m which runs from the med ial mal leolus to the calcaneus. The tunnel also

•

A case exa m ple of a patient with heel pain.

i nterphala ngeal joi nts.

conta ins the tibia l is posterior, flexor digitorum longus and flexor ha llucis longus tendons, each su rrou nded by a synovial sheath. As the posterior tibial nerve passes through the tunnel it d ivides i nto the medial and latera l plantar nerves. The syndrome may be caused by tenosynovitis (especia l ly of the posterior tibial tendon). fol lowing tra u ma , overuse or i nfla mmation or fol lowing a spra i n of the medial ligament. Furthermore, postural abnormalities may be associated with this condition (Corrigan Et Maitland 1 983, 1 994).

526

M A IT LA N D ' S P E R I PH E R A L M A N I P U LAT I O N

INTRODUCTION

In the examination of movement disorders of the foot

-

and ankle complex the functions of the following joints

The foot and ankle need to fulfil high requirements in

may need to be assessed:

relation to locomotion. They play an essential role in the maintenance of balance, transmission of loads

•

Ankle complex:

from the lower extremity to the foot and the orienta

- inferior tibiofibular joint

tion and adaptation of the foot to the ground contours.

- talocruraljoint - subtalarjoint

The complex of the inferior tibiofibular joint, ankle joint and mid- and forefoot articular structures, the plantar

fascia,

soft

tissues

•

Intertarsaljoints: - calcaneocuboidjoint

and muscles work in

- talocalcaneonavicularjoint

symphony to fulfil these requirements.

- cuneonavicular

The foot alternates in form and function between a shock-absorbing flexible platform and a rigid propul

- intercuneiform joints

sive lever during different phases of the gait cycle.

- cuneocuboidjoints

Considerable forces act on the foot and ankle complex:

•

Tarsometatarsal joints, intermetatarsal joints

•

Metatarsophalangeal (MTP)joints, interphalangeal

(proximal, distal)

for example, forces may exceed five times body weight during walking and up to thirteen times body weight during running (Nordin & Frankel

2001).

(IP) joints.

The foot may conveniently b e divided into three areas (Fig. •

16.1):

hind-foot (inferior tibiofibularjoint, ankle complex)

Movements of the foot and ankle

•

miclioot (intertarsaljoints)

•

forefoot (tarsometatarsal, intermetatarsal,

due to the above-mentioned requirements regarding

tarsophalangeal and interphalangealjOints).

locomotion.

The movements o f the foot and ankle are complex

Figure 1 6. 1 The bones of the foot: (a) dorsa l aspect; (b) plantar aspect; (c) lateral aspect with the lateral longitudinal arch ; (d) medial aspect with the medial longitudinal arch.

The ankle and foot complex

Inferior tibiofibular joint

The ligaments of the distal syndesmosis prevent separ ation of the fibula and tibia during weight-bearing. They aid in the transmission of force through the distal fibula (one-sixth of the force exerted through the lower extremity). If the syndesmosis is intact, the talus is pushed into the distal tibiofibular mortise by which means the talar surface contact is maximized and hence joint pressure is minimized during this action (Nordin & Frankel 2001). During dorsi- and plantar flexion of the ankle, the fibula and tibia move laterally and medially respectively, 'allowing some movement in the sagittal plane, especially when the foot is held in plantar flex ion (Palastanga et aI1994).

joint from dorsa-lateral-caudad towards ventro-medial cephalad (Williams & Warwick 1980). However, the movement of in- and eversion is not localized solely to the subtalar joint and is taken on in the rest of the foot: •

•

•

•

Ankle and subtalarjoint

The ankle and subtalar joint act like an oblique hinge transmitting the relative vertically oriented movements of the lower leg towards the foot: axial torques about the long axis of either the foot or the tibia will induce torques about the long axis of the other segment. For example, in the loading component of the stance phase of gait the foot rapidly pronates under the load of body weight, and an internal rotation torque is induced on the tibia (resulting in eversion movements of the hind-foot during mid-stance). The contrast takes place towards supination and external rotation torques of the tibia over the ankle. The magnitude of the axial torques in the foot and in the lower leg are increased in sports activities which require acceleration, quick deceleration and turning (Czerniecki 1988, Rose & Gamble 1994). In the hind-foot area, due to the mechanics of the distal syndesmosis and hind-foot movements, sub stantial compressive forces take place which need to be taken into consideration during assessment and treat ment of joint disorders. The subtalar joint plays an essential role in these mechanisms, with the following functions (Corrigan & Maitland 1983): • •

• • •

Initiating inversion and eversion of the foot Shock absorbing (the heel fat pad is specifically shaped to absorb shock during heel strike) Adapting to alterations of ground contours Adapting to varying positions of the leg Maintaining body balance.

Rehabilitation towards optimum mobility of the sub talar joint, particularly in transverse directions, and pro prioceptive feedback of the hind-foot therefore merit special attention in many post-traumatic states. The main movement which takes place in the sub talar joint is inversion-eversion. The axis runs through the

In the joints between the calcaneus, talus and tarsus a considerable range of gliding and rotation occurs, by which the calcaneus and navicular can rotate medially on the talus. This results in elevation of the medial border and corresponding depression of the lateral border of the foot, so that the plantar aspect of the foot faces medially (inversion). The greater part of the movement occurs at the subtalar joint. The movements are carried on in the mid- and forefoot, as well as in the talocrural joint, with a combination of supination/medial rotation, adduction movements and plantar flexion (Williams & Warwick 1980, Klein-Vogelbach 1983) (Box 16.1).

Subtalar motion is screw-like and influences the flexibil ity of the transverse tarsal joint. Subtalar inversion causes the foot to become rigid, while subtalar ever sion allows foot flexibility. This is one of the essential mechanisms that allows propulsion of the foot during gait (Rose & Gamble 1 994, Nordin & Frankel 2001). The ankle joint has multiple axes that change during motion. Minimal talar rotation is indispensable and occurs during dorsi- and plantar flexion (Nordin & Frankel 2001 ). Tarsometatarsal joints

The tarsometatarsal joints (Lisfranc) are relatively stable and comparatively immobile as a result of the arch-like configuration and the key-like structure of the second tarsometatarsal joint (Nordin & Frankel 2001).

I nversion co m b i n ations Supination mid- and forefoot • Medial rotation ankle • Adduction hind-foot, mid- and forefoot • Plantar flexion •

Eversion com binations • • • •

Pronation mid- and forefoot Lateral rotation a nkle Abduction hind-foot, m id- and forefoot Dorsiflexion

527

528

M A I TLA N D'S P E R I P H ERAL M A N I P U LAT I O N

This i s another essential mechanism that allows the transmission of forces from the hind-foot to forefoot during the stance phases of the gait cycle. Axes of movement

Within the foot various axes of movement may be distinguished (Klein-Vogelbach 1983) (Fig. 1 6.2): •

•

•

•

AnatomicaL axis: running from the calcaneus through the third metatarsal bone. Pronation/supination axis: as a midfoot and forefoot movement along an axis running through the second metatarsal bone. Inversion/eversion axis: as a 'pure' movement along the line dividing the subtalar joint. FunctionaL axis: running from the lateral border of the calcaneus towards the big toe, running through the first metatarsal bone. Most foot movements during stance phases are directed along this line.

Gait analysis frequently is an essential examination procedure and has been described in more detail in Chapter 14. With movement disorders of the foot, particular attention should be given to the various phases during the stance phase as they may aid in the generation of hypotheses regarding the impaired movements and possible joints at fault: •

•

• •

•

Heel contact (dorsiflexion, foot in relative inverted position) Foot flat (movement towards plantar flexion, eversion and pronation) Mid-stance (dorsiflexion, eversion and pronation) Heel-off (plantar flexion, towards inversion and supination) Toe-off (plantar flexion, inversion, supination) (phase from heel-off to toe-off: terminal rocker).

The foot movements should be assessed in relation to the movement of the trunk and lower limb: ankle motion, controlled by muscle action, has a direct effect on the pathway of the knee joint during walking by the Pronation/supination axis

interplay of ankle dorsi- and plantar flexion as well as the toe-off activities in the terminal rocker phase (Rose & Gamble 1994). The foot changes from a mobile structure during the first phase of the stance phase into a rigid lever at push-off. This is a complicated mechanism in which the joint structures, soft tissue mechanisms and muscu lar mechanisms interact with each other. In eversion of the heel maximal mid-foot motion is permitted, while the foot becomes rigid when the heel is inverted and forefoot fixed (Rose & Gamble 1 994). The medial and lateral longitudinal arches of the foot need to be relatively flexible, as during weight bearing they will be flattened out in order to transmit forces. These arches should recuperate once the weight is taken away from the foot. Relatively rigid feet may be observed in sitting. They may be an important con tributing factor in the development of symptoms in the structures of the foot (e.g. the foot may have become rigid due to deformities such as pes planus, after immobil ization of the foot; in neurological disorders such as hemiplegia with spasticity). In examination of the arches of the foot the follow ing joints need to be assessed: •

•

transverse arch: intertarsal and intermetatarsal joints long arches: tarsal, tarsometatarsal joint movements.

Box 16.2 ComIllOft � ...... contributing to movement disorders of the foot and ankle COMplex

--------�

Neuromusculoskeletal d isorders Deformities (va lgus /varus of hind-foot, pes planus, pes cavus, decrease of transverse arch of forefoot, hal lux va lgus, claw toes, hammer toes, ma l let toes) • Diseases • Tra u ma (bone, soft tissue, joints) • CRPS I (RSD / 'Sudeck's dystrophy') • Sports i nj uries: - d istortions and recurrent instabilities of the ankle - Ach i l les tend i nitis - soft tissue lesions, shin splints - chronic overuse disorders - stress fractures - heel pain •

Dermatolog ical disorders Vascu lar d isorders Figure 1 6.2

Functional axis Axes of the foot.

Inversion/eversion axis

Metabolic disorders

The ankl e and foot complex

529

] A range of pathobiological disorders may contribute to movement disorders or pain of the foot and ankle complex (Box 16.2). Physiotherapists may frequently encounter problems due to post-traumatic conditions or to overuse of the structures as may happen in sports. The physiothera pist's examination should concern itself with the analy sis of joint movement, muscular control, proprioceptive feedback, neurodynamic functions and assessment of the patterns of gait or sports activities (e.g. running or twisting movements such as in basketball or tennis). The ankle and foot have a close relationship to various nerves which may be a contributing factor to recurrent or ongoing pain syndromes of the foot, for example: • •

• • •

•

sural nerve in Achilles tendinitis superficial peroneal nerve in inversion sprains (Pahor & Toppenberg 1 996) posterior tibial nerve in tarsal tunnel syndrome plantar nerve in relation to symptoms of a heel spur intermetatarsal nerves in deformities such as flattened transverse arch of the forefoot (e.g. Morton's neuralgia) deep peroneal nerve in symptoms related to a hallux valgus

(for further reading, see Butler 2000).

Main problem ('Question ,') Information from the subjective examination aids in the establishment of the kind of disorder in order to develop hypotheses regarding the source(s) of the movement disorder and the degree of limitation of daily life activities. Many patients with movement disorders of the foot and ankle will present with pain as the main problem. Other symptoms they may describe include a sensation of instability with recurrent ankle sprains, paraesthesia. The symptoms may mainly disturb weight-bearing activities.

•

•

•

Areas of symptoms (body chart) •

•

•

SUBJECTIVE EXAMINATION •

In assessing movement-related disorders of the foot and

ankle the physiotherapist needs to consider various sources and contributing factors in the clinical reason ing process (Fig. 16.3).

Symptoms which are stimulus-response related and relatively easy to pinpoint may indicate the presence of local nociceptive processes (Fig. 16.4) which may be examined, differentiated and treated with manipulative procedures. An accurate determination of the site of the symptoms is essential, particularly in the hind-foot as this may guide the examiner in the generation of hypotheses concerning the possible sources of the dysfunction (Fig. 16.4). A good working knowledge of the surface anatomy of the foot and ankle will help to align the patient's symptoms with a recognizable joint, peripheral nerve or muscle. Symptoms which are more vague, ill defined or difficult to localize may originate from more proximal structures or the neurodynamic system. Additionally, central nervous system processing may contribute to more generalized pain and tenderness.

Hindfoot joints:

Referred symptoms/ contributing factors:

- talocrural

- l umbar spine - sacroiliac joints - hip - tibiofemoral joint - prox.tibio-fibular joint

-

� ,"�I�

Midfoot joints:

- calcaneocuboid - talocalcaneonavicular - intertarsal

Forefoot joints:

- tarsometatarsal - intermetatarsal - metatarsopophalangeal - interphalangeal

,I FOOT AND ANKLE

....... Movement-disorders .......

Neurodynamic structures

I

t L ,.------,

....---J

Muscles, tendons, tendon sheaths

Fi g u re 16.3 Different sou rces and/or contributing factors need to be taken into consideration in the ana lysis of movement-related foot and a n kle disorders.

530

M A I T LAND'S P E R I P H E RA L M ANI PULAT I ON

•

Next to the overall body chart, the drawing of a larger foot should be used so that the precise area of the patient's symptoms can be represented more accurately.

Behaviour of symptoms If the ankle and foot are the source of a patient's symp toms, functions in weight-bearing activities may be com promised or restricted by pain or stiffness, for example: • •

• • •

walking twisting and turning on the foot (e.g. in tennis, soccer) associated with acceleration, deceleration or changing direction jumping running getting up! down stairs.

It is essential to determine the exact movements during the above-mentioned activities as this may aid in the generation of hypotheses regarding impaired move ment directions. With these hypotheses, in conjunction with the hypotheses generated on the sources of the dysfunction, the physiotherapist may plan the physical examination more precisely and will know which joints and movements need to receive extra attention in the examination procedures. Other activities which may provoke symptoms include sitting on heels, indicative of a plantar flexion disorder with a compression component in the hind-foot. Morning stiffness would be expected when patients suffer from osteoarthritic or degenerative disorders. Morning soreness is common in patients with an inflammatory component to their disorder. However,

in rehabilitation after post-traumatic states, increased stiffness with certain activities may occur the day after an activity. This may disappear over the time of rehabili tation. Self-management strategies with automobi lizations and large amplitude repeated movements frequently improve this type of morning stiffness.

History If the symptoms are of a traumatic onset, information on the injuring movement is essential as it may give an indication of the structures involved. In later phases of healing when minor symptoms may still be present, this movement may be used as a treatment technique. If an injuring movement was rela ted to high impact, or even led to a fracture, various structures may be involved and different joints with varied movement impairments may contribute to the overall movement disorder of the patient. If symptoms are of spontaneous onset, frequently overuse or misuse of the structures may be a contribut ing or causative fact. Deformities, muscle imbalance, movement and positioning habits at work or during sports, shoes, orthotic devices, certain corrective tapes, running on a newly rounded road and so on may con tribute to the development and maintenance of certain movement disorders of the foot and ankle.

Specia l questions Next to the routine information regarding the patient's health, weight loss, radiographic findings, medication and so on, screening questions may be posed with regard to: • •

•

neurological disorders (e.g. polyneuropathy) vascular disease (arteries, veins) (e.g. frequent unhealed ulcers, cold feet, swollen feet when standing! sitting) metabolic diseases (e.g. diabetes mellitus).

PHYSICAL EXAM INATION

Lateral

CD Distal tibiofibular joint CD Talocrural joint CD Subtalar joint CD Achilles tendon (dis!. tib.fib. joint)

Figure 1 6.4

Typical areas of symptoms of the hind-foot.

Depending on the plan after the subjective examination, the physiotherapist may decide to focus the examin ation on the hind-foot and mid-foot or more on the fore foot. To examine every movement of every joint from the inferior tibiofibular joint to the metatarsal area is unnecessary and w1practical. This decision is mainly dependent on the localization of the symptoms and the limitation of activities. Following analysis of 'functional demonstration tests' and gait analysis, the examination begins with the functional physiological movements of the 'whole foot' (dorsiflexion, plantar flexion, inversion, eversion, toe

The ankle and foot complex

movements}. If any of these tests produces a compara ble sign, then that movement is broken down into its components for the appropriate joints, which are then further assessed. Screening tests for the possible involvement of other movement components may be performed as an additional procedure in, for example, the second or third treatment session. Box 16.3 provides an overview of examination pro cedures of the foot! ankle complex and its related structures.

Observation First pa l pation of temperature, effusion, swel ling • Present pain

•

+Functional demonstration/tests, including differentiation of movement components Brief appraisal Active movements Gait ana lysis, esp. forwards, backwards, sideways; heel and toe walking, on lateral and medial borders of foot • Squatti ng: spontaneously, with heels off and on g round Ba lancing on one leg, on ba l l of foot • • Heel and toe hoppi n g ; j u m ping Measu ring OF i n standing • • Active tests in supine and prone, i ncluding overpressure (note range, quality and pain): - Whole foot: OF, PF, I nv, Ev - Oifferentiation testing: OF, PF, I nv, Ev, MR, LR - Toes: extension, flexion, abd uction •

Muscle tests Isometric tests: symptom reprod uction (gastrocnemius, peroneal m m , m. tibialis a nt, extensors of toes and hallux) • Tendon sheaths: fu l l active resisted movement throug h range, i ncluding pal pation • Muscle recruitment, activity of intri nsic m uscles in sta nding, activity with i n overa ll m uscle chain Muscle length (mostly at end of passive testing - after • neurodynamic testing) •

Other structures in 'plan' Lumbar spine, sacroi l iac joi nt, hip, tibiofemoral joint, proximal tibiofibular joint, neurodynamic structures

•

Neurological examination Sensation in case of metabolic disease

•

Observation Some details on the essentials of observation in weight-bearing joints have been described in Chapters 14 and 15. The following factors may be of particular relevance in the examination of the ankle and foot complex: •

The foot and ankle should be inspected from the front and from behind, with the patient standing, sitting with the foot over the edge of the couch and lying down.

Neurodynamic tests Possibly during phase of passive testing.

•

Passive tests Neurodynamic tests: sura l , superficial peroneal, deep peroneal, posterior tibial nerves (SLR, sl ump) Movement diagram of relevant active tests: OF, PF; • toe movements • Hind-foot: - Oistal tibiofibular joint: (a) Physiological movements: routinely: ankle OF, PF, hind-foot abduction, adduction, I nv, Ev; as applicable: the i njuring movement (b) Accessory movements: i, t, ...... longitudinal caud and ceph, without and with compression (and: all accessory movements of talus and calcaneus) - Ankle (ta locrural joint and subtalar joint) : (a) Physiological movements: routinely O F, PF, I nv, Ev, MR, LR (axis in line with tibia); As applicable: differentiations OF, PF, I nv, Ev; compression added to the h i nd-foot movements (in line with tibia) (b) Accessory movements: on ta lus as well as ca lcaneus: i, t, ----- , +- , C , :J. Ta lus/ ca lcaneus combined : ...... longitudinal cau d and cep h ; solely on ta lus: ...... longitudinal caud, without and with compression • M id foot: - I ntertarsal joints: (a) Physiological movements: routinely OF, PF, I nv, Ev (b) Accessory movements: Ab, Ad (forefoot and hind-foot) ; HF and HE forefoot proxi mally; i, t ----- , +-,:J, C , ...... longitudinal ca ud and ceph, without and with compression •

531

M A I T LAND'S P E R I P H E R A L M ANI P U LAT I ON

532

•

•

•

•

•

•

•

- Tarsometatarsal joi nts: (a) Physiological movements: routinely DF, PF, I nv, Ev; toes F and E (b) Accessory movements: i. t. -- , -- (with Ab, Ad),:J, C , - longitudinal caud and ceph, without and with compression Forefoot: - I ntermetatarsal movement: (a) Accessory movements: ; , t, -longitudinal caud and ceph; H F, HE (bases of metatarsals, heads of metatarsals), without and with compression - Metatarsophalangeal joints: (a) Physiological movements: routinely F, E, Ab, Ad ; if applicable: combinations (b) Accessory movements: ; , t. -- , --, :J, C, -longitudinal caud and ceph, without and with com pression (compression may include sesamoid bone of hall ux)

The presence of an effusion can best be appreciated by inspection of the ankle with the patient standing. Effusions of the ankle joint may be seen bulging out around the malleoli. Effusions into the tendon sheaths crossing the ankle are readily visible. Posture: general posture of whole body. Tendency to sway-back postures may lead to transference of weight on the forefoot (Sahrmann 2002). Normal position of the foot: - calcaneus vertical to the floor - subtalar joint in a neutral position - five metatarsal heads lie in contact with the ground, in a light transverse arch - longitudinal arches on medial and lateral borders of the foot are present - position of the foot, as in gait: the foot may present an angle of 7-10° of abduction (toe-out) relative to the anatomical axis of the foot (functional axis) (see Fig. 16.2). - toes: relaxed in neutral positions. Observe especially possible deformities (e.g. hammer toes, hallux valgus). Observe the shoes, i.e. pattern of wear on the soles of the shoes. Observe callosities of the sole of the foot to gain an orientation of the regular loads on the foot during weight-bearing. General orientation of the relative rigidity and flexibility of the foot: keep the heel in eversion and move the midfoot in a rotary manner - the midfoot should be flexible; in inversion the midfoot should become rigid (Rose & Gamble 1994).

- I nterphalangeal joints: (a) Physiological movements: routinely F, E (b) Accessory movements: ; , t. -- , --, :J, C, -longitudinal caud and ceph, without and with compression Pal pation Temperature, swelling, effusion • Tenderness of soft tissues, m uscles, tendons, tendon sheaths • Nerves • Arterial pu lse: dorsalis pedis, posterior tibial artery •

Check case records etc.

Highlight main findings with asterisks Instructions to patient at end of the session

Functional demonstration tests •

•

•

•

Present pain: before carrying out any tests to reproduce symptoms, it should be determined if the patient has any pain at rest. Functional demonstration: the patient is asked to demonstrate an activity which provokes the pain as described in the subjective examination. This activity may serve as an asterisk. Differentiation which joints may be responsible for the symptoms. Frequently these tests will be performed in weight bearing positions. The physiotherapist may differentiate by adding stress to the joints at the medial border of the foot if symptoms are present in that area, or at the lateral border of the foot. Other differentiation procedures may be carried out during the phases of active testing, passive physiological movements and accessory movements. Brief appraisal: after the differentiatio� tests a brief appraisal or reflection is necessary to determine if the test procedures may be continued as planned, or if an adaptation of the examination plan is needed.

Active movements During active tests various parameters are assessed and recorded: • •

Willingness and ability to move Quality of movement, including muscular recruitment patterns

The a n k l e and foot com p l ex

• •

Range of active movement Any symptom response.

Gait analysis

Gait analysis is described in detail in Chapter 14. In the analysis of movement disorders related to the foot and ankle, particular attention should be given to: • •

•

•

walking forwards, backwards, sideways correcting any deviation in movement patterns to determine if the deviation is a protective deformity wi th regard to pain walking on heels, toes (walking on toes: symptom provocation? Observe specifically if the heels move towards inversion and if the weight of the body is transferred to the lateral border of the foot) walking on the lateral or medial border of the foot (mimicking walking on uneven ground) .

Next to the overall observation o f the transfer o f the centre of gravity of the body, and the trunk, pelviS, hip and knee movements, the foot movements should be observed meticulously during stance and swing phases of the gait cycle: •

• •

After heel strike the foot may rotate medially to a varying extent before being placed flat on the floor. As the foot is loaded it can be seen to pronate. As the heel is raised there is a rapid but slight inversion of the heel as the foot supinates. This movement occurs because of the subtalar linkage and is indicative of the horizontal rotations of the leg (inversion and eversion movements).

If a patient has forefoot problems due to deformities of the toes and the metatarsal transverse arch, the physio therapist may guide the patient during the movement of the terminal rocker to roll over the lateral and medial borders of the foot until the toe-off phase is reached. Some patients develop symptoms in the 4th or 5th MTP joints or intermetatarsal joints due to symptoms of hallux valgus. Their gait pattern changes frequently to a terminal rocker over the lateral border of the foot. If a patient develops symptoms particularly during running, this activity should be observed. Video analy sis of runners is frequently useful as apparently minor deviations in running patterns may turn out to be highly essential contributing factors to the development of symptoms. It is essential to observe running with and without shoes; if symptoms seem to have developed due to a deviation in pattern (e.g. eversion of the heel in a flat foot or over eversion during stance), the activity should be compared without and with corrective tapes or other corrective devices. Difference in symptoms must be observed over a few days before any lasting

orthotic device, corrective tape or shoes is recom mended. If the symptoms develop after a few miles of running, the patient may carry out the activity and immediately come to the physiotherapist once the symptoms occur, or the physiotherapist accompanies the patient. Squatting

Observe spontaneous movement, squatting on toes, and give guidance to squatting on heels (the physio therapist may need to support the patient's trunk while the patient holds the treatment plinth). If no symptoms are reproduced the physiotherapist may bounce both knees forwards to increase dorsiflexion and eversion of the ankle. Balancing on one leg and on the ball of the foot

It is essential to observe this movement in posttrau matic situations as well as in elderly patients. It has been shown that the joint position sense may decrease with age, as well as after trauma (Boyle & Negus 1998). Hopping on heels and toes andjumping

These movements may be a necessary active test if the patient's symptoms predominantly seem to occur dur ing these activities. If hopping on heels provokes more symptoms, an intra-articular movement disorder of the hind-foot may be suspected. Symptoms during jumping and hopping on the toes frequently indicate through-range and end-of-range disorders of the mid and forefoot. Other active tests

Other active tests in weight-bearing positions may be carried out, depending on the information from the subjective examination - for example sitting on the heels, twisting and rotary movements (e.g. as in tennis), walking up and down steps, etc. Restricted range of motion in dorsiflexion / eversion

Frequently patients may demonstrate a restriction of range of movement in which it is difficult to monitor progress in grades. However, the range of motion of dorsiflexion (and/ or eversion) may also be measured as shown in Figure 16.5. The phYSiotherapist monitors the contact of the heel with the floor while the patient moves the knee towards the wall (or a moveable object) or the knee beyond the foot. Movement can be until the onset of pain or until the end of the available range of movement.

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Figu re 1 6.5 Alternative method of measuring range of motion of dorsiflexion.

Active tests in supine, prone, including overpressure (,whole foot' and toes)

The following tests need to be included in the routine examination of the foot. •

•

Supine: - dorsiflexion, plantar flexion, inversion, eversion of the foot: observe especially quality and quantity of the movement (overpressure may be given in this position; however, it is more precise if carried out in prone with the knee in 90° of flexion) - extension, flexion, abduction, adduction of the toes, including overpressure (Fig. 16.6) Prone: (active tests, including overpressure) - plantar flexion (Fig. 16.7a) - dorsiflexion (Fig. 1 6.7b) - inversion (Fig. 16.7c) - eversion (Fig. 16.7d) - medial rotation (Fig. 16.7e) - lateral rotation (Fig. 16.7f).

Figure 1 6.6 Metatarsophalangeal joints: active testing including overpressure.

The differentiation testing may be a complicated manoeu vre, especially if the inversion or eversion movements are analysed. Frequently the examination of accessory movements in the pain-provoking positions will also elicit the joints and the movements at fault. However, it is essential to have developed skills in the differenti ation tests as they provide the physiotherapist with essential information about the behaviour of the passive physiological movements. The differentiation tests can be carried out in various ways: • •

Differentiation tests

If the overpressure to the active tests of dorsiflexion, plantar flexion, inversion and/or eversion provokes symptoms in the area of the hind-foot or midfoot, dif ferentiation tests may be carried out. The movements can be carried out localized at the following joint lines (Fig. 16.8): ankle (hind-foot, including inferior tibiofibular joint) 2. transverse tarsal joint (talocalcaneonavicular and calcaneocuboid) 3. cuneonavicular 4. tarsometatarsal. 1.

•

PhysiolOgical movements in the isolated single joints. Moving the foot into the pain-provoking position for example, end-of-range position of plantar flexion, then subsequently leave out one joint (Fig. 16.9a-e) and repeat the movement. After one joint line has been left out of the movement and the pain subsides, the joint line concerned may be expected to be at fault. Moving from proximal to distal into the pain provoking direction - for example, first move the hind-foot into plantar flexion, then the transverse tarsal joint, then the cuneonavicular joint and the tarsometatarsal joints (as in Fig. 16.9a-d, but in the reverse manner).

Brief appraisal

After the examination of the routine tests (whole foot movements, including overpressure; toe movements,

The a n kle and foot complex

Figu re 16.7 Whole foot movement: (a) plantar flexio n ; (b) dorsiflexio n ; (c) inversion ; (d) eversion. Hind-foot movement: (e) medial rotation; (f) lateral rotation. NB: a l l movements include overpressure.

including overpressure) the therapist needs to reflect on the subsequent plan and may decide on the exam ination (and, should the occasion arise, treatment) pro cedures (Fig. 16.10). •

Muscle tests •

Isometric tests should be carried out if muscular or tendon lesions are suspected. The following muscles may be examined in particular (Kendall & McCreary 1993): - ffi. triceps surae, including Achilles tendon (in weight-bearing) - m. tibialis anterior

•

•

- mm. extensor digitori longus - m. extensor hallucis longus - mm. peronei longus and brevis - m. tibialis posterior. Tendon sheaths may be examined by applying resistance to whole movements through range of the muscle concerned. Palpation of the painful spot during the test may increase the symptoms and a crepitus may be present. Recruitment patterns of the foot stabilizers within the overall muscular chain of foot, knee, hip and pelvis (McConnell 1996, Sahrmann 2002). Muscle length tests of the whole lower extremity (Janda 1983). Usually examined after the

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Screening of other structures in 'plan'

establishment of the status of the joint movements. Furthermore, in many cases it is essential to first have gained an impression of the mechano sensitivity of the neurodynamic tests before muscle length testing is carried out (Edgar et al 1994).

Screening tests are performed to determine if other movement components contribute to the movement disorder of the knee. It is emphasized that it is neces sary to determine if other components should be (b)

Calcaneus -j--- Metatarsal Talus Cuneiform Navicular

-+--- Talus

Tibia

Cuneiform

Tibia

Figure 1 6.8

Differentiation l ines for plantar flexion : (a) inversion ; (b) eversion and dorsiflexion.

Figure 1 6.9

Differentiation of plantar flexion : (a) whole foot plantar flexion ; (b) as in (a) but without MTP joints.

----- --

------

----

�

-

--------- -

------ -

-------

The ankle and foot complex

included in the treatment. The above-mentioned test procedures are minimum requirements. If some of the tests are not impairment free, the movement compon ents concerned need to be examined in more detail. • •

•

Lumbar spine: extension, rotations, quadrant (if possible); PAIVMs, including subsequent reassessment. Sacroiliac joint: sacroiliac provocation tests as F / Ad with compression, Patrick test (Faber sign), anterior and posterior tilts, passive accessory movements, including subsequent reassessment. Note: as F / Ad with compression is also an important procedure

•

in the examination of hip movement disorders, frequently it is useful to complete the hip examination with the relevant passive tests prior to the screening procedures of the sacroiliac joint. Hip joint: Active movements: flexion; in 90° of flexion: medial and lateral rotation, extension. Passive tests: flexion/ adduction, including combinations and subsequent reassessment. Knee joint: - Tibiofemoral joint: extension with AP movement on tibia, including E/ Ab, E/ Ad. Shaft rotation in 90° of flexion; abduction, adduction. F / Ab and F / Ad combinations. Accessory movements in

Figure 1 6.9 (Continued) (c) as in (a) but without TMT joints; (d) as i n (a) but without cuneonavicular joint; (e) hind-foot plantar flexion without transverse tarsal joint.

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Screening of lumbar spine, neurodynamics, hip, knee

1

Any specific tests necessary; e.g. skin sensation, arterial pulses?

1

Muscle testing tendon and tendon sheaths Figu re 1 6. 1 0 tests.

•

•

Passive joint movements hindfoot:

Active tests of ankle and foot

distal tibiofibular talocural, subtalar calcaneocuboid; talocalcaneonavicular

l Passive joint movements forefoot and toes:

Tarsometatarsal intermetatarsal metatarsophalangeal Interphalangeal

Passive joint movements midfoot:

ankle movements intertarsal movements tarsometatarsal movements

Flowchart o f possible decisions o n t h e exam i nation plan following active testing, i ncluding differentiation

end-of-range positions, may be assessed with firm compression. - Patellofemoral joint: all accessory movements in various positions of the knee. The movements may have to be assessed with firm compression. - Proximal tibiofibular joint: PA, AP, longitudinal movements under firm compression, in various foot positions (comparison with non-affected side necessary - not necessarily direct symptom reproduction, but differences in local symptoms and / or mobility may be present). Neurodynamic system: SLR or slump and modifications (posterior tibial, superfiCial and deep peroneal nerve, sural). May perform test for saphenous nerve (side lying) (see Butler 2000 and 'Neurodynamic testing' below). Hind-foot: in prone PF, DF, Inv, Ev, MR, LR with compression; longitudinal cephalad and caudad ankle; calcaneus transverse medially, including compression; distal tibiofibular joint: PA and AP under compression.

Neurological exa m i n ation Under normal circumstances no neurological examin ation is necessary. However, in circumstances in which it is suspected that a patient may have neuropathic changes (e.g. vascular disease, diabetes mellitus), sensation examination (light touch, pin-prick, warm cold sensation) may be carried out. It is also essential to perform this examination as a precautionary measure to treatment with electrotherapeutic modalities. If a tarsal tunnel syndrome is suspected, the muscles innervated by the medial and lateral plantar nerve

(branches of the tibial nerve in the foot) may need to be examined: •

•

Abductor hallucis, flexor digitorurn brevis, flexor hallucis brevis, first lumbricali and interossei. However, most contractions of the single muscles may take place in conjunction with the long muscles of the lower leg, hence responses may be inconclusive. Sensation: the medial plantar side of the sole of the foot is innervated by the medial plantar nerve, while the lateral plantar nerve innervates the lateral aspect of the sole of the foot (Palastanga et al 1 994).

Neurodynamic testing The neurodynamic system may be involved in post traumatic situations such as inversion trauma of the foot (Pahor & Toppenberg 1996) as well as in ot.�er movement disorders (e.g. tarsal tunnel syndrome, hallux valgus, Achilles tendinitis). Frequently variations of the straight leg raise are carried out. As a progressive test, the same variations can be performed in the slump test in sitting. •

•

•

Superficial and deep peroneal nerve: The physio therapist holds the foot in inversion, plantar flexion and flexion of the toes; under monitoring of the knee extension with both forearms, the SLR is carried out (Fig. 16.11a). Posterior tibial nerve: as above, but with abduction of the hind-foot and dorsiflexion (Fig. 16.11b). Sural nerve: as above, but with adduction of the hind-foot and dorsiflexion (Fig. 16.11c).

The ankle and foot com p l ex

Figure 1 6. 1 1 SLR: (a) i nclined to the deep and superficial peroneal nerve; (b) incli ned to the posterior tibial nerve; (c) i ncli ned to the sural nerve.

Pa l pation •

•

•

•

•

Temperature, swelling and effusion: compare the affected leg with the unaffected leg. Bony palpation of medial and lateral aspects, sinus tarsi area, hind-foot, plantar surface (heel, plantar fascia, heads of the metatarsal bones) and dorsum of the foot (Hoppen£eld 1976). Tenderness of ligaments (e.g. deltoid ligament at medial side of ankle; lateral ligaments: anterior and posterior tibiotalar ligaments, calcaneotibial ligament), other periarticular soft tissues of all other relevant joints of the foot. Tenderness of tendons, muscles, insertions, tendon sheaths (Achilles tendon, and the following muscles: extensor digitorum longus, extensor hallucis longus, tibialis anterior, tibialis posterior, flexor hallucis longus, flexor digitorum longus, peronei longus and brevis). Nerves: - posterior tibial nerve dorsal of the medial malleolus close to the posterior tibial artery - sural nerve cephalad of the calcaneus, dorsal of the lateral malleolus, may be followed into the lateral aspect of the foot - superficial peroneal nerve at the dorsum of the foot

•

- deep peroneal nerve between the heads of the first and second metatarsal bones (dorsal aspect) - intermetatarsal nerves on the plantar side between the heads of the 3rd and 4th as well as the 4th and 5th metatarsal bones (in flattened transverse arch of foot and possible Morton's neuralgia). Arteries: - pulse of the posterior tibial artery at the dorsal side of the medial malleolus between the tendons of the flexor digitorum longus and flexor hallucis longus - dorsal pedal artery at the dorsum of the foot between the tendons of the extensor hallucis longus and extensor digitorum longus.

Passive test procedu res Movement diagram

The establishment of a movement diagram of the most comparable active movements provides more detailed information on relevant parameters: pain (P), resistance (R) and motor responses ('spasm' - S) and their inter relationship. The information may guide the therapist in the determination of treatment techniques by passive movement; additionally the test may be used as an

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asterisk in reassessment procedures (see Chapters 7 and 8 and Appendix 1).

Joint techniques •

Differentiation tests

Dependent on the findings during passive physio logical tests or accessory movements, various differ entiation tests may be executed:

•

• •

•

•

•

•

•

•

DF and PF as grade IV+ at limit of range (see Figs 16.8, 16.9): (a) Ankle (DF includes inferior tibiofibular joint movement) (b) Transverse tarsal joint (talocalcaneonavicular and calcaneocuboid) (c) Cuneonavicular (d) Tarsometatarsal Inversion and eversion as grade IV + at limit of range (see Figs 16.8, 16.9): (a) Inferior tibiofibular joint (b) Talocrural (c) Subtalar (d) Transverse tarsal joint (talocalcaneonavicular and calcaneocuboid: (produce (1) rotations resp. pronation/supination; (2) Ab and Ad; (3) OF and PF) (e) Cuneonavicular (f) Intercuneiform and cuneocuboid (produce (1) rotations resp. pronation/supination; (2) Ab and A; (3) OF and PF) (g) Tarsometatarsal (produce (1) rotations resp. pronation/supination; (2) Ab and Ad; (3) OF and PF) Medial and lateral rotation (axis in line with tibia): (a) Inferior tibiofibular joint (b) Talocrural (c) Subtalar (Note: ankle grade IV and calcaneus grade IV produce inferior T /F movement) Longitudinal caudad hind-foot (prone, 90° knee flexion - in line with tibia): (a) Talocrural and distal tibiofibular (b) Subtalar PA, AP movements at ankle: (a) Talocrural and distal tibiofibular (b) Subtalar Abduction, adduction of rnid- and forefoot: (a) Tarsometatarsal (b) Cuneonavicular and calcaneocuboid (c) Talonavicular HF, HE as grade IV + at limit of range: (a) Intermetatarsal (b) Cuneocuboid (c) Cuboid-navicular

Neurodynarnic tests and muscle length tests may be carried out in this phase of the physical examination.

•

•

•

•

•

•

The following types of passive movement may be examined in the various areas of the foot: - physiological movements - accessory movements. Note the behaviour and interrelationship of pain (P), resistance (R) and motor responses (S). The accessory movements frequently need to be carried out in various foot positions of DF, PF; inversion, eversion, medial or lateral rotation of the foot. Many of the test movements may need to be executed under compression . Many examination techniques can also be used as treatment techniques. Before continuing with the examination of other areas of the foot or of other movement components, reassessment procedures are necessary to monitor the effect of the passive movement. Although examination techniques may not be carried out with the intention to treat, they may still have beneficial (or negative) effects, which need to be monitored meticulously (Chapter 5). An overview of the passive examination procedures of the ankle and foot complex is provided in Box 16.3. A detailed description of relevant passive movements is given in 'Description of techniques' below. Emphasis is placed on the principle 'the technique is the brainchild of ingenuity': examination and treatment techniques have to be adapted to the specific needs of the patient, the clinical condition and the constitution of the phYSiotherapist.

TREATMENT

Detailed information on the selection and progression of treatment techniques has been provided in Chapters 7 and 8. Treatment frequently pursues various objectives, which may be defined collaboratively with the patient: •

•

Normalization of the present impairments: - joint signs - muscular control - joint position sense (propriocepsis) - walking patterns Normalization of activity levels in daily life and in sports.

Pa i n and stiffness The treatment of foot pain or stiffness frequently is quick est and most successful when passive movements are

The a n kle and foot co m plex

localized to the precise directions of movement of the joint(s) at fault. In most instances it is necessary to use the movements which reproduce the patient's pain or which produce a comparable sign (e.g. local pain, stiffness) at an appropriate joint. Although general movements (e.g. full inversion of the whole foot) can be used in treatment, the result often will be achieved more quickly if the compara ble sign can be isolated to the movement of a single joint (or a group of involved jOints) and this movement is then used as a treatment technique. In the treatment of most pain problems of the foot, grade IV type. movements are most commonly used to increase range or to provoke a controlled degree of the patient's pain. Alternatively, with grade III movements, where intra-articular aspects of the joints are affected, large ranges of movement back and forth up to the limit of the range may be applied. In very painful conditions, the treatment may be started with generalized accessory movements and physiological movements of large amplitudes; how ever, these must be executed within a pain-free range.

of the foot. Once this has been achieved in sitting, the procedures have to be progressed into weight-bearing positions and to dynamic activities (e.g. walking).

DESCR IPT ION OF TEC H N I QUES INFERIOR TIBIOFIBULAR JOINT

The inferior tibiofibular joint is more often the cause of symptoms than the superior tibiofibular joint and should be examined routinely when ankle pain is present. Movement is described in relation to the movement of the fibula on the larger, more stable tibia. The move ments are: • • • •

• •

Trauma When the patient's foot is subjected to fairly severe trauma the inferior tibiofibular joint is often affected by the strain. This fact is often overlooked because the con dition of the joints below is frequently more severe and limiting. However, a faulty inferior tibiofibular joint can prevent normal walking and should not be omitted from routine examination and treatment of the ankle. When the joint is found to be a source of symptoms the examination technique that reproduces the patient's symptoms, or the examination technique that discloses a loss of range, should be involved in treatment. •

•

If pain is a dominant factor, treatment techniques would involve gentle grade IV- type movement, interspersed with grade III movements. If the aim of treatment is to increase range, the techniques would have more of a stretching quality with IV + type movements.

Posteroanterior movements (PA) Anteroposterior movements (AP) Compression Longitudinal movement caudad (with leverage of hind-foot) Longitudinal cephalad (with leverage of the foot) Strong rotation of the talus (produced via the foot); this also produces movement at the tibiofibular joint, as well as dorsiflexion of the hind-foot, by compression of the talus into the mortise.

Posteroanterior movement (Fig. 1 6. 1 2) •

• • •

Direction: Movement of the fibula in relation to the tibia in a posteroanterior direction. Symbol: ; Patient starting position: Prone, 90° knee flexion. Therapist starting position: Standing by patient's right knee, facing left thigh.

Localization of forces (position of therapist's hands) •

•

The heel or thenar eminence of the right hand is placed against the posterior border of the lateral malleolus, fingers pointing towards toes. The heel of the left hand is placed against the anterior border of the medial malleolus, fingers pointing towards the heel (Fig. 16.1 2a).

Foot deform ities Disorders of the forefoot occur frequently in conjunc tion with foot deformities (e.g. flattened transverse arch, pes planus, hallux valgus). It is necessary to treat the joint signs with both passive mobilizations and self management strategies (e.g. automobilizations). Increase of the tonic activity of intrinsic muscles and if possible of abductor hallucis also needs to be followed up by increasing the longitudinal arches and transverse arches, without synergistic activity of the long extensor muscles

Application of forces by therapist (method) •

Both forearms are directed opposite each other and parallel to the central axis of the patient's trunk.

Variations in the application of forces •

With compression: as above; the left hand placed at the medial malleolus moves medially towards the right hand (Fig. 1 6.12b).

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[

Figure 1 6. 1 2 Posteroanterior movement: (a) PA movement; (b) with compressio n ; (c) grades I and I I produced with t h u m b ; ( d ) a lternative method (grades III and IV).

•

•

Grades I and II (if extremely gentle movements are required): support the tibia as in Figure 16. 12a, the pad of the right thumb is placed behind the lateral malleolus with fingers spreading for stability. Movement is produced by the right arm, acting through the thumb (Fig. 16.12c). Grades III and IV: patient lying on the left side, hip and knee flexed; lower leg flat on the plinth. The therapist stands behind the patient and uses both hands to apply movement against the posterior border of the lateral malleolus with the os pisiform contacting the malleolus. Both hands work as a single unit (Fig. 16.12d).

Compression may need to be added if intra articular movement disorders are present.

Anteroposterior movement (Fig. 1 6. 1 3) •

• • •

Localization of forces (position of therapist's hands) •

Uses • •

Examination technique. Treatment techniques ranging from treating pain dominant or resistance-dominant disorders.

Direction: Movement of the fibula in relation to the tibia in anteroposterior direction. Symbol: t Patient starting position: Prone, 90° knee flexion. Therapist starting position: Standing by the patient's right knee, facing the lower leg.

•

The heel or thenar eminence of the left hand is placed against the anterior surface of the lateral malleolus, the fingers spreading posteriorly around the ankle. The heel of the right hand is placed against the posterior surface of the medial malleolus, the

The ankle and foot complex

Figure 1 6. 1 3 Anteroposterior movement: (a) AP movement; (b) with compression ; (c) grades I and II produced with thumb; (d) alternative method (grades III and IV).

fingers spreading anteriorly around the ankle (Fig. 16.13a).

•

Application of forces by therapist (method) •

The forearms are directed opposite each other parallel to the central axis of the trunk.

Variations in the application of forces •

•

With compression: as above; the heel of the right hand placed at the medial malleolus moves medially towards right hand (Fig. 16. 13b). Grades I and II (if extremely gentle movements are required): support the tibia as in the Figure 16.13a, the pad of the left thumb is placed at the anterior border of the lateral malleolus with fingers spreading for stability. Movement is produced by the left arm, acting through the thumb (Fig. 16.13c).

Grades III and IV: patient lying on the left side, hip and knee flexed; lower leg flat on the plinth. The therapist stands in front of the patient and uses both hands to apply movement against the anterior border of the lateral malleolus with the os pisiform contacting the malleolus. Both hands work as a single unit (Fig. 16.13d).

Uses • •

Examination technique. Treatment techniques ranging from treating pain dominant or resistance-dominant disorders. Compression may need to be added if intra articular movement disorders are present.

Compression (Fig. 1 6. 1 4) • •

Direction: Movement of the fibula towards the tibia. Symbol: >--<

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Figure 1 6. 1 4

•

•

I nferior tibiofibular joint: compression.

Patient starting position: Lying on left side, flexed hip and knee; lower leg flat on plinth. Therapist starting position: Standing by the patient's foot, facing the right hip.

Localization of forces (position of therapist's hands) •

•

The palm of one hand is placed under the medial malleolus. The base of the other hand is placed on the lateral malleolus, fingers pointing cephalad.

Application o f forces by therapist (method) •

Squeezing movement of both hands.

Figure 1 6. 1 5 I nferior tibiofibu lar joint: (a) longitudinal cephalad, caudad (rotations) ; (b) a lternative method : longitudinal cephalad.

•

•

Variations in the application of forces •

•

As in Figures 16.12 and 16.13: the heels of both hands are placed at the lateral and medial malleoli, fingers pointing towards the knee. Add slight AP or PA movement to the compression.

Patient starting position: Left side lying, hip and knee flexed, lower leg flat on plinth. Therapist starting position: Standing by the patient's foot, facing the right hip.

Localization of forces (position of therapist's hands) • •

One hand holds the heel of the hind-foot. The other hand palpates either the superior tibiofibular joint (Fig. 16.1Sa) or the distal tibiofibular joint.

Uses • •

Examination technique. Treatment of intra-articular disorders, as progression of treatment.

Application o f forces by therapist (method) •

•

Long itud i n a l movement: cephalad and caudad (Fig. 1 6. 1 5) •

•

Direction : Movement of the fibula in cephalad/ caudad direction in relation to the tibia. Symbol: ...... ceph and caud

Eversion of the hind-foot produces longitudinal movement cephalad. Inversion of the hind-foot produces longitudinal movement caudad.

Variations in the application of forces •

With medial rotation of the talus in the mortise, the fibula is pulled anteriorly; with lateral rotation

The a n kle and foot complex

545

J

• •

of the talus in the mortise the fibula is moved posteriorly. Movements can be produced by the therapist using the patient's heel and foot as a lever. May be used in combination with compression. Alternative longitudinal cephalad: the heel of one hand is cupped around the inferior border of the lateral malleolus, fingers pointing towards the knee. The other hand fixates the medial malleolus (Fig. 16.15b).

Uses • •

Examination technique. Treatment techniques ranging from treating pain dominant or resistance-dominant disorders. Compression may need to be added if intra articular movement disorders are present.

TALOCRURAL JOINT AND SUBTALAR JOINT (ANKLE JOINT)

When learning movements and techniques of the foot it is advisable to have an articulated set of bones available. During examination and treatment the required movements are more easily performed by using the foot as a lever, thus incorporating intertarsal movement with talocrural movement. However, mobilization techniques are most effective if they are localized to the movement of the join t at fault. During most techniques, movement can be isolated to the hind-foot, but it is sometimes difficult to differentiate completely between subtalar and talocrural movement disorders. The physiological movements of the ankle joint encompass: • • • •

plantar flexion dorsiflexion inversion eversion.

The accessory movements, carried out in various pos itions of the foot, should include: • • • • • • • •

posteroanterior movement anteroposterior movement medial rotation lateral rotation longitudinal cephalad longitudinal caudad transverse movement medially transverse movement laterally.

Pla ntar flexion (Fig. 1 6. 1 6) •

•

Direction: Plantar flexion of the talus and calcaneus in relation to the tibia and fibula. SymboL: PF.

Figure 1 6. 1 6 Ankle joint: (a) pla ntar flexion; (b) plantar flexion, g rade 1 1 1 + . • •

Patient starting position: Prone, 90° knee flexion. Therapist starting position: Standing by patient's knee, placing the left knee on the couch to support the patient's right shin.

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Localization o f forces (position o f therapist's hands) •

•

The right hand holds the calcaneus: the thumb around the lateral surface, the fingers around the medial surface, the Mep of the index firmly contacting the sole. The web of the first interosseous space of the left hand is placed over the neck of the talus adjacent to the ankle; the thumb resting against the lateral side of the foot, fingers against the medial malleolus.

Application of forces by therapist (method) •

Movement by simultaneous action of the arms (Fig. 16.16a).

Variations in the application of forces •

•

•

Inclusion of the forefoot in the movement: the left hand of therapist is placed more distally. As Figure 1 6.16a: include compression as treatment of intra-articular disorders. Grade III + : Patient prone, feet near end of couch. The therapist stands by the patient's feet, facing the head; holding the right foot in both hands. The thumbs form a fulcrum, pointing proximally, along the medial and lateral borders of the sole of the heel. The fingers meet over the dorsum of the foot. The therapist raises the patient's leg to c. 20° of knee flexion while partially dorsiflexing the ankle and then drops the leg those c. 20° at the same time as strongly plantar flexing the foot (Fig. 16.16b).

•

grips around the superior-posterior surface of the calcaneus. Left hand: the web of the first interosseous space is placed across the plantar surface of the distal and lateral part of the calcaneus; the thumb passes around the foot laterally, fingers are placed medially.

Application of forces by therapist (method) •

Forearms work in opposite directions.

Variations in the application of forces •

•

This technique can be performed in any grade; however, tension in the gastrocnemius may need to be reduced by altering the angle of knee flexion. Grade III + and IV + : for stronger techniques, change the left hand position to use the heel of the hand against the metatarsal heads. This change of position incorporates intertarsal movement with the talocrural movement.

Uses •

Movements of small or large amplitude are easily controlled and can be performed in any part of the range.

Uses •

• •

As in Figure 16.16a: movements of small or large amplitude are easily controlled and can be performed in any part of the range. Examination technique. Through-range and end-of-range treatment techniques; compression may be added.

Dorsiflexion (Fig. 1 6. 1 7) •

• • •

Direction: Dorsiflexion of the talus and calcaneus in relation to the tibia and fibula. Symbol: DE Patient starting position: Prone, 90° knee flexion. Therapist starting position: Standing by the right knee; the left knee on couch to support the patient's shin.

Localization of forces (position of therapist's hands) •

The right hand holds the calcaneus, thumb along the lateral surface, fingers along the medial surface. The web of the first interosseous space

Figure 1 6. 1 7

Ankle joint: dorsiflexion.

The ankle and foot complex

• •

Examination technique. Through-range and end-of-range treatment techniques; compression may be added.

Compression : h i nd-foot (Fig. 1 6. 1 8) •

• • •

Direction: Dorsiflexion, plantar flexion of the talus and calcaneus with compression. Symbol: >-+-< Patient starting position: Prone, 90° knee flexion. Therapist starting position: Standing by the right knee; the left knee on couch to support the patient's shin.

Localization of forces {position of therapist's hands} •

Both hands grasp the hind-foot; the right lower arm is in the direction of the heel.

Application of forces by therapist {method} • •

The lower arm pushes towards compression. The therapist, using both arms, moves towards dorsi- and/ or plantar flexion.

Variations in the application of forces •

The therapist's chin placed against the back of the hand overlying the calcaneus enhances compression.

Uses • •

Examination technique. Treatment of stable, minor intra-articular disorders.

I nversion. eversion (Fig. 1 6. 1 9) •

• • •

Direction: Inversion/eversion movements of the talus and calcaneus in relation to the lower leg. Symbol: Inv, Ev. Patient starting position: Prone, 90° knee flexion. Therapist starting position: Standing by the right knee, the left knee on the couch to support the patient's shin.

Localization of forces {position of therapist's hands} •

• •

The calcaneus is grasped with one hand; the other hand supports the forefoot. Alternative: grasp the calcaneus with both hands. The thumbs are placed on the lateral surface of the foot, fingers over the medial surface (Fig. 16.19a).

Application of forces by therapist {method} •

•

Inversion: The therapist holds the patient's foot away. The patient's leg is pulled towards the therapist while at the same time the calcaneus is inverted (swinging movement of the leg with a rotary movement of the hip medially). Eversion: as in inversion, the therapist moves the patient's leg away.

Variations in the application of forces •

Localized inversion of the talocrural joint: the therapist grasps with both index fingers and thumbs just distal of the malleoli around the talus; production of the movement: as above (Fig. 16.19b,c).

Uses • •

Examination technique. Treatment grades II and ill.

Posteroanterior movement (Fig. 1 6.20) •

Figure 1 6. 1 8 compression.

Ankle joint: dorsi- a nd plantar flexion with •

Direction: Posteroanterior movement of the ankle in relation to the tibia and fibula. Symbol: i

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• •

Patient starting position: Prone, 90° knee flexion. Therapist starting position: Standing by the right knee, the left knee on the couch to support the patient's shin.

Localization of forces (position of therapist's hands) •

•

The right hand cups around the posterior surface of the calcaneus, the fingers and thumb spreading over and arow1d the calcaneus. The heel of the supinated left hand is placed against the anterior surface of the tibia with the fingers pointing proximally (cushioned contact).

Application of forces by therapist (method) •

Forearms are moved opposite to each other.

Variations in the application of forces •

•

More localized talocrural: the thumb, index finger and web of the first interosseous space of the right hand are placed around the talus, just distal of the malleoli. The left hand is placed as described above. More localized subtalar: the left hand grasps around the malleoli; the thumb, index finger and web of the first interosseous space grasp around the anterior aspect of the talus.

Figure 1 6. 1 9

Ankle joint: (a) inversion/eversion ; (b) localized talocrural inversion; (c) local ized talocrural eversion.

Figure 1 6.20

Ankle joint: (a) posteroa nterior movement; (b) more loca l ized ta locrura l ; (c) more local ized subta lar.

The ankle and foot complex

•

Right hand: the thumb along with the lateral surface and the fingers along the medial surface, the web of the first interosseous space grips around the posterior surface of the calcaneus.

• • •

SymboL: t Patient starting position : Prone, 90° knee flexion. Therapist starting position: Standing by the right knee, the left knee on the couch to support the patient's shin.

Uses • •

Examination technique. Treatment as grade III + or IV + .

Anteroposterior movement (Fig. 1 6.2 1 ) •

Direction: Posteroanterior movement of the ankle in relation to the tibia and fibula.

Localization of forces (position of therapist's hands) •

•

The heel of the right hand is placed at the posterior aspect of the tibia and fibula, the fingers pointed proximally. The left hand grasps around the medial border of the forefoot, the thumb at the plantar side, the fingers at dorsum (Fig. 16.21a).

Figure 1 6.21 Ankle joint: (a) a nteroposterior movement; (b) more localized ta locrura l ; (c) more loca l ized subtalar; (d, e) localized talocrural as treatment.

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Application of forces b y therapist (method) •

Forearms move in line with each other.

• •

Patient starting position: Prone, 90° knee flexion. Therapist starting position: Standing by the patient's right knee; the left knee on the couch to support the patient's shin.

Variations in the application of forces •

•

•

LocaLized taLocruraL: the left hand grasps around the anterior aspect of the talus, just distal of the malleoli. The index finger, thumb and web of the first interosseous space are in contact with the talus (Fig. 16.21b). LocaLized subtaLar: the fingers of the right hand grasp around the posterior distal aspect of the lower leg, the fingers of left hand cup around the plantar side of the calcaneus, the heel of the hand is placed against the distal border of the calcaneus; the left lower arm rests on the sole of the foot (Fig. 16.21c). LocaLized talocrural as a treatment for example in plantar flexion or in standing in dorsiflexion: the thumbs are placed against the anterior aspect of the talus (Fig. 16.21d,e).

•

•

•

Direction: Medial/lateral rotation of the talus in relation to the tibia; of the calcaneus in relation to the talus. SymboLs: :J, c:

Figure 1 6.22

The left hand stabilizes the lower leg by holding around the malleoli. The right hand grasps around the talus posteriorly with the index finger passing medially and the thumb laterally. Skin slack must be taken up (Fig. 16.22a).

Application of forces by therapist (method) •

Both lower arms are held opposite each other; the right hand carries out either medial or lateral rotation of the talus; the left hand fixates.

Variations in the application of forces

Examination technique. Treatment in all groups.

Medial rotation. latera l rotation (Fig. 1 6.22) •

•

•

Uses •

Localization of forces (position of therapist's hands)

SubtaLar medial and LateraL rotation (Fig. 1 6.22b,c): the left hand fixates the lower leg by grasping around the malleoli; the index and thumb grasp around the talus. The right hand grasps around the calcaneus and performs either medial or lateral rotary movements.

Uses • •

Examination technique. Important mobilization techniques in the talocrural joint (although very small movements).

Ankle joint, medial and lateral rotation: (a) taloerural joint; (b) subtalar medial rotation ; (e) subtalar lateral rotation.

------

--

_._

The a n k l e and foot complex

Long itudi n a l cephalad (Fig. 1 6.23) •

• • •

Direction: Movement of the hind-foot in a cephalad direction along the line of the tibia. Symbol: ...... ceph (or: >-+-<) . Patient starting position: Prone, 90° knee flexion. Therapist starting position: Standing by the right knee with the left knee on the couch to support the patient's shin.

Localization of forces (position of therapist's hands) •

•

The left hand supports the lower leg from the anterior (Fig. 16.23a). The left hand supports the lower leg from the anterior; right hand cups around the sole of the calcaneus (Fig. 16.23b).

Variations in the application of forces •

•

Uses • •

•

•

The heel of the right hand taps on various aspects of the calcaneus (Fig. 16.23a). The right hand applies compression towards the mortise.

Figure 1 6.23

Examination technique. Treatment (minor symptoms).

Long itud i n a l caudad (Fig. 1 6.24) •

Application of forces by therapist (method)

As in Figure 16.23a: the technique may be performed in different positions of DF, PF, Inv, Ev. As in Figure 16.23b: the technique may be combined with accessory or physiological movements.

• • •

Direction: Movement of the hind-foot in a caudad direction along the line of the tibia. Symbol: ...... caud. Patient starting position: Prone, 90° knee flexion. Therapist starting position: Standing by the patient's right knee; the right knee supports on the posterior aspect of the thigh to stabilize.

Ankle joint, longitudinal cephalad : (a) tapping of h ee l ; (b) appl ication of compression into the mortise.

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Figure 1 6.24

Ankle joint: (a) longitudinal caudad, hind-foot; (b) longitudinal caudad, more localized talocrura l .

Localization o f forces (position o f therapist's hands) •

•

The therapist grasps the hind-foot in the right hand with the thumb laterally, the index finger medially around the talus and calcaneus, and the web of the first interosseous space stretching across the posterior process. The left hand holds the neck of the talus immediately anterior to the ankle joint, the thumb crossing the lateral surface towards the heel, index crossing the medial surface pointing towards the heel.

Application of forces by therapist (method) •

The knee is stabilized and the hind-foot is lifted towards the ceiling with both arms.

•

Uses • •

•

More localized talocrural: the talus is grasped in the right hand with the thumb laterally, the index finger medially and the web of the first interosseous space stretching across the posterior process.

Examination technique. Treatment.

Transverse movement med i a l ly and latera lly (Fig. 1 6.25) •

•

Variations in the application of forces

The left hand holds neck of the talus immediately anterior to the ankle joint, the thumb crossing the lateral surface, the index finger crossing the medial surface.

•

•

Direction: Transverse movements of the hind-foot, talus, calcaneus respectively in relation to the lower leg. Symbols: __, __ Patient starting position: (a) Side lying, hip and knee in flexion; lower leg flat on the plinth, foot over the edge of plinth (Fig. 16.2Sa,b); (b) prone, 90° knee flexion (Fig. 16.2Sc,d). Therapist starting position : (a) Standing in front of the foot (Fig. 1 6.2Sa,b); (b) standing by the right

The a n k l e and foot com p lex

Figure 1 6.25 Ankle joint, transverse movements: (a) transverse laterally hind-foot; (b) localized transverse medially hind-foot (c) localized talocrural, tra nsverse latera l ly; (d) localized talocrural, transverse medial ly.

knee; the left knee is on the couch to support the patient's shin (Fig. 16.25c,d). Localization of forces (position of therapist's hands) •

•

•

(a) Hind-foot transverse laterally: the right hand fixates the distal part of the lower leg; the left hand grasps around the calcaneus (Fig. 16.25a). (b) More localized subtalar transverse laterally: the right hand fixates the distal part of the lower leg, the index under the medial aspect of the talus; the left hand grasps around the calcaneus. (c) More localized talocrural transverse laterally: the heel of the right hand is at the lateral malleolus, the fingers pointing towards the knee; the web of the first interosseous space, the index and the thumb of the left hand grasp around the medial border of the talus, just inferior of the lateral malleolus (Fig. 16.25c).

Application of forces by therapist (method) •

•

(a) and (b): The hand at the calcaneus moves towards the floor. (c) and (d) Both forearms move opposite to each other.

Variations in the application of forces •

•

Hind-foot and localized subtalar transverse laterally: Figure 16.25b; patient lies on the other side. Talocntral transverse medially: same technique, change hands (Fig. 16.25d).

Uses • •

Examination technique. Important mobilization of the hind-foot, especially the subtalar joint.

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INTERTARSAL JOINTS

The intertarsal joints play an important role in the trans mission of forces from the hind-foot towards the forefoot. Inversion and eversion movements as a complex, as well as supination and pronation as more localized rotary movement, need specific attention, both in examination and in treatment. The passive physiological movements include: • • • • • • • •

supination of forefoot to hind-foot pronation of forefoot to hind-foot inversion as combined movement eversion as combined movement abduction adduction plantar flexion dorsiflexion.

• • • •

Supi nation-pronation (Fig. 1 6.26) •

• • •

• • •

posteroanterior movement anteroposterior movement longitudinal caudad longitudinal cephalad

Fig u re 1 6.26

I ntertarsal movement: (a) su pination ; (b) pronation.

Direction: Movement of forefoot towards hind-foot in supination/pronation direction. Symbols: Sup, Pron. Patient starting position: Prone, 90° knee flexion. Therapist starting position: Standing by the right knee; the left knee on the couch to support the patient's shin.

Localization of forces (position of therapist's hands) •

The accessory movements which are possible include: •

transverse medially transverse laterally rotation (supination) rotation (pronation).

•

The right hands grasps around the sole of the calcaneus, the fingers around the medial border, pointing cephalad, the thumb at the lateral border. The web of the first interosseous space of the left hand is placed at the dorsum of the foot, fingers spread over the medial border, the thumb partially over the lateral border (Fig. 1 6.26a).

The a n kle and foot complex

Application of forces by therapist (method) •

The right hand fixates, the left hand and left arm make supination movement.

Variations in the application of forces •

•

Pronation: right hand as above; the web of the first interosseous space grasps the medial border of the foot, the thumb plantar, the fingers at the dorsum (Fig. 16.26b).

•

Variations in the application of forces •

Uses • •

Examination technique. Treatment.

Inversion (Fig. 1 6.27) • • •

•

Direction: Movement of the midfoot into inversion. Symbol: mv. Patient starting position: (a) Prone, 90° knee flexion; (b and c) prone c. 20° knee flexion; (d) side lying on the left side, hips and knees comfortably flexed, the right foot extends over the couch. Therapist starting position: (a) Standing by the right knee, the left knee on the couch to support the patient's shin; (b and c) at the end of the plinth, lower leg supports on the table; (d) behind the patient.

(b and d) Grade III +: the therapist lifts the foot from the couch by flexing the patient's knee, then lowers the leg medially rotating the hip and inverting the foot, resting the fully inverted foot against the therapist's thigh. (c) Grade IV +: small amplitude oscillations are performed strongly at the limit of range by the right hand.

Eversion: as b and c; the movement of the patient's foot is away from the therapist, which is the important part of the swinging action (Fig. 16.28b).

Uses • •

Examination technique. Treatment.

Eversion (Fig. 1 6.28) • • • •

Direction: Movement of the midfoot into eversion. Symbol: Ev. Patient starting position: Prone, 90° knee flexion. Therapist starting position: Standing by the right knee with the left knee on the couch to support the patient's shin.

Localization of forces (position of therapist's hands) Localization of forces (position of therapist's hands) •

•

•

(a) The right hands grasps around the sole of the calcaneus, the fingers around the medial border, pointing cephalad, the thumb at the lateral border; left hand: the web of the first interosseous space is placed at the dorsum of the foot, fingers spread over the medial border, the thumb partially over the lateral border. (b and c): The forefoot is held in both hands with the thumbs and thenar eminences along the sole of the forefoot, fingers overlapping on the dorsum of the foot. (d): The left hand is placed between the medial side of the foot and the edge of couch (fulcrum), if necessary: the forearm over the lower leg to stabilize; the heel of the left hand is placed over the lateral border of the lateral tarsometatarsal joints, the fingers over the plantar surface, the thumb over the dorsal surface.

Application of forces by therapist (method) •

(a) The right hand fixates, the left hand and left arm make the inversion movement.

•

•

The right hand fixates the calcaneus: the palm of the hand at the sole of the calcaneus, fingers spread over the medial border of hind-foot, the thumb at lateral border. The left hand is placed over the sole of the foot at the level of the tarsometatarsal joint, fingers at the medial border, the thumb and thenar eminence at the lateral border.

Application of forces by therapist (method) •

The right hand fixates, the left hand produces the eversion movement.

Variations in the application of forces •

See Figure 16.27b,c (same technique; patient lays on other side); see Figure 16.27d (movement of patient's foot is away from the therapist) (Fig. 16.28b).

Uses • •

Examination technique. Treatment (grades II and III ) . -

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Figure 1 6.27

Ankle joint: (a) inversion ; (b, c) grade I I I ; (d) grade IV.

Abd uction-adduction (Fig. 1 6.29) •

Direction: Forefoot movements in abduction or adduction direction in relation to the rnidfoot.

• • •

SymboLs: Ab, Ad. Patient starting position: Prone, 900 knee flexion. Therapist starting position: Standing by the right knee with the left knee on the couch to support the patient's shin.

The a n k l e and foot com p l ex

( a)

Adduction

Abduction

Figure 1 6.29

Forefoot abduction I adduction.

which will be moved, the thumb is over the cuboid. Figure 1 6.28 Intertarsal movement, eversion: (a) grade I I ; (b) grade 1 1 1 - .

Application of forces by therapist (method) •

Localization o f forces (position o f therapist's hands) •

•

The right hand is placed over the heel, fingers at the medial border, the thumb at the lateral border at the joint line (calcaneocuboid). The left hand is placed over the distal part of the foot; the index finger is over the joint line

The therapist's arms transmit pressure through the fingers for abduction, through the thumbs for adduction.

Variations in the application of forces •

Adduction: as abduction but the hands move in the opposite direction.

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•

Techniques can b e localized t o metatarsal I, cuneiform I, navicular, calcaneus, cuboid.

•

Uses • •

Examination technique. Treatment.

Plantar flexion (Fig. 1 6.30) •

• • •

Direction: Movement of the forefoot towards plantar flexion in relation to the midfoot. Symbol: PE Patient starting position: Prone, 90° knee flexion. Therapist starting position: Standing by the right knee; left knee is on the couch to support the patient's shin.

The ulnar border of the left hand is placed over the joint line, fingers at the medial border, the thumb at the lateral border; the lower arm is positioned in the direction of movement.

Application of forces by therapist (method) •

The left lower arm levers the forefoot into plantar flexion.

Variatians in the application of forces •

The movement can be localized in the tarsometa tarsal, cuneiform-navicular, navicular-talar and calcaneocuboid joints.

Uses • •

Examination technique. Treatment.

Localization of forces (position of therapist's hands) •

The right hand is placed over the sole of the calcaneus, the thumb at the lateral border, pointed towards the lateral malleolus, the fingers at the medial border spread over the medial malleolus.

Figure 1 6.30

Forefoot: plantar flexion.

Dorsiflexion (Fig. 1 6.3 1 ) •

•

Direction: Movement of the forefoot towards dorsiflexion in relation to the midfoot. Symbol: DE

Figure 1 6.31

Forefoot: dorsiflexion.

The ankle and foot co m plex

• •

Patient starting position: Prone, 90° knee flexion. Therapist starting position Standing by the right knee, the left knee on the couch to support the patient's shin.

Localization of forces (position of therapist's hands) •

•

The right hand is placed over the sole of the calcaneus, the thumb at the lateral border, pointing towards the lateral malleolus; the fingers at medial border spread over the medial malleolus. The left hand is placed over the plantar side of the forefoot, the thumb and index finger are over the joint line.

•

versa; cuboid:calcaneus; cuboid:navicular / cuneiform and vice versa. Without/with compression.

Uses • •

Examination technique. Treatment (in different physiological positions of the foot - ranging from PF, OF, Inv, Ev and combinations).

Application of forces by therapist (method) •

Movement is produced by the lever of the left forearm.

Variations in the application of forces •

The movement can be localized in the tarsometatarsal, cuneiform-navicular, navicular-talar and calcaneocuboid joints.

Uses • •

Examination technique. Treatment.

Accessory movements of the i nter tarsa l joi nts (Fig. 1 6.32) • •

Symbols: ; ' t C:, :J, -+ , --, ""'-' ceph and caud Patient and therapist starting positions: These depend on the objective of the technique, the position of the foot, the patient and the therapist.

Localization of forces (position of therapist's hands) •

Frequently with the pad of the thumb and the phalanx of the index finger; both hands are placed as closely together at the joint line as possible.

Application of forces by therapist (method) •

Usually one hand fixates, the other hands moves. However, in situations of stiffness with little pain, both hands may produce movement in opposite directions.

Variations in the application of forces • •

'The technique is the brainchild of ingenuity.' Movements are possible: metatarsals:tarsals and vice versa; cuneiform I-III:navicular and vice

Figure 1 6.32 (a) Position for PA, AP, t ransverse lateral ly, rotation, longitudinal movements of the navicu lar; (b) antero posterior movement of the navicular to the tal us, with the foot placed in some pla ntar flexion.

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TARSOMETATARSAL JOINTS, INTERMETATARSAL JOINTS

Tarsometatarsa l joints: flexion l extension (Fig. 1 6.33) •

The following passive movements maybe produced: •

•

Tarsometatarsal joints: - Physiological movements: F (Fig. 1 6.33a), E (Fig. 1 6.33b), Sup, Pron (Fig. 1 6.34). - Accessory movements: PA, AP, shaft rotations, longitudinal cephalad, longitudinal caudad, transverse medially, laterally (technique is identical to the technique described in Fig. 1 6.32b, 1 6.33a). Intermetatarsal joint movements: - HF (Fig. 1 6.35), HE (Fig. 1 6.36). - PA, AP, longitudinal cephalad, longitudinal caudad (Fig. 16.37).

Many of the movements which can be produced in the tarsometatarsal joints and the intermetatarsal joints are similar to the teclmiques described in 'Intertarsal joints' above.

Figure 1 6.33

Tarsometatarsal joint: (a) flexion; (b) extension.

• • •

Direction: Movement of the metatarsal bones in relation to tarsal bones into flexion! extension direction. Symbols: F, E. Patiellt starting position: Prone, 90° knee flexion. Therapist starting position: Standing by the right knee with the left knee on the couch to support the patient's shin.

Localization of forces (position of therapist's hands) •

•

•

The tarsometatarsal joint is held in both hands, with the thumbs on the plantar surface of the adjacent bones. Index fingers curl around the medial border of the foot. The fingers of each hand support the remainder of the dorsum of the foot.

The a n k l e and foot com p l ex

Application of forces by therapist (method) •

•

Flexion: the heel of each hand and the arms pivot around the thumbs (Fig. 16.33a). Extension: the heel of each hand and the arms pivot around the fulcrum of the index fingers adjacent to the joint line (Fig. 16.33b).

•

Localization of forces (position of therapist's hands) •

Variations in the application of forces •

May be localized towards the 1 st, 4th and 5th tarsometatarsal joints.

Uses • •

Examination technique. Treatment.

Tarsometatarsal joi nts : supination/pronation (Fig. 1 6.34) •

• •

Direction: Movement of the metatarsal bones in relation to the tarsal bones into supination/ pronation direction. Symbols: Sup, Pron. Patient starting position: Prone, 90° knee flexion.

Therapist starting position: Standing by the right knee with the left knee on the couch to support the patient's shin.

•

The right hand grasps around the calcaneus; the fingers spread over the medial border of the hind foot, the index finger fixates the os cuneiforme. The palm of the supinated left hand is against the dorsum of the forefoot.

Application of forces by therapist (method) •

The right hand fixates; the left forearm and hand produce supination or pronation movement.

Variations in the application of forces •

May be applied more locally at the medial or lateral border of the foot.

Uses • •

Examination technique. Treatment.

I ntermetatarsal joints : horizontal flexion (Fig. 1 6.35) •

• •

Figure 1 6.34 Tarsometatarsa l joint: pronation.

Direction: Increasing the transverse arch of the foot around the second metatarsal bone. Symbol: HF. Patient starting position : Prone, feet near the end of the couch; knee slightly flexed.

Figure 1 6. 3 5

Intermetatarsal movement, horizontal flexion.

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•

Therapist starting position: Standing at the end o f the couch, kneeling on the right knee to support the right hand against thigh.

Localization of forces (position of therapist's hands) •

•

The pads of the thumb point to each other over the plantar surface of the head of the second metatarsal bone. The fingers grasp around each side of the foot. The main finger contact is with the dorsum of the 1st and 4th metatarsals.

Application of forces by therapist (method) •

Variations in the application of forces •

•

•

Application of forces by therapist (method) •

The therapist's arms pivot the fingers around the fulcrum of the thumbs by abduction of the shoulder.

•

•

These may be applied locally: cuneiform I:cuboid; bases of metatarsal I:metatarsals IV and V; heads of metatarsal I:metatarsals IV and V. The fulcrum may be changed from 2nd metatarsal bone to 3rd or 4th metatarsal bone. Compression may be added by a horizontally applied pressure.

• •

•

• •

•

Examination technique. Treatment (often after the immobilization phase; rigid foot).

Examination technique. Treatment (often after immobilization phase; rigid foot).

I ntermetata rsal j o i nts : accessory movement (Fig. 1 6.37)

Uses •

These may be applied locally: cuneiform I:cuboid; bases of metatarsal I:metatarsals IV and V; heads of metatarsal I:metatarsals IV and V. The fulcrum may be changed from 2nd metatarsal bone to 3rd or 4th metatarsal bone. Compression may be added by a horizontally applied pressure.

Uses

Variations in the application of forces •

Supination movement of the forearms pivoting thumbs around the fingers.

•

Direction: Accessory movements of the heads or the bases of the metatarsal bones in relation to each other. Symbols: ; , t , ...... ceph and caud. Patient starting position: Prone, feet near the end of the couch, knee slightly flexed. Therapist starting position: Standing at the end of the couch, kneeling on the right knee to support the right hand against the thigh.

I ntermetatarsal joi nts : horizontal extension (Fig. 1 6.36) •

• •

•

Direction: Flattening of the transverse arch of the foot around the 2nd metatarsal bone. Symbol: HE. Patient starting position: Prone, feet near the end of the couch; knee slightly flexed. Therapist starting position: Standing at the end of the couch, kneeling on the right knee to support the right hand against the thigh.

Localization of forces (position of therapist's hands) •

•

The metacarpals and phalanges of the thumbs and thenar eminence over the plantar surface of the heads of 1 st and 5th metacarpal bones. The thumbs point towards the heel. The pads of the fingers are placed over the dorsum of 2nd metatarsal bone.

Figure 1 6.36

Intermetatarsal movement, horizontal extension.

The ankle and foot com p l ex

Localization of forces (position of therapist's hands)

The pads of the thumbs at the plantar surface of the heads or bases of the metatarsal bones. The fingers grasp around each side of the foot towards the dorsum.

•

•

Application of forces by therapist (method) •

One thumb stabilizes, the other thumb produces the movement.

It responds well to mobilization techniques, particularly if the chosen direction of movement is combined with a degree of axial compression. However, the treatment needs to be complemented with recruitment of the intrinsic muscles, abductor muscles and normalization of gait patterns. The technique as described for tl1e first metatarso phalangeal joint may be modified to apply to all other metatarsophalangeal and interphalangeal joints.

Movements of MTP I (Fig. 1 6.38) Variations in the application of forces •

•

Movement of the bases of the metatarsal bones in relation to each other. Movement of the heads of the metatarsal bones in relation to each other.

Uses • •

Examination technique. Treatment (often after immobilization phase; rigid foot; metatarsalgia due to movement dysfunctions of the intermetatarsal connections).

METATARSOPHALANGEAL JOINTS

Any toe may cause trouble; however, the hallux with the metatarsophalangeal joint is most frequently involved.

F ig ure 1 6.37

Intermetatarsal movement, accessory movements PA, AP, longitudinal caudad and cephalad.

•

• •

Direction: All physiological and accessory movements may be applied with this technique. Patient starting position: Supine, pillow under knee. Therapist starting position: Standing by the side of the patient's foot.

Localization of forces (position of therapist's hands) •

•

The left hand stabilizes the distal part of the first metatarsal bone with the pad of the thumb and the index around the ball of the foot. The right hand holds the first phalanx of the hallux by grasping around it with the thumb and the first phalanx of index.

Application of forces by therapist (method) •

The left hand fixates; the right lower arm guides the movements.

Figure 1 6.38 movement.

Metatarsophalangeal, i nterphalangeal

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M A ITLAN D ' S P E R I P H E R A L M A N I P U LATI O N

Variations i n the application o f forces •

•

•

All accessory movements may be carried out in different physiological positions of the toe (F, E, Ab, Ad). All physiological and accessory movements may be performed with a certain degree of extension.

are presented for the following com mon disorders related to the ankle and foot complex:

Clinical profiles

• •

Uses •

Treatment (in all stages of treatment, see Chapters 7 and 8).

•

ankle distortion (Box 16.4) Achilles tendinitis (Box 1 6.5) shin splint (Box 16.6).

Examination technique.

Box

1 8.4

Clinical profile: ankle distortion --��----� wall' thinki n g

Exa m i nation

Clinica l evidence / 'brick

Kind of d isorder

Pa i n and stiffness after d istortion of foot (most freq uently i nversion trauma)

Body cha rt featu res

Symptoms may be local ized to lateral border of an kle. In recurrent sprains symptoms may be felt i nteriorly in med ial part of talocrura l joint

Activity l i m itations/24-hour behaviour of symptoms

I n acute phase ga it, ru n n ing, j u m ping, turn i ng and twisting pa i n ; foot may be severely i m pa i red

Present / past h istory

I nj u ring movement: typical inversion axis follows lateral border of hind-foot, possibly i nvolving latera l liga ments, d istal syndesmosis, cuboid (SUbluxation), peroneal muscles, su perficial peroneal nerve, proximal tibiofibular joint. However, many d istortions may have d ifferent injuring movements, i nvolving rotary movement of the intertarsal joints

Special questions Sou rce / mechan isms of symptom production

Peri- and i ntra-articu lar structures may provoke nociceptive pain. If peroneal nerve is i nvolved, symptoms may last longer, may be of burn i ng qua lity - neurogenic symptom mechanisms may be present

Cause of the source Contributing factors

Loss of m uscu lar control, impaired joint position sense

Observations

Swelling and effusion may be present

Functional demonstration of active movements

Usu a l ly in weight-bea ri ng. OF, PF, I nv, Ev may be pai nful and restricted

If n ecessa ry tests Other structures in plan

May test neurodynamic structure (peroneal nerve)

Isometric/m uscle length tests

Usu a l ly i nconclusive. However, tendons of peroneal m uscles may have been involved in the i nj u ry

N eurological exa m ination N eu rodyna mic testin g

Su perficial peroneal nerve

Pa lpation findings

Ligaments of hind-foot

Passive movement, accessory / physiological combined movements

Accessory movement of d istal tibiofibular joint, talocru ra l , subtalar, calca neonavicu lar-ta lar joi nts have to be exa m i ned

Mobi lization / m a n i p u lation techn iq ues preferred

Accessory movements i n d ifferent positions of hind-foot. In later phase (earl iest beg i n n i n g of late remodelling phase after c. 6-8 weeks) D F / PF u nder com pression of ta locrura l joi nt, if i ntra-articular d isorders are present

----

.-.- ------ - ----- -

--

- - --

� ------

---�

----� --

----

-

-

�

The ankle and foot comp l ex

Other management strategies

In acute phase: rest, compression (tape/ brace - to a l low and a lso to restrict movement; however, no neurophysiological effect on propriocepsis and muscle reaction [Al lison et al 1 999]), elevation / walking on crutches; muscle contractions and movements after c. 3 days; initially within 'resistance' free ranges of motion (short of increase of resistance). Increase of passive mobilizations gently into resistance, muscular control, training of joint position sense

Prog nosis/natural history

Frequently spontaneous recovery of symptoms; however if left untreated stiffness and residual symptoms may remain, as well as restricted joint position sense

Evidence base

Pa hor Et Toppenberg ( 1 996), de Bie et al ( 1 998), Al lison et al ( 1 999), Ca u lfield (2000)

Exa m i nation

Cli n ica l evidence/ 'brick wa l l ' thinking

Kind of disorder

Symptoms and at times swe l l i ng i n a rea of Ach i l l es tendon, mostly i n weig ht-bearing activities

Body chart features

Local symptoms, sharp qual ity

Activity lim itations/24-hour behaviour of symptoms

Gait, getting down stairs, j u m ping, squatting on heels, ru n n i ng, etc. may be strongly impaired

Present/ past history

Symptoms mostly develop sponta neously, frequently i n relation with overuse

Specia I q uestions Sou rce /mechan isms of symptom production

Local tend o n / peritendoneal structures cause nociceptive pain. If the sural nerve is i nvolved, neurogenic pain mechan isms may be present

Cause of the sou rce Contributing factors

Foot deformities (pes cavus, rigid arch in combination with activities such as joggi n g ; pes planus with pronation of hind-foot). History of low back pain may be a contributing factor to the local tissues having become more vul nerable. Cave: complete rupture of tendon (Test: prone, foot over edge of plinth; squeeze m uscle of gastrocnemius. If tendon is i ntact plantar flexion of heel will take place; if tendon is ruptured no movement of heel occurs)

Observations

Position of foot. Swel ling of tendon may be visible

Functional demonstration of active movements

Correct any deformation i n gait/standing /ru n n ing with e.g. corrective tape and observe if symptoms decrease. Dorsiflexion, eversion freq uently provoke symptoms. In severe cases active plantar flexion may a lso provoke symptoms (unusual)

If necessary tests Other structures in plan

Relation to l u m bar movement dysfu nction, neurodynam ics

Isometric/muscle length tests

Testing of triceps surae: standing on toes (both l egs, one leg) provokes symptoms. Resistance to plantar flexion movement throughout the ra nge of motion and pa l pation may indicate tendon sheath problem

Neurological exa mination Neurodynamic testing

Sura l nerve, posterior tibial nerve

Palpation findings

Local tenderness of tendon and peritendoneal structures

Passive movement, accessory /physiological combi ned movements

Examine d istal tibiofibular joi nt, a n kle joint

Mobil ization / manipulation techniques preferred

Treat joint signs of h i nd-foot, mobil ize arch of foot (if possible), treat joints signs of l u mbar spine (if related). I n later stage, integrate neurodynamic treatment (if related)

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M A I T LA N D ' S P E R I P H E R A L M A N I P U LAT I O N

Other management strategies

I n itial acute phase : rest, ice, elevation, protective taping with use of heel lift. Soft tissue techniq u es after 3-5 days; progression towards more i ntense techniques and careful stretchi n g exercises

Prognosis / natura l history

In most patients the tendin itis g radually settles over a few weeks; infiltration (in medial or lateral borders a round the tendon - never i nto the tendon substance!) may be considered i n some residual cases

Evidence base

Corriga n Et Maitland ( 1 983), McPoil Et Culotta McGarvey ( 1 988)

Box

1 6.6

Exa m ination

Cl i n ical evidence/'brick wall' thinking

Kind of d isorder

Pain i n a nterior, medial or occasiona l ly lateral reg ion of the sh i n

Body cha rt featu res

Local sharp p a i n i n a rea o f muscles or tendons

Activity l i m itations/24-hour behaviour of symptoms

Activities in weig ht-bearing which involve contraction and stretch ing of the involved structures w i l l be pain provoking

Present/past h istory

Symptoms mostly develop spontaneously

Special q u estions Source/ mecha n isms of symptom production

Nociception a rising from m uscles, tendons or tendon sheaths of the sh i n

Cause of the source Contributing factors

Often i n u ntrained or u nconditioned athletes, change i n event or playing su rface, i ncrease in j u m ping activities, a change in footwear, changes in training sched ule

Observations

Local swel l i ng may be present

Functional demonstration of active movements

Tests which involve contraction and stretch ing of the structure are usua lly pain provoking

If necessary tests Other structures in plan

Relation to l u m bar movement dysfu nction, neurodynamics

Isometric /muscle length tests

Testing of the m uscles i nvolved, including pal pation : reproduce symptoms. Tendon sheaths tests: may provoke symptoms

Neurological exam ination Neurodynamic testing Pa l pation fi ndings

Local tenderness of structu res

Passive movement, accessory/physiolog ical combined movements

Similar to Box 1 6.5

Mobil ization / manipu lation tech n iq ues preferred

If joint signs a re present

Other management strategies

Soft tissue treatment (e.g. transverse frictions), careful stretching exercises of the muscles i nvolved, ada pted to the stage of healing. Add ress the contributing factors

Prog nosis / natu ra I h istory

Good prognosis

Evidence base

Beck ( 1 998)

The ankle and foot com plex

CASE STU DY 1 6 . 1

H E E L PA I N

I n this section the procedure of exa m i nation and treatment of a patient will be described, while simu ltaneously aspects of the physiotherapist's clin ica l reasoning processes, which g u ide towards the next steps in exami nation and treatment, will be mentioned. It shows how i n an initial stage of exa m i nation several hypotheses are formed which d u ri n g the course of exami nation and treatment may be d iscarded or confirmed. It this case study it became evident that the therapist had to consider several sources of the problem and had to be careful in the progression of treatment techniques to prevent any exacerbation due to too high dosed movement at mecha nosensitive structu res. In agreement with the patient, the physiotherapist's thoug hts were spoken i nto a tape recorder after severa l

Procedures of exa m ination and treatment

steps in the subjective and physical exa m i nations. The patient has not heard the therapist's thoug hts and hypotheses. M r E is an active 64-year-old man who reti red from his profession as a bookkeeper 2 years ago. He l i kes h i king in the mountains and goes dancing reg ularly with his wife. He has been sent to physiotherapy with the diagnosis 'heel spur' on the right. Six months ago he had an arth roscopy of the right knee, where abrasion of the tibial cartilage tissue was performed. He has had no problems with this knee ever since. On g reeting M r E i n the waiting room, I observe a friendly laughing m a n who is obviously i n pain a s soon as he gets u p to wa l k and needs a stick. He expla i ns that he took to his crutches from the knee operation again a bout 1 week ago as otherwise walking was a l most u n bearable.

Physiotherapist's thoughts and hypotheses

Subjective examination Main problem Pain i n the foot, especially a round the medial hind-foot, which inte rferes strongly with weight-bearing d u ring walking. Dancing is not possible. As soon as patient is sitting, the symptoms subside within min utes.

I would like to see this man walking: strange that a heel spur might be so painful and disabling! I have seen people with a painful heel spur whojust had to transfer their weigh t a bit and they could walk fairly well. Apparently this does nat work for Mr E. Hopefully it is nat something similar as the situation of my friend C, a physiotherapist, who presented years ago with a similar disabling pain, but in the lang term they found aut that it was an osteosarcoma. However C had also pain at night and was often in pain. Mr E appears to be pain free as soan as he sits dawn.

Body chart (Fig. 1 6.39) Location and qual ity of symptoms. No relationship between the different symptom areas appears to exist.

This seems to be a strange location of pain for a heel spur. The quality of the symptoms leads me to think mare of a neurogenic dysfunction; well the n. plantaris goes araund the calcaneus, so who knows, maybe he had a specific pain under the heel when he was visiting his doctor. which has now moved mare towards the medial side of the heel? 1'/1 have to ask for this in the history! However. maybe it is a more local disorder. as the pain in the heel does nat seem to have a direct relationship with, for example, the lumbar symptoms, which might be expected if the source was a neuradynamic disorder.

Behavio u r of symptoms Pa i n a round the foot increases with weight-bearing. Once in weight-bea ring, nothing i nfl uences the pa i n ( n o specific movements or positions). Sitti ng down : after 2 min utes the pain reduces 1 00%. Wa lking with crutches makes it 'bea ra ble', though not pain free. During the night the pa i n may i ncrease and awaken him about 3-4x. As soon as the leg is

If this is something of compression in the hind-foot, then it may indicate an intra-articular disorder. However. he cannot influence his pain by changing the position of the foot a bit. Well, that happens with inflammations as well. But here I doubt it. If it is a mare inflammatory disorder. then I would expect it to be painful in sitting as well.

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MAITLA N D'S P E R I P H ERAL MAN I P U LATI O N

Procedu res o f exa m i nation and treatment

Physiotherapist's thoughts and hypotheses

raised and the foot is moved, the pain reduces and the patient is able to sleep again.

The night pain is interesting. It seems to resolve itself easily when he is supine, lying with his leg a little bit in SLR and then moving his foot. Is this maybe a neurodynamic disorder?

The genera l level of activity is now fa r below the patient's desired level ; he has ca ncelled h i king vacations i n the Alps because the pa i n is too intense. He is considerin g cancel l i ng biki n g vacations in France as well.

However, if this is the case I have to be careful because afthe physiological components: I do not want to move anything at the price of the conduction qualities of nerves! This night pain might be explained by changes in pressure gradients in blood circulation as described by Sunderland {7978}.

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Burning Stabbing

Figure 1 6.39 of Mr E.

Body chart

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The a n kle and foot com p l ex

Procedures of examination and treatment

Physiotherapist's thoughts and hypotheses

H istory

Symptoms in the foot have existed for about 6 weeks. Had never before had pain in the foot or in the heel. If he had low back pain it was only loca l ly or slig htly in the right buttock. After a party 6 weeks ago where he had been dancing for 4 hours with very tight shoes he felt a slight pain medially in his heel, but no change in lumbar symptoms. After about 2 days he felt twinges of pain under his heel, which g radually i ncreased. Went to his physician after about 2 weeks, because symptoms appeared to i ncrease. Had an X-ray, where indications of heel spurs under both heels were shown. Doctor told the patient to rest and to use Voltaren cream. Did so; after 3 weeks of rest the pain was the same, if not more, especially medially of the heel and about 1 week ago M r E decided to use crutches in order to be able to wa l k. Doctor has sent h i m to try a series of physiotherapy.

See, it seems to fit with what I thought previously during the body ch art. However, I hove to be careful not to be biased towards a neurodynomic disorder, his lumbar spine is not free of symptoms and why did he need his knee operation 0 couple of months ago? Are his footjoints and soft tissues free of signs? I certainly will need to perform a comprehensive examination. Heel spur in both feet - why only symptoms in his right foot? He may have had this spur for years - why did he develop symptoms only 6 weeks ago and never before? I doubt the heel spur is the cause of his movement disorder; maybe it is a contributing factor. However, what happened during the dancing? Friction of the shoe on the medial side of his foot?

Special questions

All questions indicate a good general health. Arthroscopy of the knee was about 6 months ago because of some pa i n deep i n the knee when playing tennis. Surgeon removed some meniscus tissue and did abrasion of ca rtilage tissue. M r E has not had any pain or movement impa irment si nce the operation.

So I think I can discard my fear that h e may have a more 'sinister' pathology. His weight is stobie, he feels healthy, likes to be active and is not taking any medication at this time.

Pla n n ing of physical exa m i n ation

Contraindications to movement proced u res: no. Preca utions: yes, because of the severity of the pain and the nature: it may be a neurogenic disorder, with changes in conduction. Procedure of tests: short gait ana lysis, active l u m bar tests i n sta nding, active knee tests i n supine, active foot tests until the onset of pain. Regular questioni n g about t h e present p a i n level is needed. Passive testing with regular reassessment of joi nts of hind-foot, soft tissues, neurodynamics and lumbar spine.

What kind of h ypotheses do I have? I have to be careful in physical examination, because the pain is so intense; however, it seems to improve quickly as soon as he sits down. Sources? Neurodynamic dysfunction? Local soft tissue???? How about the fascia plantaris? Local joint problem in hind-foot? Some sort of referred symptoms from the lumbar spine? Causes? Something with the activities during dancing? If h e has a neurodynamic disorder i t might b e explained b y the rubbing of the h ard shoe on the n. tibialis post? Or were the soles of his shoes too hard, which irritated the fascia plantaris and the n. plantaris? Well I need to carefully plan my examination, in order to keep track of the sources of the problem and with thot I might find better answers to the question of why this problem developed. I will not be able to examine all passive tests, otherwise I might lose the overview of the possible sources. I might plan two or three sessions with careful examination and probationary treatments before I can feel more secure about the sources, the causes and contributing factors of his problem.

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M A IT LA N D'S P E R I P H ERAL MAN I PU LATI O N

Procedu res o f exa m i nation and treatment

Physiotherapist's though ts and hypotheses

Physical examination I nspection

In standing, no weight on foot; otherwise norma l. No swel l i ng or local temperature changes. A. dorsa lis ped is and posterior tibial a rteries on both feet i n different positions a re t h e sa me. Gait: l imping and pain reproduction especially at the beg i n n i n g of heel contact until mid-stance. Active movement testi n g Lu mbar spine movements (F, E , LF, Rot tested i n standi ng) i n c l u d i n g overpressu re a re slightly l i m ited i n mobil ity and provoke o n l y local l u mbar symptoms.

I do not often palpate the A. dorsalis pedis, but this pain seems to follow a more atypical, uncommon clinical pattern. I have to be aware of certain circulatory conditians which can be very painful and which need treatment other than physiotherapy. However, I am happy that the pulses in the left and right foot are the same, in supine, in sitting and in standing.

On the first view the active lumbar, hip and knee mavements do not seem to be a part of this patient's movement disorder. However, I should not immediately dismiss them as possible sources as I have not moved them locally with accessory

H i p and knee movements i n supine lying have normal mobil ity and do not provoke any discomfort. Foot movements: active OF and eversion with some overpressu re (grade IV-) reproduce the patient's main pain. They both have normal mobi lity. Plantar flexion, i nversion and toe movements have normal mobil ity and a re pa i n free, even after strong passive overpressure. Local d ifferentiation tests indicate the sou rce of the movement d isorder as being between ca lcaneus and talus.

movements and other more specific passive physiological movements. I am happy though that the basic pain did not increase after all these test movements. The nociceptive process seems to be located around the foot and less from the structures tested until now. This indicates a joint mavement dysfunction; however, it does not indicate yet if it has a more periarticular dysfunction, where movements of tendons or tendon sheaths of m. tibialis post. or neurodynamic movements may be contributing to these problems in OF and Ev.

M uscle tests

Isometric tests in supine lyi ng, tendon tests and tests for the tendon sheaths of m. tibialis posterior show a normal quantity and no pain provocation.

I think I can exclude muscular components as a source of this acute pain, otherwise I should have provoked at least some of the patient's main pain. However, a lack of recruitment may be a contributing factor; that is something which needs to be reconsidered at a later stage, once I knaw better how to control the pain and once the pain is less dominant.

Neuro l ogical exa m i nation

Sensation (soft touch) in the whole leg is the sam e as in the left leg ; m uscle power of loca l foot m uscles is normal (5, without pain). Reflexes of Ach i l les tendon and patellar tendon left and right are sym metrical (++).

I've performed these tests nowjust to be sure; it is not indicative of a lumbar radicular disorder but maybe some peripheral neurological disorder? Fortunately no changes; no indication af disturbances in the physiological aspects of nerve function. Later under the group of passive testing I may not need to be quite so cautious with tests of the mechanical aspects of the nervous system (SLR and its variatians).

Palpation of soft tissues Soft tissue palpation of the fascia plantaris is pain free, but pa lpation of the dorsa l-medial side of the medial mal leolus is very painful and the pain remai ns. It a ppears that especially the n. tibialis posterior is very sensitive, while the tendon and tendon sheath of the m. tibialis posterior a re without pain.

This is indicative of hyperolgesia; even if the cause is a local soft tissue problem, this shows already that at the moment I cannot treat it with soft tissue tech niques such as transverse frictions as I might irritate the problem at this stage.

The a n kle

and foot co mplex

Proced u res of examination and treatment

Physiotherapist's thoughts

Passive testing (i ncl. reassessments and passive test movements) Joints: particularly i n eversion positions accessory (medial and internal rotation) movements of the ca lcaneus in relation to the talus are pai nfu l . The accessory movements a re lim ited because of resistance to tissue stress, but the concomitant pa i n is relatively strong. On reassessment after these movement tests the patient did not feel any increase or decrease i n pain. A second series o f gentle accessory movements was performed, with the foot i n DF/ Ev and the medial and internal rotation accessory movement stayed within the pain limit. This treatment was performed for about 3 m i n utes, then the whole heel got slightly sensitive. In reassessment: no increase or decrease of symptoms during gait or DF and eversion of the foot.

I might start to use these accessory movements of the

and hypotheses

calcaneus in treatment; on the first view in reassessment he did not get worse, in contrast to the local palpation of the medial-dorsal side of the heel. This sometimes happens during first treatment; after a few minutes the symptoms may increase; however. in reassessment no significant negative or positive changes occur. If symptoms are still irritable, this is the time to stop a treatment for that session and wait for the result the following day.

Reflection on the first assessment session With the information fram this first examination I have the following hypotheses: the lumbar spine, hip and knee do not seem to be very relevant sources; however. I have not performed any passive movement testing of the lumbar spine yet, nor of the neurodynamic system. Certainly there are some signs in the subtalarjoints and in the periarticular structures which need to be addressed in treatment. It appears to be a peripheral nociceptive and a peripheral neurogenic pain mechanism. Because of the irritability of the pain and the apparent mechanosensitivity of the posterior tibial nerve I do not want to perform treatment techniques which are provoking pain; my tech niques will stay short of pain. The disablement is very high for the man, as many of the daily life activities that he enjoys so much are not possible at this stage. I should try to help him also to 'help himself, once we have found out more about the sources and the movement directions at fault. I think he will certainly be motivated to do some home exercises, as long as he feels they are of benefit to him. The first goals of treatment will be pain reduction as well as finding movements in which the patient himself can do something about the pain. Other goals of treatment depend on other examination findings (e.g. muscle imbalance, mobility of neurodynamic structures, general condition {which may be decreased after avoiding activities for more than 6 weeks], quality of gait after walking for a prolonged period with crutches}. Hypotheses an clinical pattern or diagnosis: it seems to be more indicative of a tarsal tunnel syndrome rother than a heel spur. However. no large neurological changes appear to exist, which may indicate a good prognosis with physiotherapy. Nevertheless, I know that a tarsal tunnel syndrome may often be more complicated to treat than a similar carpal tunnel syndrome. Plan Session 2

Reassess subjective (wa lking, night) and physical (gait, DF, eversion) exa mination fi ndings. Seek for possible contributions of l u m bar spine and neurodynamics with passive testing and fol lowing reassessment. If better: continue treatment on the impairments found; if same: conti nue treatment of the foot.

It is often better to leave examinations of other camponents to the second or even the third session, as many components may be involved and may cause changes in symptoms and signs. If the physiotherapist decides to examine and treat them all at once in the first session, there may be confusion in the following session as to what may have caused the decrease (or increase) in the patient's symptoms and signs.

Session 2

Mr E did not feel many changes. It seemed more sensitive for about 3-4 hours, then it reduced to 'norma l'. Weight-bearing on the leg is as painful as

Good, at least he did not get any worse from all the test movements that I performed yesterday! However. it's now time that we tried to improve some of these symptoms!

571

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M A I T LA N D ' S P E R I P H E R A L M A N I P U LAT I O N

Procedures o f exa m i nation a n d treatment

Physiotherap ist's thoughts and hypotheses

before ; d u ri n g the night he woke up and did his movements again 3-4x d u ring the nig ht.

As the SLR on the right is more limited than on the left, this

Recapitu lation of the physical exam ination tests: Gait: pa i n com mences i m mediately with 'heel-on' phase of weig ht-bea ring. OF and eversian: both provoke the pa i n at a gentle overpressu re (grade IV-). Passive SLR: restricted in compa rison with the left side (70·); however, the pa i n in the dorsal side of the thigh is similar left and rig ht. Madified SLR: in DF (before pain) of the foot: add SLR of the leg : in 50· of hip flexion the foot pain was reproduced, which i ncreased with added h i p / i nternal rotation and decreased i n 40· of hip flexion.

start with OF and then add SLR as described by Butler (799 1).

may be an indication of some neurodynamic disorder. I may have to change the sequence of the test movements and

Although I am quite sure now that the patient's problem has a neurodynamic component, I feel I should not yet use neurodynamic mobilizations, but continue with local joint techniques. He reacts too much with an increase of pain after only one short examination procedure. I can imagine that with the progression of thejoint techniques of the calcaneus I might position Mr. E slightly in some SLR position, but I certainly do not want to offer any direct techniques to the neurol system at this stage. I do not think that the lumbar spine is directly referring

In reassessment after the exa m i nation tech nique the patient felt slightly more pain i n weight-bearing. Passive Lx palpation and accessory movement of T l O- L5 : provoked some of the local l u mbar pa in. I n reassessment l u mbar extension and lu mbar rotation a re 'freer' and less pain provoking. However, the SLR has been u nchanged as well as the gait and DF resp. eversion of the foot.

symptoms to the foot, as in reassessment the main parameters of the foot pain have not been changed at all. There are for the moment enough clear signs in the footjoints and the neurodynamics to start treatment from a more local basis. However, I want to stay short of onset of pain while the condition is so irritable. It seems to be better than yesterday as I am now able to perform the techniques for at least 5 minutes without

Treatment: local joint techniq ues. In DF (short of pain) do transverse accessory movements and internal rotation accessory movement (short of pa i n). After a bout 3 m i n utes: resistance and pain seem to change? After about 5 minutes: no further change d u ri n g treatment.

increase in pain - on the contrary it seems that the passive range of motion of the accessory movements has increased during the treatment procedures.

In reassessment: for the fi rst 5 steps i n gait the patient felt 'freer', then it was the same as before. DF and eversio n : a stronger overpressu re was needed before the pa i n was provoked. After a second series of the same loca l joint techniques the patient felt freer for about 1 0 m ga it, DF and eversion a ppeared to be similar i n overpressure. Pla n Session 3

Reassess the same parameters as in Session 2, including S L R and modified SLR.

The reaction on the joint techniques was quite promising; however, if he falls back totally in symptoms and signs I may only be 'stirring up' things. If he comes back better

Treatment of joint structures: maybe progression to SLR - positioning (before onset of pain however).

or the same I will continue with joint techniques; if the modified SLR is less painful and less dominated by pain, I may use some SLR positioning to the localjoint techniques. However, if he comes back much worse I may have to reconsider my examination (especially neurological exam.) and may want to have a talk with the physician if e.g. local infiltrations might be indicated or that the patient and I should practise more patience ...

The a nkle and foot complex

Procedures of examination and treatment Session 3 Patient felt better after Session 2 for about 5-6 hours ; felt that it was lighter to have some weight on the foot, the pain was sti l l there but less intense than before. After about 6 hours it was the sa me as usual. However, it was q u ite unusual for the patient to be i n less intense pain for 5-6 hours. During the night: was only woken up once, did same movement and slept again. Also this is q u ite u n usua l : since the onset of the symptoms there h a s been n o night u ntil now where he was not woken u p a t least 3x.

Physiotherapist's thoughts <jnd hypotheses

Well, stick to your treatment plan! However, be careful of 'treatment greediness' as the problem certainly is not stable yet. It seems to be slightly improving, but it may easily fall back and you know from the literature and from your personal clinical experience that, if neurodynamic problems fall back, they are much harder to treat than joint problems! The patient seems to be 'plateauing ' already with the more local joint techniques; he does not get much better now, but neither does he get worse. I can carefully try a next step in progression of treatment by positioning the leg in slightly

Gait: qual ity of rol l i ng over foot more as in left foot; however, walking without crutches after 10 steps becomes very painful. DF does not provoke the symptoms anymore, even with strong passive overpressure, whereas eversion sti l l provokes the patient's pain.

more neurodynamic tension - however, I do want to keep the position of the leg pain free!

Treatment: local joint techniq ues as i n Session 2. I n the first series with the leg eversion of the foot and 'off-tension' of the neural system. I n reassessment there was not m uch i mprovement of the gait and of the eversion. Therefore, progression towards positioning in eversion of the foot and knee extension and hip flexion - treatment techniq ues continue with accessory movements of the calcaneus. In reassessment: gait for about 10 m without crutches without pain. Eversion : a lmost pain free with maxi m u m overpressure. Plan Session 4 As in Session 3 ; retrospective assessment.

It seems to be a less complicated problem than I initially thought. However, I have to identify from all the different things I did over the past three sessions which ones may have helped the patient the most. I need to do a retrospective assessment, otherwise I might just treat on and on, without really knowing what helps him the most and to know which goals (activities) need to be improved next from the perspective of the patient.

Session 4 Patient felt much better. Had two nights where he had no pain, last night he felt a bit of pain, but was not woken by it. Gait: without crutches possible. After walking for about 50 m he feels some pain, stops, wriggles his foot and can conti nue to walk for a nother 50 m. Physical exa m i nation : gait normal for 1 0 m. Walking on heels provokes the pain. DF normal qual ity, quantity and no pain provocatio n ; eversion normal qua lity and quantity, slightly painful (tiny spot dorsa l ly of medial mal leolus) i n maxim u m overpressure. Pa lpation of the dorsomedial side of the hee l : less sensitive - posterior tibial nerve sl ightly sensitive but not such a strong hyperalgesic reaction as i n the first session.

Yippee! It seems that the mechanosensitivity of the nerve decreases?

573

574

M A ITLA N D ' S P E R I P H E R A L M A N I P U LAT I O N

Procedures

o f exam ination a n d treatment

Physiotherapist's thoughts

and hypotheses

Sessions 4-8 The treatment continued in the sa me manner. On the one hand the joint tech niques were contin ued as the patient felt that these have hel ped him most until now. As soon as the modified SLR was also less dominated by pa i n , direct long a mplitude mobilizations to the nervous system were performed i n side lying. A home prog ra m m e was developed with two exercises of a utomobil ization of the calca neus and of the nervous system. The patient would do these exercises as soon as he felt some pain com ing on, wh ich enabled h i m after some short i nterruption t o continue with walking. The walking distance i ncreased over the period of time towards a more normal d istance without pain. I n the m eantime the patient needed to be encouraged to take up some hiking tours to test how his body was reacting and how he might be h e l ped by the two a utomobil ization exercises. Session 9 (last session) Patient feels more or less pain free - pain ca me on only yesterday after a h i king tour of 2 hours in the mounta i ns. He performed his a utomobi l ization exercises, which enabled him to continue walking. After h i king today he did not feel any i ncrease i n pain.

It would have been nice to follow up this man a little bit longer; however, I have to stay pragm atic - there are no more sessions prescribed and I am not sure if it is necessary to ask for a second series of nine sessions. If he calls me in 2 weeks (and hopefully he does) we can

The session today consisted of reassessment of ga it, SLR and foot movement. No differences exist anymore on the left side. Treatment consisted of controlling the home exercises and some fu rther coordination exercises on the wobble-board, in gait and in different daily l ife movements as he did not feel confident i n several daily life activities.

decide if a request for a second series might be needed. I do expect, however, that he will now be able to manage on his own, with the home exercises and with increases in activity level. Hopefully he will think of the home exercises as a 'warm up' before dancing and when he feels a little bit of pain coming on.

Therapy will be stopped here (doctor's prescription) patient may ca l l in 2 weeks if further treatment seems i n dicated. Adapted from Hengeveld (2000).

References Allison, G., Hopper, D., Martin, 1. et aJ.

1999. Influence of

rigid taping on peroneal latency in normal ankles.

45, 195-201 1998. Tibial stress injuries. Sports Medicine, 26, 265-279 Boyle, J. & Negus, V. 1998. Joint position sense in the Australian Journal of Physiotherapy,

Beck, B.

recurrently sprained ankle. Australian Journal of

Physiotherapy,

44, 159-163

Butler, D.

1991. Mobilisation of the Nervous System . Melbourne:

Churchill Livingstone Butler, D.

2000. The Sensitive Nervous System. Adelaide:

NOI Group Caulfield, B.

2000. Functional instability of the ankle joint. 86, 401-411 & Maitland, G. D. 1983. Practical Orthopaedic

Physiotherapy, Corrigan, B.

Medicine. London: Butterworth-Heinemann

The a n k l e and foot com p l ex

Corrigan, B. & Maitland, G. D. 1994. Musculoskeletal and

Sports Injuries. Oxford: Butterworth-Heinemann Czerniecki, J. 1988. Foot and ankle biomechanics in walking

McConnell, J. 1 996. Management of patellofemoral problems. Manual Therapy, 1, 60--66 McPoil, T. & Culotta McGarvey, T. 1988. The foot in athletics.

and running. American Journal of Physical Medicine and

In Physical Therapy of the Foot and Ankle, ed. G. Hunt.

Rehabilitation, 67, 246-252

New York: Churchill Livingstone

de Bie, R, Hendriks, H., Lenssen, A. F. et al. 1998. KNGF Richtlijn: Acuut Enkelletsel. Nederlands Tijdschrift voor

Fysiotherapie,

108(1) (supplement)

Edgar, D., Jull, G. & Sutton, S. 1994. The relationship between upper trapezius muscle length and upper quadrant neural

tissue extensibility. Australian Journal of Physiotherapy, 40,

99-103 Hengeveld, E. W ; OO. n concetto Maitland per la fisioterapia manipolativa. In Riabi/itazione Integrata delle Patologie della

Caviglia e del Piede, ed. A. Poser, pp. 105-129. Milan: Masson Hoppenfeld, S. 1976. Physical Examination of the Spine and

Extremities. Norwalk, CT: Appleton-Century-Crofts Janda, V. 1983. Muscle Function Testing. Oxford: Butterworths Kendall, F. P. & McCreary, E. K. 1993. Muscles, Testing and

Function. Baltimore: Williams and Wilkins Klein-Vogelbach, S. 1983. Funktionelle Bewegungslehre. Berlin: Springer-Verlag

Nordin, M. & Frankel, V. 2001. Basic Biomechan ics of the

Musculoskeletal System. Philadelphia: Lippincott, Williams and Wilkins Pahor, S. & Toppenberg, R 1996. An investigation of neural tissue involvement in ankle inversion sprains. Manual

Therapy, 1, 192-197 Palastanga, N., Field, D. & Soames, R 1994. Anatomy and

Human Movement. Structure and Function. Oxford: Butterworth-Heinemann Rose, J. & Gamble, ] . 1994. Human Walking. Baltimore: Williams and Wilkins Sahrmann, S. 2002. Diagnosis and Treatment of Movement

Impairment Syndromes. St. Louis: Mosby Sunderland, S. 1978. Nerves and Nerve Injuries. Edinburgh: Churchill Livingstone Williams, P. 1. & Warwick, R, eds. 1980. Gray's Anatomy, 36th edn. London: Churchill Livingstone

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Chapter

17

The temporomandibular joints, larynx and hyoid (the craniomandibular complex)

THIS CHAPTER INCLUDES: • • •

Key words for this chapter G lossary of terms for this chapter The role of manipulative physiotherapy in the management of cran iomand ibular dysfunction

KEY WORDS Temporoma ndibular joi nts, larynx,

GLOSSARY OF TERMS Bruxism - the act of grinding the teeth together, usually subconsciously or during sleep. Bruxism is associated with stress states and results in myofascial pain and associated pain from the temporoma ndibular joints.

•

• • •

Causes of temporomand ibu l a r j o i n t disorder Subjective exa m i nation I ntegrated physica l examination Exam ination and treatment techniques

•

An integrated approach to rehab i l itation following temporoma nd ibular joint d i sorder A case exa m p l e of mobil ization in the ma nagement of movement related temporoma ndibular joint d isorders.

hyoid, intracapsular dysfunction, trigem i n a l nerve, masseter,

tem pora l is, latera l pterygoid, medial pterygoid.

Craniomandibular complex - a term used to describe not on Iy the temporomandibular joints but a lso the functional interrelationships between the skull, the cervical spine, the thorax, the mand ible, the teeth, the tongue, the hyoid and the larynx. Dental occ l us i on - the manner i n which the teeth m a ke contact with each other. Malocclusion,

therefore, is abnormal contact such as when a filling has not been shaped correctly. Overbite - loss of the vertical d i mensions of the lower mandible i n relation to the sku l l d i mensions. Trismus - sustai ned contraction of the jaw muscles ('lockjaw').

INTRODUCTION There are several clinical reasons why examination and manipulative physiotherapy assessment and treatment of the temporomandibular joints should be considered. These include:

•

•

• •

•

patients who are referred specifically with movement-related disorders of the joints (Trott 1986)

•

patients who suffer from headaches related to the cervical spine and craniomandibular complex (Carstenson 1986) patients who have suffered from whiplash-type injury and have head, neck, throat and face symptoms (Schellhas 1989) patients with head, neck, throat, face and shoulder girdle symptoms in the absence of clear spinal signs patients with any unresolving symptoms which are postural/alignment related and where the

578

MAITLAND'S P ERIPH ERA L MAN IP ULATION

[ temporomandibular joints or craniomandibular complex could be the cause of the source of such symptoms. Manipulative physiotherapy has an important role to play in the management of temporomandibular joint (TMJ) movement impairment. The desired effects of treatment should include the following. •

or II medial transverse movement on the painful or pain-free joint side may have the desired effect of relieving the joint's movement-related pain. •

-

is chronic or the limitation is severe, then the use of spatulas may be necessary to maintain the range gained paSSively and to activate the muscles pro ducing the depression using hold/relax techniques (Trott 1986) (Fig. 17. 1). In such cases transverse medial movements may be the technique to effect more range of depression, with spatulas being inserted to maintain the acquired range. This is a good example of the use of accessory movements at the limit of the available range.

Restoration of the joint(s) to their pain-free status (Chapter 2) patients who suffer from painful click ing and mechanical locking of the joint(s). In such cases where the painful locking is due to internal mechanical derangement of the intra-articular disc, such techniques as longitudinal movement caudad or lateral transverse movement of the mandible com bined with repeated oscillatory opening/closing, lat eral deviation or protraction/retraction movements may go some way to restoring the joint to its ideal mechanically efficient pain-free status. Alternatively, while the joint is held in its distracted position the head of the mandible can be rocked in an anteropos terior, posteroanterior, medial or lateral direction to try to effect unlocking of the joint. -

•

•

Stretching tight structures

Technique used when very limited depression is prevent ing the patient from eating normally if the condition

•

Creating an ideal environment for healing after injury -

or surgery involving the joint, passive mobilization of opening and closing may help to reduce the effects of immobilization and help to maintain an ideal functional environment during the period of natural recovery and healing. •

mobilization techniques designed to stretch the tight structures which may be inhibiting ideal mobility of the joints. Such movements may include depression, lateral chin movements, protraction/retraction or any acces sory movement in the tight physiological direction. -

Prevent further loss of movement or maintain mobility in cases of established and painful degenerative changes to the joint passive mobilization techniques to main -

tain the nutrition and the tensile strength of the joint tissue may help the patient with osteoarthritic tem poromandibular joints to maintain or improve the joint's function (Haskin et aI1995).

Pain-relieving techniques where the joint has become very painful and accompanying protective spasm is present, mobilization techniques such as grade I

There are several factors which influence the rest pos ition of the temporomandibular joints, alteration in which predisposes the joint to processes leading to

(a)

(b)

-

Figure

17.1

(a) Transverse accessory movement at the limit of mandibular depression; (b) inserting spatulas following mobilizing

and contract! relax techniques.

579

The temporomandibular joints. l a rynx and hyoid (th e cranioma n d ibul a r complex)

degenerative joint disease (Haskin et al 1995). These include the following. •

•

Dental occlusion

the temporomandibular joints are two synovial condylar joints with teeth. Dental mal occlusion such as lack of posterior support, or bal ance interference (asymmetry of bite after fillings), will alter the ideal rest position of the joint.

or growth disorders will affect the development of the mandible and influence the resting position of the head of the mandible in its fossa.

-

Sensory inputfrom the joint's capsular mechanoreceptors

The most common reasons for the temporomandibular joints to become disordered can be classified as follows (Sturdivant & Fricton 1991). •

-

•

•

•

Cervical spine position and mobility the poking chin posture results in alteration in vestibular, ocular and neck proprioceptive input. -

Tongue position - the tongue should ideally rest against the top palate. Any alteration in tongue position, hyoid bone position and supra- or infrahy oid muscle function will affect the resting position of the mandibular head. Viability of nasal airways

blocked sinuses, for example, may lead to mouth breathing or extension of the head to enhance the available nasal capacity. -

•

Upper joint

Root of

Posterior

Intermediate zone

mandibular fossa

band

(intracapsular disc)

I

•

Anterior band

•

condyle

Figure 17.2

Temporomandibular joint in sagittal section.

Trauma (e.g. accompanying whiplash-type injury)

-

Schellhas (1989) examined MRI scans of patients who had suffered injury to the jaw as a result of whiplash type injury. The inertia of the impact can lead to excessive mandibular depression or the protective contraction of the anterior cervical muscles. MRI findings included mandibular neck fracture, swelling of retrodiscal tissue and internal disc derangement.

Skull, soft palate and mandibular development and anatomical variations -conditions such as cleft palate

compartment

-

in such instances if the position of the head of the condyle or the fossa changes, the intracapsular disc will also change position or displace. The result is likely to be the development of a reCiprocal click whereby an opening click occurs with mouth open ing when the condyle moves below the disc, snaps under the posterior attachment of the disc and then falls into its ideal alignment (Fig. 1 7.3a). A closing click may follow whereby during mouth closing the condyle slides posteriorly to the retrodiscal tissue, the disc having been displaced anteriorly (Fig. 17.3a). A progression of this dysfunction is when, during mouth opening, the disc may displace too far anteri orly and may become stuck, resulting in an opening lock and an inability to open the mouth further. If the joint is hypomobile and maximum opening is not possible and translation of the condyle is lost, the condyle may dislocate resulting in protective spasm and an inability to close the mouth (closed lock) (Fig. 17.3b). Related retrodiscal inflammation is likely to be a consequence of such dysfunctions.

the joint's retrodiscal tissue is highly vascularized and proprioceptive (Fig. 17.2). Alteration in this input will be affected by the rest position of the mandible or movement impairment of the joint. The joint pos sesses the physiological movements of depression, elevation, protraction, retraction, lateral deviation and the accessory movements of anteroposterior/ posteroanterior, longitudinal cephalad and caudad and transverse medially and laterally. Combinations of these movements occur during the joint's functions of biting, chewing, yawning and talking. •

Intracapsular dysfunction (reciprocal click, closed lock)

Dental malocclusion -lack of posterior support (miss ing molars) will result in excessive compressive loading through the mandibular head onto the very sensitive retrodiscal tissue. Balance interference, where contact of teeth on one side of the mouth is different from that on the other, will lead to exces sive loading of the joint on the side opposite to that where contact is greatest. Maximum intercuspation where the teeth are all in maximum contact may well lead to the mandibular head being distracted from its glenOid. Cervical spine alignment and mobility predisposition the poking chin posture, for example, will result in: 1. the mandible relocating its rest position 2. the mandible being retracted

MA I TLAND'S PERIPHERAL MANIP ULATION

580

CD

®

®

(a) Figure

1 7.3

Temporomandibular joint internal derangement, reciprocal click. Reproduced from Kraus,

Temporomandibular joint disorders: management of the craniomandibular complex. Churchill Livingstone, pp.

68 and 70, with

•

Generalized hypermobility Westling and Mattiason (1992) suggested that in a group of 17-year-olds who were deemed as being generally hypermobile according to the Beighton Classification (Beighton et al1983) there was a higher incidence of signs and symptoms of TMJ internal derangement than in a similar population who were not hypermobile. these have been identified in female temporomandibular joints. -

1985.

Epidemiological studies suggest a greater incidence of TMJ dysfunction and reported symptomatology in females (Lawrence 1987). Oestrogen is believed to promote the degenerative process in temporo mandibular joints (Li et al1993).

-

Functional oestrogen receptors

(Ed.)

kind permission.

3. tightening of the skin of the face and the upper cervical posterior soft tissue and the supra- and infrahyoid regions. •

S.

Clinics in Physical Therapy, Vol. 18. Edinburgh:

•

•

Degenerative joint disease

Haskin et al (1995) have reviewed the processes, both mechanical and physiological, which contribute to the pathogenesis of degenerative joint disease in the human tem poromandibular joint. -

Growth disorder genetic predisposition (e.g. hypo plasia, hyperplasia) will influence the development -

The temporomandibular joints. larynx and hyoid (the craniomandibular complex)

CD

®

(b) Figure 1 7.3

•

•

®

(Continued) temporomandibular joint internal derangement-closed lock.

and ideal functioning of the mandible and its mandibular fossa.

SUBJECTIVE EXAMINATION

Myofascial pain (stress-related bruxism)

Kind of disorder

teeth grind ing mainly at night, believed to be a consequence of life stresses, will result in an increase in the rest ing tone of the masticatory muscles (masseter and temporalis), resulting in myofascial pain and trig ger spots in the muscles. This condition is usually managed with a load-absorbing night splint for the teeth. -

Overuse at the dentists during repeated visits to the dentist or when extensive dental work is carried out, the result may be painful overstrain of the joint's capsular structures. -

If one (or both) temporomandibular joint(s) is mechanically, functionally or pathologically disor dered the patient will seek help because of pain over the joint or in and around the ear. Such pain often results in difficulty in biting, chewing or yawning. Movements of the jaw are frequently accompanied by a click which is often loud and embarraSSing. Crepitation may be felt if the joint has become degen erate. Accompanying symptoms may also be present in the form of headaches or soreness of the facial muscles.

581

MAITLAND'S PERIPHERAL MANIP ULATION

Areas of symptoms (body chart)

Figure 17.4 shows the commonest pain areas described by patients with TMJ disorder. Synovial joints also occur between the thyroid cartil age and the sides of the cricoid cartilage, the laminae of the cricoid cartilage and the base of the arytenoid cartilage and occasionally between the lesser and greater cornua in the hyoid bone (Maitland 1991). It is not common for these joints to be painful but as they possess synovial joint material and are sup ported by ligaments, they occasionally give rise to local symptoms. Behaviour of symptoms (over a 24-hour period) •

Compromise of the pain-sensitive structures of the TMJ, in particular the pain-sensitive retrodiscal tissue, will result in painful limitation of such activities as biting, chewing and yawning.

•

A painful click on opening the mouth is also a common manifestation of a TMJ disorder. A closing click may also occur but only in the presence of an accompanying opening click.

•

The patient may also complain of frequently biting the tongue.

•

Morning stiffness and accompanying crepitations may be a feature of degenerative joint disease.

•

Teeth grinding can be a frequent contributing factor to painful temporomandibular joints especially

during the night. The patient will then experience soreness and aching of the facial/masticatory muscles such as masseter and temporalis (Fig. 17.5). •

The laryngeal or hyoid joints will cause local symptoms with swallowing, talking or coughing. A musician who plays wind instruments may well develop symptoms in the larynx or hyoid under circumstances such as fatigue or overuse.

History of symptoms (present and past)

The most common cause of TMJ problems is intra capsular dysfunction due to alteration in the rest pos ition of the joint. The history of symptoms will often mirror the underlying predisposing factors: •

Trauma - such as whiplash or fracture of the condyle of the mandible, or from a punch - will result in a relatively sudden onset of symptoms related to the traumatic event, although detailed questioning may be needed to establish such a relationship.

•

Alteration in the rest position of the joint due to cer vicothoracic alignment faults (poking chin) or due to dental malocclusion may result in insidious onset of symptoms starting with a feeling of restriction within the joint. A painless opening click will fol low, which then becomes painful. An opening and a closing click, an inability to fully open the mouth (closed lock) and painful aching crepitations will progressively develop as the degenerative processes take hold.

Temporalis

Figure 1 7.4

Pain areas.

Figure 1 7.5

Temporalis and masseter muscles.

-_._----

The temporomandibular joints, larynx and hyoid (the craniomandibular complex)

•

•

Other predisposing factors such as generalized hypermobility or overuse and new use may result in the apparently spontaneous onset of symptoms. Periods of life stress resulting in bruxism have often been associated with the development of TMJ symptoms.

•

•

•

•

•

Central nervous system lesions, such as space occupying lesions, may result in masticatory mus cle rigidity and vague pain unrelated to movement. Care should be taken to assess the functions of the relevant cranial nerves as well as any signs of cen tral nervous system dysfunction, including loss of concentration, memory loss, visual, ocular or vestibu lar disturbance, and motor functional loss.

•

•

Odontogenic pain

pain in the jaw can be related to tooth decay or infection, which may also cause referral of pain locally from the teeth along the jaw. -

Sinus pain symptoms such as pain along the zygo matic arch accompanied by pressure changes and respiratory dysfunction may well be of sinus origin. -

Otological disorder (middle ear infections) - pain in and around the ear will be accompanied by alteration in auditory function and vestibular function (vertigo) if the inner ear is affected and should first be inves tigated by a physician.

•

Developmental abnormalities

•

Neoplasm

Rocabado (1985) rec ognized the link between good management of con ditions such as cleft palate and the ability for the mandible to develop more normally. -

the mandibular condyle is a relatively common site of (thankfully) benign tumours. The obvious accompanying signs will be a swollen mass and other signs of impending or actual inflamma tion. Pain will be relatively constant and unchan ging with rest. Other symptoms may include deafness and trismus of the masticatory muscles.

-

Cervical spine disorder - as the upper cervical spine

PHYSICAL EXAMINATION (Boxes 17.1, 17.2) In sitting Observation •

•

• •

Vascular disease facial symptoms and accompany ing aura to migraine may on occasions mimic symp toms similar to those of TMJ disorder. Migraine usually responds to anti-migraine medication. has close neuronal connections with the trigeminal nerve nucleus there is always the chance that the origin of pain referred into the TMJ area from the upper cervical spine will be misinterpreted and vice versa.

Trigeminal neuralgia - burning neuralgic pain felt in the distribution of the trigeminal nerve as a conse quence of the herpes zoster virus. At some point in time the patient will have felt unwell due to the effects of the virus.

-

be due to a disorder of the parotid glands. This will be accompanied by changes in function of the saliv ary glands such as overproduction or (more often) dryness of the mouth, even during eating.

Special questions

As well as the routine special questions it is important to recognize that there is a whole array of conditions which can mimic disorders of the TMJ (Kraus 1985) and include the following.

Parotid disease aching in the cheeks and jowls could

•

•

• • •

•

Facial symmetry - any obvious skull or mandibular developmental abnormalities. Horizontal plane of the eyes, zygomatic arches and mouth. Overbite. Resting position of the jaw (mouth slightly open). Resting position of the head on neck, neck on neck and neck on trunk (alignment, poking chin). Resting position of the tongue and hyoid bone. Inspection of the tongue (indentations). Inspection of the teeth (posterior support, malocclusion, wear patterns). Shoulder girdle, trunk and scapula alignment faults.

Functional demonstration •

If throat pain is reproduced during extension of the head, stabilize the head at the point of onset of the symptoms and ask the patient to swallow or move the position of the tongue to differentiate between the laryngeal and hyoid joints and the anterior cer vical intervertebral structures.

•

If pain around the TMJ is reproduced during end-of-range neck rotation, stabilize the head at the 'bite' of pain and increase or decrease the lat eral deviation of the mandible in the appropriate direction.

-

583

MA I TLAND'S PERIPH ERA L MANIP ULATION

584

Physia1f

� Box 17.1 temporomandibular joint

"_�;0!I:'�;'

-

The cervical spine should form part of the exa m i nation.

Synovial joints a re present and related to movement of hyoid. cricoid. a rytenoid and thyroid cartilages and bones. The cervical spine should form part of the exa m i nation.

Observation * Functi o n a l d e m onstration/tests Theirdemonstration of their functional movements affected by their disorder • Differentiation of their demonstrated fu nctional movement(s)

•

Observation •

*Functional demonstration /tests • Theirdemonstration of their functional movements affected by their disorder • Differentiation of their demonstrated function a l movement(s)

Brief appra isal Active movements (move to pa i n or move to l i m it) Routinely

Note occlusal position Depression. elevation. protraction. retractio n ; note ra nge and teeth a l ignment; lateral movement Note ra nge and pa i n for all movements •

Brief appra isal

•

Active movements Routinely

As applicable

•

Upper cervica l spine

• •

Isometric tests

•

Other structures in 'plan'

Other structures in 'plan'

Routinely

•

• • •

Swa l low Cou g h Speak (volume). s i n g Blow (resisted)

Isometric tests

Passive movements •

Swa l l owing. speaking and coughing

Passive movements

Depression. e l evation. protraction. retraction and latera l mandibular movements ;. t. ----. -- (with and w ithout com pression). ...... ceph and caud Note range. pain. resistance. spasm and behaviour. Note a l ig nment d u ring movement Upper cervical spine

----. --.;. t.:J. C ..... (

Pal pation • + When 'comparable signs' il l-defined. reassess 'injuring movement' (wind-instrument player. si nger) • + Thickening • Cervical .J L

Palpation • Capsular thickening temporomandibular joint • Cervical spine • + When 'comparable signs' i l l-defined. reassess 'injuring movement'

Check case records etc. Highlight main findings with asterisks

Instructions to patient Reproduced by kind permission from Maitland

Check case records etc.

(1992).

Highlight main findings with asterisks

Movement

I nstructions to patient Reproduced b y kind permission from Maitland

(1992).

•

Assess the functional stability of cervical spine dur ing mouth opening or other jaw movements (does the head tilt into extension during mouth opening?).

•

Screening of cervical movements (Maitland et al 2001).

•

Screening of thoracic spine and rib movements (Maitland et aI2001).

Brief appraisal • •

Opening the mouth as widely as possible. Clenching the teeth tightly.

The temporomandibular joints, larynx and hyoid (the craniomandibular complex)

Figure 17.6

Screening of temporomandibular joints: opening.

•

Shoulder/shoulder girdle movements (Chapter 11).

•

Screening of laryngeal/hyoid joints with coughing, swallowing and talking.

•

Mouth opening/closing, measurement of opening, overpressure (Fig. 17.6).

•

Quality of movement during opening (rotation/ translation phases).

•

Clicks during opening and closing (How many? Which phase? Relationship to pain?).

•

Correction of deviation during opening and closing (effects on range, pain and clicks).

•

Lateral deviation left and right - measure range/ symptom response, overpressure (Fig. 17.7).

•

Protraction/retraction - measure range/symptom response, overpressure (Figs 17.8, 17.9).

•

Stability in position of click, pain or deviation (iso metric testing of the mandible in various directions using one finger against the chin).

•

Effects of correction of head on neck, neck on neck and neck on trunk alignment faults on ranges of TMJ movement, pain response and clicking.

In supine •

Palpation (kneeling at the head of the bed facing the patient's feet). Palpate the joint line, mandible,

Figure 1 7.7 deviation.

Screening of temporomandibu lar joints: lateral

Figure 17.8

Screening of temporomandibular joints: protraction.

• •

muscles and local superficial branches of the facial and trigeminal nerves. ULNPTs (Butler 2000). Trigeminal nerve neurodynarnic test (Von Piekartz & Brydon 2000).

585

586

MAITLAND'S PERIPHERAL MANIPULATION

•

Cervical and thoracic intervertebral movements (Maitland et aI200l).

Physical examination (further explanation) •

Overbite or loss of vertical dimensions can be assessed by measuring the distance: 1. between the lateral canthus of the eye and the corner of the mouth 2. the anterior nasal spine and the point of the chin (Trott 1986). These two distances are normally equal but overbite is present if the second measurement is more than one centimetre less than the first.

•

Resting position ofthe mandible -part the patient's lips to reveal the incisors. The teeth should be slightly separated and the incisors should be aligned. If the mandible is deviated, correct this and assess the effects this has on the patient's symptoms.

•

Figure 1 7.9

of the tongue should rest against the anterior part of the upper palate just posterior to the upper incisors (Rocabado 1985).

Screening of temporomandibular joints: retraction. •

• • • • • •

• • •

•

•

•

•

Intra/ extra oral muscle palpation for tenderness. Cranial bone mobility (suture lines). Shoulder quadrant (screening tests) (Chapter 11). TMJ depression/ elevation. Protraction/retraction. Lateral deviation right and left (head turned for convenience). Lateral transverse movement. Longitudinal caudad movement. Longitudinal caudad with depression, elevation, protraction, retraction, deviation. Hyoid, thyroid cartilage transverse and rotary mobility. Muscle length scaleni, trapezius, sternomastoid (Chapter 11). Cervical anteroposterior unilateral intervertebral movements (Maitland et al 200l). Upper cervical PPIVMs (Maitland et aI2001).

In side lying •

• • •

Anteroposterior and posteroanterior TMJ movements. Transverse medial movement of the TMJ. Transverse movement Cl (Maitland et aI2001). C7-T4 PPIVMs (Maitland et aI200l).

•

Cervicothoracic palpation (Maitland et aI200l).

Resting position of the hyoid bone -the hyoid bone can be located anteriorly just below the mandible. It can be moved from side to side with the index finger and the thumb to assess its mobility and any pain response to movement.

•

Inspection of the tongue - if the tongue's resting posi tion has been forced downwards and forwards it will push against the lower teeth and on inspection inden tations of the teeth on the tongue will be visible.

•

Malocclusion - ask the patient to bite, noting any pain, then part the lips and note whether there are any signs of malocclusion such as contact of the teeth on one side more than the other or overbite due to lack of posterior support. This will force the mandible into retraction, compressing the pain sensitive retrodiscal tissue.

•

Inspection of the teeth - ask the patient to open the mouth and look for excessive wear patterns on the teeth which may be related to bruxism.

Movements of the mandible

The average ranges of mandibular movement are as follows (Trott 1986) and can be measured using a small metal ruler. Measurements should be taken from the edges of the incisors or from their centre lines •

In prone lying

Resting position of the tongue -the anterior one-third

• • •

depression: 50-60mrn protraction: 5mrn retraction: 3-4 mrn lateral deviation: 12-15mm.

The temporomandibular joints, larynx and hyoid (the craniomandibular complex)

Palpation of the joint line

The joint line is located directly anterior to the external auditory meatus and can be palpated from within the ear or laterally just in front of the ear. The posterior joint tissue is likely to be most tender and swollen and thickened.

the patient to clench their teeth and palpating the fan-like muscle at its temporal location. •

Palpation of the superficial branches of the trigeminal and facial nerves •

These nerves can be palpated for sensitivity where they become superficial: • • •

supra- and infraorbitally along the zygomatic arch along the lower border of the mandible around the chin.

Trigeminal nerve (mandibular branch) neurodynamic test

Von Piekartz and Brydon (2000) have described neuro dynamiC tests for all the cranial nerves: •

For example, for the trigeminal nerve the patient lies supine with the head resting on a pillow; the therapist stands beyond the patient's head facing the patient's feet.

•

The therapist's left hand supports the occipital region of the neck and the right hand spreads over the crown of the patient's head with all the fingers pointing to the patient's forehead.

•

The upper cervical spine is then flexed, laterally flexed to the left and rotated to the left (for the right trigeminal nerve).

•

The patient is then asked to depress the mandible and laterally deviate it to the left. In this way the mechanosensitivity of the mandibular branch of the trigeminal nerve can be assessed.

Lateral pterygoid, which acts to pull the mandible anteriorly and medially during opening and stabi lizes the intracapsular disc during clOSing, can be palpated using a gloved little finger intraorally by entering the maxillary buccal vestibule then mov ing superiorly, posteriorly and medially towards the insertion on the head of the mandible. Medial pterygoid, which acts to elevate the mandible and move it laterally, can be palpated extraorally at the medial side of the angle of the mandible.

Cranial bone mobility

Von Piekarz and Brydon (2000) have described tech niques which assess the response of the fibrous suture lines of the skull to pressure changes. The suture lines do contain nerve receptors so are considered a possible source of symptoms. A detailed description of the tech niques possible are beyond the scope of this book but it is fair to say that skull development and alteration of transmission of forces between the skull bones may well result in painful conditions and influence the development and ideal functional environment of the temporomandibular joints.

EXAMINATION AND TREATMENT TECHNIQUES Transverse movement medially (Fig. 17.10) •

Direction: Movement of the condyle of the mandible in a transverse medial direction in relation to the mandibular fossa.

•

Symbol:

+-

Intra- and extraoral palpation of masticatory muscles

The masseter, temporalis, medial and lateral pterygOid muscles can be palpated for tenderness in cases where myofascial symptoms are present (Kraus1985): •

Masseter can be palpated intraorally (using a gloved little finger) at its origin along the zygomatic arch and extraorally from inferior to the zygomatic arch moving inferiorly and posteriorly to the angle of the jaw. Have the patient clench their teeth to locate this strap-like muscle extraorally.

•

Temporalis can be palpated intraorally (using a gloved little finger) as it inserts into the coronoid process of the mandible and extraorally by asking

Figure 1 7. 1 0

Transverse movement media l ly.

587

588

MAITLAND'S PERIPHERAL MANIPULATION

•

•

Patient starting position: Supine, lying with the head on a pillow and turned to the left, or side lying with the head supported on a pillow. Therapist starting position: Standing behind the patient's head facing across the patient's body.

Localization of forces (position of therapist's hands) •

•

•

•

The pads of both thumbs are placed over the head of the mandible pointing towards each other. The backs of the thumbs may be positioned close together. The fingers of both hands spread comfortably around the thumbs to provide stability. The arms must be directed in line with the transverse movement of the mandible.

Figure 1 7. 1 1

Transverse movement lateral ly.

Application of forces by therapist (method) •

•

•

Small amplitude (grade J) oscillatory mobilizations are produced by the therapist's arms acting through stable thumbs. Very little pressure is required to produce quite a lot of movement. Care must be taken to make sure the movement is as comfortable as possible.

•

•

•

Uses •

•

•

Where patients are unable to relax the jaw effectively. The main use is treatment of jaw pain and spasm related to the pain (as are other accessory movements which apply pressure to the head of the mandible). Mobilization on the pain-free side will often effect relief of severe pain on the opposite side.

•

The pad of the thumb of the left hand, facing laterally, is placed against the medial surface of the ramus of the mandible, close to, or against, the head of the mandible, within the patient's mouth. The fingers of the left hand grasp around the angle of the jaw and the mandible laterally to reinforce the hold on the ramus. Note that this is an invasion of the patient's personal space. Respect should be given to this and the procedure must be explained in detail at every stage. The patient's gag reflex may be stimulated. The therapist must allow the patient to overcome this before proceeding. Note: It is recommended that any examination or treatment technique which is performed intraorally should be done hygienically. This should involve the appropriate washing of the hands and the use of latex gloves.

Transverse movement laterally (Fig. 17.11) •

• •

•

Direction: Movement of the head of the mandible in a transverse lateral direction in relation to the mandibular fossa.

•

Symbol: -+ Patient starting position: Supine, lying with the head supported by a pillow. The patient's head is turned to the left a few degrees for convenience and accessibility to the head of the mandible within the patient's mouth. Therapist starting position: Standing or kneeling on the right side of the couch, level with the patient's head.

Localization of forces (position of therapist's hands) •

Application of forces by therapist (method)

The right hand stabilizes the patient's head around the crown and forehead.

•

•

•

Gentle oscillatory pressures are applied to the medial side of the mandible so as to produce lateral movement of the head of the mandible in the mandibular fossa. With the grasp of the thumb and fingers, the movement is produced by the action of the therapist's arm, care being taken not to use the thumb flexors concentrically, but rather eccentrically. If the technique is not performed in this manner, pressure on the medial side of the mandible will be most uncomfortable. One finger of the right hand should be placed over the TMJ laterally so that the range of lateral movement can be readily discerned.

The temporomandibular joints, larynx and hyoid (the craniomandibular complex)

Variations in the application of forces •

If the position of the left thumb is too uncomfortable against the head of the mandible, drop it down onto the medial side of the molar teeth and produce the movement with pressure applied against here.

Uses • •

•

Very painful movement of the jaw. Stiffness in opening the mouth (performed with the mouth fully open). Restoration of the joint to its ideal pain-free status if the joint's intracapsular disc has been moved to a more medial resting position. Figure 1 7. 1 2

Posteroanterior movement.

Figure 1 7.1 3

Anteroposterior movement.

Posteroanterior and anteroposterior movement

(Figs 17.12, 17.13) •

• •

Direction: Movement of the head of the mandible in a posteroanterior and anteroposterior direction in relation to the mandibular fossa. Symbols: L f Patient starting position: Supine, lying with the head turned to the left, or lying on the left side.

•

Therapist starting position: - for posteroanterior: standing by the patient's right shoulder facing across the patient's body

- for anteroposterior: standing by the patient's left shoulder facing across the patient's body. Localization of forces (position of therapist's hands)

For posteroanterior The pads of both thumbs, pointing towards each other are placed against the posterior surface of the head of the mandible, behind the ear lobe, with the backs of the thumbs close together. • The fingers rest comfortably over the forehead and mandible. • Both forearms are directed in line with the posteroanterior movement of the joint.

•

For anteroposterior The pads of both thumbs, pointing towards each other are placed against the anterior surface of the condyle of the mandible as close to the head as is possible without losing contact with the anterior surface of the condyle, with the backs of the thumbs close together.

Application of forces by therapist (method) •

•

•

•

The fingers spread comfortably around the patient's forehead, mandible and neck.

•

Both forearms are directed in line with the anteroposterior movement of the joint.

The mobilization in these directions is produced by the therapist'S arms acting through both thumbs. As these areas of contact are normally sensitive to touch it is necessary to position the thumbs carefully and produce the movement with the arms and not the thumb flexors.

Variations in the application of forces •

•

The posteroanterior movement can also be produced by making contact with the head of the mandible from within the external auditory meatus. The anteroposterior movement can be produced by making contact with the ala of the mandible rather than the condyle.

589

590

MAITLAND'S PERIPHERAL MANIPULATION

Uses • •

Very painful jaw movements in particular. When stiffness is detected in these directions.

Longitudinal movement caudad and cephalad

(Fig. 17.14} •

• •

•

Direction: Movement of the head of the mandible in a longitudinal direction both caudad and cephalad in relation to the mandibular fossa. Symbol: - caud and ceph. Patient starting position: Supine, lying over towards the therapist. Therapist starting position: Standing or kneeling by the patient's side, level with the shoulder.

•

Cephalad The technique is one of pushing cephalad to jam the head of the mandible against the articular disc and mandibular fossa. • Movement may be incorporated with the compression.

•

Uses •

Localization of forces (position of therapist's hands)

Caudad The left thumb is placed in the patient's mouth. • The pad of the left thumb faces caudad and is braced against the patient's lower right molars. • The right hand and arm then stabilize the patient's head with one finger of the right hand in a position to be able to palpate for movement of the right TMJ.

•

Cephalad The therapist's left hand and thorax stabilize the patient's head. • The heel of the right hand is placed on the inferior margin of the angle of the mandible.

against the right lower molars so as to distract the TMJ. This is best produced as an oscillatory movement at the limit of the range.

•

The caudad movement is most useful as a technique to stretch into when there is limitation of mouth opening due to tightness of the joint's capsular structures, or in combination with physiological movement when the joint appears to be internally deranged by a less than ideal position of the intracapsular disc. The cephalad movement is used rarely but may influence pain from the joint which occurs with compression of the intra-articular surfaces.

Depression of the mandible (Fig. 17.15) •

•

Direction: Depression of the mandible in the mandibular fossa as in opening of the mouth.

• •

Symbol: De. Patient starting position: Supine, lying with the head resting on a pillow.

•

Application of forces by therapist (method)

Therapist starting position: Standing by the patient's right upper arm facing the patient's head.

Caudad While the therapist's right hand stabilizes the patient's head, the therapist exerts pressure

•

Figure 1 7. 1 4

Figure 1 7.15 fossa.

•

Longitudinal movement caudad and cepha lad.

Localization of forces (position of therapist's hands)

Both hands hold each side of the patient's mandible.

Depression of the mandible in the mandibular

The temporomandibular joints. larynx and hyoid (the craniomandibular complex)

•

•

•

The pads of the middle and ring fingers contact the posterior surface of the ramus of the mandible near its head. The metacarpophalangeal joint of the thumb and the thenar eminence are placed against the superior margin of the body of the mandible near the chin. Care must be taken to use as much of the pads of the fingers as possible to make the contact comfortable.

Application of forces by therapist (method) •

•

•

•

•

•

Protraction and retraction of the mandible (Figs 17.16, 17.17) •

•

This movement must be produced by the therapist's wrists and arms while the hands move with the jaw as a single unit. The therapist can control the depression to encourage protraction of the head of the mandible or backward movement of the angle of the jaw. This is achieved by increasing the work performed through the fingers or that performed through the base of the thumbs because patients find relaxation so difficult. By performing the movements smoothly and encouraging relaxation a finely controlled movement can be performed.

Variations in the application of forces (Fig.

by which physical therapy, and in particular continuous passive motion, may decrease inflammatory mediators of the TMJ.

•

•

Direction: Protraction and retraction of the head of the mandible in relation to the mandibular fossa of the temporal bone. Symbols: Protr, Retr. Patient starting position: Supine, lying with the head resting comfortably on a pillow. T herapist starting position: Kneeling by the side of the patient, level with the patient's head (Protr). Standing beyond the patient's head faCing the patient's feet (Retr).

1 7. 15)

Alternatively, the therapist can stand or kneel by the patient's shoulder facing across the patient's body. The therapist can localize forces by placing two fingers of each hand into the patient's mouth so as to grasp over the upper and lower incisors. The therapist can then stabilize the patient's maxilla using the left hand and apply oscillatory movements (usually at the limit of the range of depression) holding firmly with the fingers of the right hand while producing the movement with the right arm.

Figure 1 7. 1 6

Protraction of the mandible.

Figure 1 7. 1 7

Retraction of the mandible.

Uses •

This technique is most valuable for regaining relaxation of movement during opening of the mouth or regaining the range of physiological movement of mouth opening which has been painful or is stiff.

Evidence base •

Sambajon et al (2003) conclude that a decrease in prostaglandin E2 production in synovial fibroblasts could help elucidate the mechanism

591

592

MAITLAND'S PERIPHERAL MANIPULATION

L

Localization of forces (position of therapist 's hands)

Protraction The index and middle fingers of the right hand are placed inside the patient's lower incisors. • The right thumb stabilizes the mandible laterally. • The left hand and arm hug the patient's head to stabilize it. • The fingers grasp comfortably under either side of the mandible.

•

Retraction The pads of both thumbs, pointing towards the patient's feet, are placed against the anterior margin of the ramus of the mandible. • The fingers reach comfortably around the side of the patient's head. • The base of the pad of the thumbs makes the main contact, not the tip. •

Figure 1 7. 1 8

Application of forces by therapist (method)

Protraction • Oscillatory protraction movements are produced by pulling the mandible forwards with the fingers of the right hand. • The left hand stabilizes the patient's head. The fingers of the left hand can palpate the joint for movement. Retraction The retraction is produced by the therapist's arms acting through the base of the thumbs. • Care must be taken to prevent the thumbs from sliding laterally off the ramus by directing some pressure medially.

•

•

•

•

Uses •

To help to restore both protraction and retraction to their full pain-free range.

•

•

Lateral ch i n movements (Fig. 17. 1 8)

• •

•

Direction: Lateral movement of the chin. SymboL: Lat Dev. Patient starting position: Lying supine with the head turned to the left, resting on a pillow. Therapist starting position: Standing behind the patient's head facing across the patient's body.

•

•

The left hand is placed over the patient's left zygomatic arch to stabilize the head, preventing it

The index finger and thumb are placed along the line of the jaw laterally. The middle finger is placed beneath the jaw so that the grasp can control its opening and closing movements. The ring and little finger of the right hand are flexed at the metacarpophalangeal and proximal interphalangeal joints so that the lateral border of the ring finger can be placed behind the angle of the jaw. The little finger reinforces the ring finger.

With the patient's mouth slightly open and the jaw held firmly in the therapist's right hand the movement is produced by the therapist's right hand. The therapist should endeavour to pivot the right half of the jaw around the left TMJ.

Uses •

Localization of forces (position of therapist's hands)

from rotating further to the left during the mobilization. A particular grasp of the right side of the mandible is adopted so that the therapist's right hand can protract the right TMJ and displace the chin to the left.

Application of forces by therapist (method) •

•

Lateral chin movement.

• •

Restoration of pain-free range of lateral chin movement. When chewing is painful. When stiffness is also inhibiting other jaw movements such as mouth opening.

The temporomandibular joints, larynx and hyoid (the craniomandibular complex)

•

•

•

• •

Figure 1 7. 1 9

Thyroid cartilage movement.

Uses •

Transverse and rotary movement of the laryngeal and hyoid joints (Fig. 17. 19) •

Direction: Transverse or rotary movement of the thyroid cartilage in relation to the hyoid bone or the hyoid bone in relation to the mandible and thyroid cartilage. c:

•

SymboLs:

•

Patient starting position: Supine, lying without a pil

-+ ,

low so that neither the head nor neck is flexed. •

Therapist starting position: Standing by the patient's side, facing across the patient.

Localization of forces (position of therapist's hands)

Movement of the thyroid cartilage The thumb and index finger of the left hand loosely grasp the upper margin of the thyroid cartilage. • The thumb and index finger of the right hand loosely grasp the lower margin of thyroid cartilage. • The fingers spread forwards over the adjacent neck, chest and face. • The little fingers make the firmest contact. •

Movement of the hyoid bone The index finger and thumb of the left hand hold the hyoid bone. • The right hand stabilizes the thyroid cartilage.

•

Application of forces by therapist (method) •

Movement of the thyrOid cartilage away from the therapist is produced by pressure through the thumbs.

The little fingers form a pivot about which the thumb movement takes place. To make the pressure as comfortable as possible the movement should be produced by glenohumeral joint adduction and slight elbow extension rather than by the thumb flexors. Movement of the thyroid cartilage towards the therapist is produced by the opposite movement of the therapist's arms acting through the index fingers. A rotary movement can also be performed. The hyoid bone can be moved in much the same way.

•

When transverse or rotary movements of the laryngeal and hyoid joints are painful. When tightness of the supra- and infrahyoid structures is affecting movement of the mandible or its resting position.

AN INTEG RATED APPROACH TO THE MANAGEMENT OF MOVEMENT-RELATED DISORDERS OF T H E TEMPOROMANDIBULAR JOINTS Due to the complexity of the craniomandibular region, disorders which manifest as TMJ pain or dysfunction are often multicomponential and multidimensional. Any physical therapy management programme must, therefore, reflect this fact and aim towards restoring the ideal rest position of the temporomandibular joints. This in turn will contribute to the normal func tional environment of the joint and the restoration of pain-free movement. Passive mobilization of painful or stiff TMJ move ments is used only as part of the overall management and may, on the one hand, be a means to an end in the restoration of ideal function or, on the other hand, an adjunct to functional rehabilitation. Functional rehabilitation programmes and dealing with the multifaceted contributing factors are essential for both short- and long-term recovery from TMJ dis orders. Rocabado (1985), for example, advocated the use of a rehabilitation programme which included the following ingredients in order to maximize the poten tial recovery and restoration of ideal TMJ rest position and joint function. The 6 X 6 programme includes 6 instructions, 6 times each, 6 times per day. The patient should: • •

learn a new postural position fight the 'soft tissue memory ' of the old position

593

594

MAITLAND'S PERIPHERAL MANIPULATION

• • • •

1.

restore original muscle length restore normal joint mobility restore normal body balance return to the exercise programme when symptoms reappear

Rest position of the tongue -place the tongue on the top palate behind the upper teeth and make a click ing sound (similar to the action during swallow ing). Teach the patient how to keep the anterior one-third of the tongue against the anterior part of the top palate with a slight pressure. Also encour age nose and diaphragmatic breathing.

2. ControL TMJ rotation with the tongue in its ideal rest -

ing position and maintained there and the body ideally aligned, ask the patient to hinge open the mouth. If the tongue stays on the top palate this will reinforce control of ideal rotation of the head of the mandible in relation to the disc and mandibular fossa and reduce the tendency for early translation of the head of the mandible and the disc in the fossa. Control of this rotation with functional activities such as chewing should then be introduced (Fig. 17.20). 3. Perform rhythmicaL stabilization techniques using the index fingers against the chin with varying points of contact, perform hold-relax or rhythmical stabiliza tion of the mandible in varying jaw positions, most usefully in the position of the click or where the jaw deviates during opening and closing. This will enhance proprioceptive and functional stability of movements of the mandible. -

4. Cervical joint liberation - relevant neck exercises or automobilization to retain ideal functional mobility of the cervical spine and stretch tight posterior neck muscles.

5. Axial extension of the cervicaL spine - thus reinforcing both ideal cervical and thoracic alignment and restoration of ideal muscle length. Standing against a wall and sliding the back of the head up the wall is the best way to enhance the feedback mechanisms. 6. Shoulder girdle retraction in contemporary practice this relates to the restoration or awareness of func tional stability of the scapula during arm, head or jaw movements. -

CAS E STU DY 1 7 . 1 T H E R O LE O F M O B I L I ZAT I O N I N T H E M A N A G E M E N T O F M OV E M E N T- R E LATE D T E M PO R O M A N D I B U LA R J O I N T D I S O R D E RS

M rs H , a 42-yea r-o l d comm u n ity psychiatric nurse has devel oped a pa i nfu l click in her jaw when she opens her mouth. This she believes had developed in l ine with occlusion problems as a result of dental work and gum d isease. She a lso has a very stressfu l job which does not help. Kind of disorder (Question 1 ) M rs H indicates that her main problems are: •

• • •

a n inabil ity to fu l ly open her mouth without experienci ng a very pa i nfu l click i n her jaw a sharp pain i n the jaw when biting hard associated pins and need les in her face on occasions tension-type headaches when she is stressed.

Areas of symptoms (body chart) Figu re 1 7.21 is M rs H's a reas of symptoms represented on a body chart Activity Iimitations/24-hour behaviour of symptoms M rs H only experienced the pai nfu l click on trying to open her mouth fu l ly as in yaw n i ng or trying to shout.

•

•

•

•

•

History (present and past) M rs H had been having a lot of dental work to sta b i l ize her loose u pper front incisors w h ich had become loose due to progressive gum d isease.

•

Figure 1 7.20

Control of temporomandibular joint rotation.

She experienced the sharp pain in her jaw w hen biting hard down on the molars, usua l ly on the opposite side to the pain. The pins and needles i n the face would only be present for a few m inutes as an after-effect of the jaw pain. The tension headaches a re only present once or twice per week at the end of the day and the fol lowing morning after a stressfu l day at work. None of h e r symptoms l i m its any of her activities except not being able to fu l ly open her mouth as m uch as she cou ld.

;---;--------- ---

The temporomandibular joi nts, larynx and hyoid (the craniomandibular complex)

Patient's Name: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Patient's Age:

. . . . . " . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Profession: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hobbies/Sport: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Doctor:

Diagnosis

. . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . . . . . . . .

Physiotherapist: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date of Assessment: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Main Problem:

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@ Sepo.n:>ote Figure 1 7.21

•

•

.

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

P0!�:i:\A.I c;!\c;\<:'!'�. j0.� . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

P's

+

.

.

.

N's

Cough / Sneeze Spinal Cord Cauda eq.

Body chart of M rs H .

She felt she had a ltered her bite so as not to d islodge her front teeth so all her eating now i nvolved use of the molars. Stress at work in the last 6 months was thought to have contributed to the onset of the tension headaches and she thought the pins and needles had developed with her jaw problem. This was the worrying factor which had led her to see her G P, who referred her on to physiotherapy for exercises to help her jaw pa in.

•

•

The click had developed sponta neously and had only recently become pai nfu l. On further reflection, she recog n ized the onset of the pins and need l es at the sa me time as the click became painful. Currently she is u nder the care of a n orthodontist.

Special questions • Routine special questions a bout general health, effects of medication and relevant screening were u n remarkable.

595

596

MAITLAND'S PERIPHERAL MANIPULATION

•

There was no evidence of red flags or conditions m i micking TMJ d isorders (Kraus 1 985).

o

Deviation to CD

Phys i cal exa mination Observation •

• •

•

•

Long slender neck, pokin g chin with upper cervical spine in extensi o n ; correction of this caused a stretching sensation in the occiput, further opening of the mouth did not reveal any function a l i nstabil ity of the cervical spine or a ny change i n symptoms. Nasal airways - clear with i n spiration right and l eft. Resting position of the mandible - deviated to the l eft, correction of this caused 00. Bite - no overbite but front i n cisors maxi m a l ly i ntercuspated, balance interference with more contact of the teeth on the left side. Inspection of tongue - i ndentations of the lower teeth evident a round the edge of the tongue.

'Click' 30 mm -

L 40 mm

50 mm

Figure 1 7.22 Diagram showing mouth opening with deviation and cl ick.

C

R2 (IV+++)

Present pain

Headache @, neck feels stiff, jaw pain 00 when opening the mouth only. Functional demonstration"""

Mouth opening 40 m m click and pai n 00 at 30 m m opening, 5· deviation to the left (Fig. 1 7.22), headache ISO.

A

Active movements •

•

•

• • • • •

Cx Ext 30· stiff++ , headache i ncreased, change tongue position ISO **Cx RR 50· stiff++ , headache ISO with right latera l deviation of the mandible added 00 + + Clench teeth 00, cotton wool ba l l i n l eft s i d e 00 + + , cotton wool ba l l i n right s i d e 00 - Lateral deviation o f mandible t o (L) .I, .I **Lateral deviation to the right 10 mm stiff 00 + "Retraction o f t h e m a n d i b l e 3 m m I V - overpressure 00 Protraction .l, .I Hyoid, laryngeal movements, transverse and rota ry .I, .I

Fig u re 1 7.23 Movement diagram showing stiff, painful limitation of +-+ caudad of the right temporomandibular joint and grade IV mobilization technique.

•

Screening tests •

Passive movements •

U n i l ateral PA (""1) C2 stiff/pa i nful loca l ly Mandible longitudinal caudad (R) and transverse latera l (R) stiff and pai nful 00 (Fig. 1 7.23)

•

Treatment/ management •

U n i latera l PA (""1) mobilization C2 (grade I I I ) - with the effect of i m proving the pain and stiffness - free range of cervical extension and rotation and a l lowing a further 5 m m of pain-free opening of the mouth. Lateral deviation and retraction of the mandible were

B

Range

Shoulder, thoracic spine .I, .I

•

p'CD L % � Caud @ TMJ

R1 V2

•

•

u nchanged and the cl ick remained the same a lthough less painfu l . Longitudinal ( +-+ ) and transverse latera l ( -- ) movements of the mandible (R) (grade IV) with the mouth open with the desired effects of restoring the ideal pain-free status of the joint (Chapter 2) and stretching the structures to regain accessory range (Chapter 2). Th is i m proved the range of opening further and the painful click was less obvious; the cervical spine a lso felt freer. The desired effects of the cervical and mandibular mobil ization were to act as a n adjunct to the home progra m me (6 x 6) (Rocabado 1 985). M rs H continues to have dental treatment and still suffers from the clicking jaw but she has retained her range of mouth opening and suffers from fewer tension headaches now that her neck is less stiff and aching. M rs H is less worried about her symptoms now as she has a home progra m me w hich gives her some confidence that she ca n control her symptoms. The resolution of the symptoms, long term, is dependent on the completion of her dental reconstruction.

The temporomandibular joints, larynx and hyoid (the craniomandibular complex)

References Beighton, P, Graham, R. & Bird, H. 1983. Hypermobility of

Joints. Berlin: Springer-Verlag Butler, D. 2000. The Sensitive Nervous System. Adelaide: NOI Group Carstenson, B. 1986. Indications and contraindications of manual therapy for temporomandibular joint

Maitland, G. D. 1992. Neuro/musculoskeletal Examination and

Recording Guide, 5th edn. Adelaide: Lauderdale Press Maitland, G. D., Hengeveld, E., Banks, K. & English, K., eds.

2001 . Maitland's Vertebral Manipulation, 6th edn. Oxford: Butterworth-Heinemann Rocabado, M. 1985. Arthrokinematics of the temporo

dysfunction. In Modern Manual Therapy of the Vertebral

mandibular joints. In Clinical Management of Head, Neck

Column, ed. G. Grieve, pp. 700-705. Edinburgh: Churchill

and TMJ Pain and Dysfunction. New York: W. B. Saunders

Li vingstone Haskin, C, Milan, S. & Cameron, 1. 1995. Pathogenesis of degenerative joint disease in the human temporomandibular joint, Critical Reviews in Oral Biologtj

and Medicine, 6, 248-277 Kraus, S. 1985. Temporomandibular joint disorders: management of the craniomandibular complex. Clinics in

Physical Therapy, Vol 18. Edinburgh: Churchill Livingstone

J. S.

1987. The epidemiology of degenerative joint disease: occupational and ergonomic aspects. In Joint

Lawrence,

Loading, Biologtj and Health of Articular Structures, ed. H.

J. Helminen, 1 . Kiviranta, M. Tarnmi et al, pp. 316-351 .

Borough Green, UK: Wright/Butterworth Scientific Publications Li, Z. G., Danis, V. A. & Brooks, P M. 1993. Effects of gonadal

Sambajon, v., Cillo,

J., Gassner, R. & Buckley, M. 2003. The

effects of mechanical strain on synovial fibroblasts.

American Journal of Oral and Maxillofacial Surgery, 61,

707-712 Schellhas, K. 1989. Temporomandibular joint injuries. Head

and Neck Radiology, 173, 211-216 Sturdivant,

J. & Fricton, J. 1991. Physical therapy for

temporomandibular disorders and orofacial pain. Current

Opinion in Dentistry, 1, 485-496 Trott, P. H. 1976. Temporomandibular Myofascial Pain

Dysfunction Syndrome. Thesis for graduate diploma in manipulative therapy. Trott, P H. 1986. Examination of the temporomandibular joint. In Modern Manual Therapy of the Vertebral Column, ed. G. Grieve, pp. 521-529. Edinburgh: Churchill Livingstone Von Piekartz, H. & Brydon, L. 2000. Cranial Facial

steroids in the production of IL-1 and IL-6 by blood

Dysfunction and Pain, Manual Therapy Assessment and

mononuclear cells in vitro. Clinical and Experimental

Management. Oxford: Butterworth-Heinemann

Rheumatologtj, 11, 157-162 Maitland, G. D. 1991. Peripheral Manipulation, 3rd edn. London: Butterworth-Heinemann

Westling, L. & Mattiasson, A. 1992. General hypermobility and temporomandibular joint derangement in adolescents. Annals of the Rheumatic Diseases, 51, 87-90

597

•

599

Appendix 1

Movement diagram theory and compiling a movement diagram

Appendix 1 remains as it was presented by Geoff Maitland in t he 3rd edition of this book (1991). How ever, in view of contemporary developments arising from researc h and peer review of t his subject, it was felt necessary by t he current authors to add a contem porary perspective. W hat is clear is t hat movement diagrams remain a valuab le too l for bot h current and deve loping clinica l practice (Cheswort h et a l1 998).

A CONTEMPORARY PERSPECTIVE ON DEFINING RESISTANCE, GRADES OF MOBILIZATION AND DEPICTING MOVEMENT DIAGRAMS Petty et a l (2002) in t heir peer review article 'Manual examination of accessory movement-seeking R / have right ly c ha llenged the long-he ld belief t hat for an asymptomatic

joint, t he resistance first fe lt by t he t herapist (RI) w hen the joint is moved passively occurs towards t he end of t he range. RI is considered to be at t he transitiona l point between t he toe and linear regions of a load dis p lacement curve (Lee & Evans 1994) (Fig. ALl). Petty et al (2002) used a spinal assessment mac hine w hic h app lied a posteroanterior force to t he L3 spin ous process w hereby resistance was found to com mence at t he beginning of t he r ange, t he curve ascending as soon as t he force was app lied (Fig. A1 .2). T he suggestions, t herefore, are t hat t here is no c lear transition point between t he toe and linear regions, t his having previous ly been to t he point of definition of RI. T he lack of definite transition may exp lain t he poor re liability of t herapists in judging t he onset of resistance to passive movement (RI) (Latimer et al 1996 ). Petty et a l (2002) suggest t hat RI s hou ld be depicted as ear ly as A on t he movement diagram, A being 160

c �------�

140 1 20 �

3S Q) 2 0 LL

1 00 80 60 40

�--� A �----------�� ------�� Toe Displacement Resistance thought to be imperceptible in this region Figure A 1 . 1 Relationshi p of movement diagra m (ABCD) to load-displacement cu rve. Reprod uced by kind permission from Petty et a I (2002).

20 0

0

2

4

6

8

10

12

14

Displacement (mm) Figure A 1 .2 Typica l force-displacement cu rve of a central PA applied to L3 obtained using the spinal assessment machine. The left-hand curve is loading and the right hand curve is u n loading curve. Reproduced by kind permission from Petty et al (2002).

600

Movement diagram theory and compiling a movement diagram

the starting point of the range of movement. The con sequence of this would be to call into question the accuracy of the resistance-based defined treatment

retained but redefined as follows: •

grades of mobilization/manipulation (grades I-V)

ance but no firm resistance (a note should also be

resulting in the loss of grades I and II and limiting the

made that A is the starting point of the movement

definitions to grades III and IV.

and can be varied according to where the start of

After due consideration of the case presented by

the movement needs to be for best effects).

Petty et al (2002), the authors of this edition of Maitland's

Peripheral Manipulation have proposed a reappraisal of

•

the following: 1.

Grade I - a small amplitude movement at the begin ning of the available range where there is soft resist

II - a large amplitude movement performed

Grade

within the available range where there is soft resist ance but no firm resistance.

the retention of grades I and II in the context of the redefinition of Rl

•

Grade III - a large amplitude movement performed

2. the redefining of resistance

into firm resistance or up to the limit of the available

3.

range.

the depiction of movement diagrams.

The authors, therefore, are minded that such a reap

•

Grade IV - a small amplitude movement performed

praisal may affect the future direction of qualitative or

into firm resistance or up to the limit of the available

quantitative research into movement diagrams, particu

range.

larly in relation to the reliability of therapists' definition of Rl and the accurate calibration of treatment grades of mobilization and manipulation.

•

V - a small amplitude high velocity thrust

Grade

performed usually, but not always, at the end of the available range.

Redefi ning g rades of mobilization

c

R2 (IV+++)(firm)

D

When a joint is moved passively (accessory or physio logical, vertebral or peripheral) a variety of resistances are encountered, for example: •

the

soft, immediate resistance to movement which

fits to the laws of physics •

a firmer resistance to movement when the joint is nearing its end of range or its impaired limit (a stiff joint)

•

the through-range resistance encountered when arthritic joints are moved with their joint surfaces squeezed together

•

;

the resistance of involuntary protective muscle

Range

spasm •

R1 (soft)_=---� -'----..l. --6--'---J..J A '14 L � B % L3 Figure A 1.3 R1 defined in terms of the firm resistance of a stiff, hard end-feel.

the resistance of voluntary holding.

The original resistance-defined grades of mobiliza tion/manipulation (Maitland

(stiffness) or hard and soft end-feel in the ideal or

nor

maL joint (Maitland 1992). From the authors' viewpoint, therefore, the refer ence to resistance refers to the

firmer

resistance felt

when a joint is nearing its end range or impaired limit (Fig. A1.3), rather than the

soft resistance to movement

which is felt immediately the joint is moved. It is clear that this definition of resistance can also be related to the resistance encountered due to protective involun tary muscle spasm (Fig.

C

1991) relate to resistance

(R) being defined in terms of spasm-free resistance

If such an argument is valid - and it may not be -

D

:::l

co c:

I � :.c .l!! °E

·T

Y2

Y2

.?;.� > Q) en

R 1 (soft)

A

A1.4).

then the grading system I, II, III, IV and V can still be

82 (IV+++)

�

Figure A 1 .4 resistance.

81 L '14

Y2

Range

�

Protective involu ntary muscle spasm as a

B

Movement diagram theory and compiling a movement diagram

Redefi n i ng resistance

(1991) depicts

Resistance (R1), in this context, would be redefined as follows: •

•

B as a thickened point to account for

the variation in the therapist's judgement of the end of the normal average range of passive movement. This should be extended to other reference points and

R1 (soft) - the onset of resistance encountered at the

parameters of measurement so that margins of error

immediate moment that movement commences.

can be accounted for and clinical variations between

Minimal; may even be imperceptible.

individual therapist's perceptions can be recognized.

RJ (firm) - the onset of resistance encountered due to: stiffness, the joint surfaces being squeezed

Therefore: •

together and moved, the hard and soft end-feel of a normal joint, protective involuntary muscle spasm (S1 would be the qualifying term in this case) or vol untary holding.

A still remains a fixed starting point but can be var ied (all movements have a definite starting point)

• •

B has already been recognized as a thickened line

R1 (soft) is easy to represent because it can be assumed its onset corresponds to the start of the movement at A

Movement diagram: parameters of reliability In view of the low intertherapist reliability in detecting

•

the relevant reference points and measurable param

individual perceptions of the onset of firm resistance

eters of a movement diagram, the authors suggest a redefining of some of these parameters. Maitland

c

R2 (firm}(IV+++)

� :::J

ro c

I �

:0 .l!l :� I � .� > Q) en

=

•

L being the limit of impaired range should also be a thickened line to take account of the margins of

D

error encountered in determining the limit of the impaired movement by P2' R2 or S2

margins of error (inter tester) •

'(Ioe sev)

Y2

The lines PI to P2 (PI), R1 to R2 (R/) (soft or firm) and 51 to 52 (5') should all be depicted with mar gins of error to account for individual variations in their perception.

Figures A1.5 and A1.6 show the representation of such natural variations on movement diagrams.

L V.

A

R1 (firm)

Y2

P1 (Ioe)

B

Range Figure A 1.5

Movement diagram depicting margins of error. R2 (firm)(IV+++) D

c � :::J

ro c

I �

:0 .l!l % 'E

'T

� ·c Q) > Q) en

R1 (firm) should be represented as a thickened line as is B in order to account for the margins of error in the

Geography would be incomprehensible w ithout maps. They've reduced a tremendous muddle of facts into somet hing you can re ad at a glance. Now I suspect . . . economics [read passive movement1 is fundament ally no more difficult than geography except it's about things in motion. If only somebody would invent a dynamic map. Snow (1965). The movement diagram is intended solely as a teaching

R1 (soft) A

THE MOVEMENT DIAGRAM: A TEACHING AID, A MEANS OF COMMUNICATION AND SELF-LEARNING

aid and a means of communication. When examining,

V.

% Range

�

B

Figure A 1.6 Pictorial relationship between soft and firm resistance (soft end-feel ) . The transitional shaded area between the toe and linear phases of the compliance curve is the area which is probably least reliable (intertherapist) during passive movement testing.

say, a posteroanterior movement of the acromio clavicular joint produced by pressure on the clavicle (see Figure 11.65), newcomers to this method of exam ining will find it difficult to know what they are feel ing. However, the movement diagram makes them analyse the movement in tenns of range, pain, resist ance and muscle spasm. Also, it makes them analyse

601

602

Movement diagram theory and compiling a movement diagram

the manner in which these factors interact to affect the movement. Movement diagrams (and also the grades of move ment) are not necessarily essential to using passive movement as a form of treatment. However, they are essential to understanding the relationship that the various grades of movement have to a patient's abnor mal joint signs. Therefore, although they are not essen tial for a person to be a good manipulator, they are essential if the teaching of the whole concept of manipu lative treatment is to be done at the highest level. Movement diagrams are essential when trying to separate the different components that can be felt when a movement is examined. They therefore become essential for either teaching other people, or for teach ing one's self and thereby progressing one's own analysis and understanding of treatment techniques and their effect on symptoms and signs. The components considered in the diagram are pain, spasm-jree resistance (i.e. stiffness) and muscle spasm found on joint examination, their relative strength and behaviour in all parts of the available range and in relation to each other. Thus the response of the joint to movement is shown in a very detailed way. The theory of the movement diagram is described in this appen dix by discussing each component separately at first (for the practical compilation of a diagram for one direction of movement of one joint in a particular patient, see 'Compiling a movement diagram' below). Each of the above components is an extensive sub ject in itself and it should be realized that discussion in this appendix is deliberately limited in the following ways: •

•

the spasm referred to is protective muscle spasm secondary to joint disorder spasticity caused by upper motor neurone disease and the voluntary contraction of muscles is excluded.

Frequently this voluntary contraction is out of all pro portion to the pain experienced yet in very direct proportion to the patient's apprehension about the examiner 's handling of the joint. Careless handling will provoke such a reaction and thereby obscure the real clinical findings. Resistance (stiffness) free of muscle spasm is discussed only from the clinical point of view, i.e. discussion about the pathology causing the stiffness is excluded. A movement diagram is compiled by draWing graphs for the behaviour of pain, physical resistance and muscle spasm, depicting the position in the range at which each is felt (this is shown on the horizontal line AB) and the intensity, nature or quality of each (which is shown on the vertical line AC) (Fig. A1.7).

c

I

� -� > Q) CI)

A

%

B

Range Figure A 1 .7

Beginning a movement diagram.

The baseline AB represents any range of movement from a starting position at A to the limit of the average normal passive range at B, remembering that when examining a patient's movement of any joint, it is only considered normal if firm proportionate overpressure may be applied without pain. It makes no difference whether the movement depicted is large or small, whether it involves one joint or a group of joints work ing together, or whether it represents 2mm of pos teroanterior movement or 1800 of shoulder flexion. Because of soft-tissue compliance, the end of range of any joint (even 'bone to bone') will have some soft tissue component, physiological or pathological. Thus the range of the 'end of range' (B) will be a moveable point, or have a depth of position on the range line. To locate halfway through the range of the 'end of range' as a grade IV and to fit in either side of it a plus sign ( +) and a minus sign (-) allows the depiction of the force with which this 'end of range' point is approached (Edwards, A., unpublished observations). Point A, the starting point of the movement, is also variable: its position may be the extreme of range opposite B or somewhere in mid-range, whichever is more suitable for the diagram. For example, if shoul der flexion is the movement being represented and the pain or limitation occurs only in the last 1 0° of the range, the diagram will more clearly demonstrate the behaviour of the three factors if the baseline represents the last 20° rather than 90° of flexion. For the purpose of clarity, position A is defined by stating the range represented by the baseline AB. In the above example, if the baseline represents 90°, A must be at about 90°; similarly, if the baseline represents 20°, position A is with the arm 20° short of full flexion (assuming of course that the range of flexion is 180°). As the movement diagram is used to depict what can be felt when examining passive movement, it must be clearly understood that point B represents the

Movement diagram theory and compiling a movement diagram

C �

I

I

I

D

C

I

�

:::>

ro

I

I

I

I

D

:::>

ro c:

c:

I �

I �

:a

.!!l Y2 -

%

:� I

� Q; > Q) en

A

I 'i4

I Y2

I %

:a '"

-E 'T

%,

-"=' .� > Q) en

B

I

A

%

Figure A 1.8

Completion of a movement diagram.

B

Range

Range Figure A 1.9

Onset o f pain.

extreme of pa ssive movement, and that this lies variably, but very importantly, beyond the extreme of active movement. The vertical axis AC represents the quality, na ture or intensity of the factors being plotted; point A represents complete absence of the factor and point C represents the maximum quality, nature or intensity of the factor to which the examiner is prepared to subject the person. The word 'maximum' in relation to 'inten sity' is obvious: it means point C is the maximum intensity of pain the examiner is prepared to provoke. 'Maximum' in relation to 'quality' and 'nature' refers to two other essential parts. They are:

The first step is to move the joint slowly and care fully in the range being tested, asking the patient to report immediately when any discomfort is felt. The position at which this is first felt is noted. The second step consists of several small oscillatory movements in different parts of the pain-free range, gradually moving further into the range up to the point where pain is first felt, thus establishing the exact position of the onset of the pain. There is no danger of exacerbation if:

1 . Irritability - when the examiner would stop the testing movement when the pain was not necessar ily intense but when it was assessed that if the movement was continued into greater pain there would be an exacerbation or latent reaction.

The point at which this occurs is called PI and is marked on the baseline of the diagram (Fig. A1 .9). Thus there are two steps establishing PI:

2.

- when PI represents the onset of, say, scapular pain, but as the movement is continued the pain spreads down the arm. The examiner may decide to stop when the provoked pain reaches the forearm.

Nature

Thus meaning of 'maximum' in relation to each com ponent is discussed again later. The basic diagram is completed by vertical and horizontal lines drawn from B and C to meet at D (Fig. A1.B).

PAIN P, The initial fact to be established is whether the patient has any pain at all and, if so, whether it is present at rest or only on movement. To begin the exercise it is assumed that the patient only has pain on movement.

a. sufficient care is used b. the examiner bears in mind that it is the very first provocation of pain that is being sought.

1. A single slow movement first. 2. Small oscillatory movements. If the pain is reasonably severe then the point found with the first single slow movement will be deeper in the range than that found with oscillatory movements. Having thus found where the pain is first felt with a slow movement, the oscillatory test movements will be carried out in a part of the range that will not pro voke exacerbation.

L (1 of 3) where (L

=

l imit of range)

The next step is to determine the available range of movement. This is done by slowly moving the joint beyond P1until the limit of the range is reached. This point is marked on the baseline as L (Fig. AUO).

L (2 of 3) what The next step is to determine what component it is that prevents or inhibits further movement. As we are only

603

604

Movement diagram theory and compiling a movement diagram

e � .a ro

I

I

I

D

e � ::::J

c

ro

:0

I �

I � ro

�

P2 (latent)

I

I

I

D

c

V2

%-

1

i!' '" .Q) > Q) en

:0 ro

'E '1

V2 -

V2

i!'

A

I

% P1

I

L%

I

3f4

.� > Q) en

B

A

Range Figure A 1 . 1 0

e �

Figure A 1 . 1 2 of pain.

P2

I

I

L V2

I

3f4

B

Range

Limit of the range.

I

I

% P1

I

Latent reaction o f maxi m u m quality o r intensity

D P2 (qualify)

e

� c

D

�

I

�

::::J

ro

:0 .l!l V2 "E

%

T

i!' .� > Q) en

c

I

�

:0 .l!l V2 "E

V2

'1 A

I

% P1

I

L V2

I

3f4

B

Range Figure A 1 . 1 1

Maximum quality or intensity o f pain.

i!' ·c Q) > Q) en A

Figure A 1 .1 3

discussing pain at this stage, P2 is then marked verti cally above L at maximum quality, nature or intensity (Fig. A1.11). The intensity or quality of pain in any one position is assessed as lying somewhere on the vertical axis of the graph (i.e. between A and C) between no pain at all (i.e. A) and the limit (i.e. C). It is important to realize that maximum intensity or quality of pain in the diagram represents the max imum the physiotherapist is prepared to provoke. This point is well within, and quite different from, a level representing intolerable pain for the patient. Estima tion of 'maximum' in this way is, of course, entirely subjective, and varies from person to person. Though this may seem to some readers a grave weakness of the movement diagram, yet it is in fact its strength. When a student's 'L', 'P2' is compared with the instructor's, the differences that may exist will demonstrate whether the student has been too heavy handed or too 'kind and-gentle'.

L (3 of 3) qualify Having decided to stop the movement at L because of the pain's 'maximum "quality or intensity'" and

% P1

L%

3f4

B

Range Pain increasing evenly with movement.

therefore drawn in point P2 on the line CD, it becomes necessary to qualify what P2 represents: if it is the intensity of the pain that is the reason for stopping at L, then P2 should be qualified thus: 'P2 (intensity)'. If, however, the examiner believes that there may be some latent reaction if the joint is moved further even though the pain is not severe, then P2 should be , qualified thus: 'P2 (latent) (Fig. A1.12).

The next step is to depict the behaviour of the pain during the movement between PI and P2. If pain increases evenly with movement into the painful range, the line joining PI and P2 is a straight line (Fig. A1.13). However, pain may not increase evenly in this way. Its build-up may be irregular, calling for a graph that is curved or angular. Pain may be first felt at about quarter range and may initially change quickly, and then the movement can be taken further until a limit at three-quarter range is reached (Fig. A1.14).

Movement diagram theory and compiling a movement diagram

c

c

I

I

o

I

I

� -� > Cl) en

A

Figure A 1 . 1 4

V2

P ' (qualify)

I

A

B

% P1

B

Range

Range Early increase o f pain.

Figure A 1 . 1 6

Pain with no l imiting intensity.

C

A

B

A

----

I

I

I

I

1

L

Figure A 1 .17

Pai n at rest.

Cr-

�D

-,____-. ______.-____

____

In another example, pain may be first felt at quarter range and remain at a low level until it suddenly changes, reaching P2 at three-quarter range (Fig. Al.15). The examples given demonstrate pain that prevents a full range of movement of the joint, but there are instances where pain may never reach a limiting inten sity. Figure Al.15 is an example where a little pain may be felt at half range but the pain scarcely changes beyond this point in the range and the end of normal range may be reached without provoking anything approaching a limit to full range of movement. There is thus no point L, and P' (P' means P prime) appears on the vertical line BD to indicate the relative signi ficance of the pain at that point (Fig. A1.16). The math ematical use of 'prime' in this context is that it represents 'a numerical value which has itself and unity as its only factors' (Concise Oxford Dictiona ry). If we now return to an example where the joint is painful at rest, mentioned above, an estimate must be made of the amount or quality of pain present at rest, and this appears as P on the vertical axis AC (Fig. Al.17). Movement is then begun slowly and carefully

B

Range

Range Figure A 1 . 15 Later increase of pain reaching a maxi m u m at three-quarter range.

0

I

I

I

I V2

I

I

�

.�en

P A

B

Range Figure A 1 . 1 8

Level where pain begins to i ncrease.

until the original level of pain begins to increase (PI in Fig. A1.18). The behaviour of pain beyond this point is plotted in the manner already described, and an example of such a graph is given in Figure Al.19. When the joint is painful at rest the symptoms are eas ily exacerbated by poor handling. However, if exam ination is carried out with care and skill, no difficulty is encountered.

605

606

Movement diagram theory and compiling a movement diagram

Break point

�

o LL

Toe Range Figure A 1 . 1 9

Figure A 1 .2 1

Pain due to subsequent movement.

C.-

D

____-n ,-____.-, -.____

____

e!

:::J

rn

c:

I �

P'(qualify)

:0 � % "E

'1

z:.

"fii > Q) en

V.

A

B

Range Figure A 1 .20

Arc of pain.

Again it must be emphasized that this evaluation of pain is purely subjective. Nevertheless, it presents an invaluable method whereby students can learn to per ceive diHerent behaviours of pain, and their appreci ation of these variations of pain patterns will mature as this type of assessment is practised from patient to patient and checked against the judgment of a more experienced physiotherapist. An arc of pain provoked on passive movement might be depicted as shown in Figure Al.20.

RESISTANCE (FREE OF MUSCLE SPASM) These resistances may be due to adaptive shortening of muscles or capsules, scar tissue, arthritic joint changes and many other non-muscle-spasm situations. A normal joint, when completely relaxed and moved passively, has the feel of being well oiled and friction free (Maitland 1980). It can be likened to wet soap sliding on wet glass. It is important for the physiotherapist using passive movement as a form of treatment to appreciate the difference between a free-running, friction-free movement and one that,

Displacement Compl iance diagram.

although being full range, has minor resistance within the range of movement. A strong recommendation is made for therapists to feel the movements suggested in the article. When depicting a compliance diagram of tl1e forces applied to stretching a ligament from start to breaking point, tl1e graph includes a 'toe region', a 'linear region' and a 'plastic region'; tl1e plastic region ends at the 'break point' (Fig. Al.21). When a physiotherapist assesses abnormal resist ance present in a joint movement, physical laws state that there must be a degree of resistance at the imme diate moment that movement commences. The resist ance is in the opposite direction to the direction of movement being assessed, and it may be so minimal as to be imperceptible to the physiotherapist. This is the 'toe region' of the compliance diagram, and it is omit ted from the movement diagram as used by the manipulative physiotherapist. The section of the compliance graph that forms the movement diagram represents the clinical findings of the behaviour of resistance when examining a patient's movement in the linear region only (Fig. Al.22). R, When assessing for resistance, the best way to appreci ate the free running of a joint is to support and hold around the joint with one hand while the other hand produces an oscillatory movement back and forth through a chosen path of range. If this movement is felt to be friction free then the oscillatory movement can be moved more deeply into the range. In this way the total available range can be assessed. With experi ence, by comparing two patients, and also comparing a patient's right side with the left side, the physiother apist will quickly learn to appreciate minor resistance to movement. Point RJ is then established and marked on the baseline AB (Fig. Al.23).

---

--- �-

Movement diagram theory and compiling a movement diagram

R2 (IV - , Rheu m atoid arthritis)

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Displacement ' Figu re A 1.22 Movement diagra m (ABCD) within com plia nce diagram. The dotted rectangular area (ABCD) is that part of the compliance diagra m that is the basis of the movement diagra m used for representing abnorm a l resistance (R1R2 or R1 R'). C

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I

V,

B

A Figure A 1 .24

I

L %

B

Qualifying R2.

The next step is to determine the behaviour of the resistance between R1 and L, i.e. between R1 and R2. The behaviour of resistance between R1 and R2 is assessed by movements back and forth in the range between R1 and L, and the line depicting the behaviour of the resistance is drawn on the diagram (Fig. A1.25). As with pain, resistance can vary in its behaviour, and examples are shown in Figure A1 .25. The foregoing resistances have been related to extra-articular structures. However, if the joint is held in such a way as to compress the surfaces, intra-articular resistance might be depicted as in Figure A1 .26.

Range F i g ur e A 1.23

L

-

Positioning of R , .

where. L

-

what

The joint movement is then taken to the limit of the range. If resistance limits movement, the range is assessed and marked by L on the baseline. Vertically above L, R2 is drawn on CD to indicate that it is resist ance that limited the range. R2 does not necessarily mean that the physiotherapist is too weak to push any harder; it represents the strength of the resistance beyond which the physiotherapist is not prepared to push. There may be factors such as rheumatoid arth ritis which will limit the strength represented by R2 to being moderately gentle. Therefore as with P2, R2 needs to be qualified. The qualification needs to be of two kinds if it is gentle (e.g. R2 (IV-, RA)), the first indicat ing its strength and the second indicating the reason why the movement is stopped even though the strength is weak (Fig. A1.24). When R2 is a strong resistance (e.g. R2 (IV + + )), its strength only needs to be indicated (Fig. A1 .24).

MUSCLE SPASM There are only two kinds of muscle spasm that will be considered here: one that always limits range and occupies a small part of it, and the other that occurs as a quick contraction to prevent a painful movement. Whether it is a spasm or stiffness that is the limiting factor, the range can frequently only be accurately assessed by: 1. repeated movement taken somewhat beyond the point at which resistance is first encountered 2. being performed at different speeds. Muscle spasm shows a power of active recoil. In con trast, resistance that is free of muscle activity does not have this quality; rather it is constant in strength at any given point in the range. The following examples may help to clarify the point. If a resistance to passive movement is felt between Z1 and Z2 on the baseline AB of the movement diagram (Fig. A1.27), and if this resistance is 'resist ance free of muscle spasm', then at point '0', between Z1 and Z2 (Fig. A1 .28), the strength of resistance will

607

608

Movement diagram theory and compiling a movement diagram

R2(IV+)

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Range

R' (IV+) I

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%

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Spasm-free resistance.

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Crepitus.

be exactly the same irrespective of how quickly or slowly a movement is oscillated up to it. Furthermore, any increase in strength will be directly proportional to the depth in range, regardless of the speed with which the movement is carried out, i.e. the resistance felt at one point in the movement will always be less than that felt at a point deeper in the range. However, if the block is a muscle spasm and test movements are taken up to a point '0' at different speeds, the strength of the resistance will be greater, with increases in speed.

Y2

Y2 -

I

A

X

I

II

Y2

Zl

Range Figure A 1 .27 Z, and Z2'

I

�

I

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Z2

B

Resistance to passive movement felt between

Test movement

.! •

0(

A Figure A 1 .28

Zl

0

Z2

I B

Differentiating resistance from spasm.

The first of the two kinds of muscle spasm will feel like spring steel and will push back against the testing movement, particularly if the test movement is varied in speed and in position in the range.

Movement diagram theory and compiling a movement diagram

609

J C

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I � :0 !!l

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S2(IV+) I

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5, Testing this kind of spasm is done by moving the joint slowly to the point at which the spasm is first elicited, and at this point it is noted on the baseline as S. Further movement is then attempted. If maximum intensity is reached before the end of range, spasm thus becomes a limiting factor.

L

-

where, L

-

what

This limit is noted by L on the baseline and S2 is marked vertically above on the line CD. As with P2 and R2, S2 needs to be qualified in terms of strength and quality, for example S2 (N-, very sharp).

The graph for the behaviour of spasm is plotted between Sland S2 (Fig. A1.29). When muscle spasm limits range it always reaches its maximum quickly, and thus occupies only a small part of the range. Therefore, it will always be depicted as a near-vertical line (Fig. A1 .29a,b). In some cases when the joint disor der is less severe, a little spasm that increases slightly

Figure A 1.29

Muscle spasm.

but never prohibits full movement may be felt just before the end of the range (Fig. A1.29c). The second kind of muscle spasm is directly pro portional to the severity of the patient's pain: move ment of the joint in varying parts of the range causes sharply limiting muscular contractions. This usually occurs when a very painful joint is moved without adequate care and can be completely avoided if the joint is well supported and moved gently. This spasm is reflex in type, coming into action very rapidly dur ing test movement. A very similar kind of muscle con traction can occur as a voluntary action by the patient, indicating a sharp increase in pain. If the physiother apist varies the speed of the test movements it should be possible to distinguish quickly between the reflex spasm and the voluntary spasm by the speed with which the spasm occurs - reflex spasm occurs more quickly in response to a provoking movement than voluntary spasm. This second kind of spasm, which does not limit a range of movement, can usually be avoided by careful handling during the test. To represent this kind of spasm, a near-vertical line is drawn from above the baseline; its height and pos ition on the baseline will signify whether the spasm is easy to provoke and will also give some indication of

61 0

Movement diagram theory and compiling a movement diagram

0

c

0

C

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s·

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%

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%

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%

A

(a)

Figure A 1 .31

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Modified movement diagram.

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(b) Figure A 1 .30

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Spasm that does not l imit ra nge of movement.

its strength. Two examples are drawn of the extremes that may be found (Fig. A1.30a,b).

MODIFICATI ON There is a modification of the baseline AB which can be used when the significant range to be depicted occu pies only, say, 1 0° yet it is 50° short of B. The movement diagram would be as shown in Figure A1.31 and, when used to depict a movement, the range between 'L' and 'B' must be stated. The baseline AB for the hypermobile joint move ment to be depicted would be the same as that shown earlier where grades of movement are discussed, and the frame of the movement diagram would be as in Figure A1.32. Having discussed at length the graphing of the sep arate elements of a movement diagram, it is now nec essary to put them together as a whole.

COMPILING A MOVEMENT DIAGRAM This book places great emphasis on the kinds and behaviours of pain as they present with the different

A Figure A 1 .32 joint.

B

H

Frame of movement diagram for hypermobile

movements of disordered joints. Pain is of major importance to the patient and therefore takes priority in the examination of joint movement. The following demonstrates how the diagram is formulated. When testing the acromioclavicular (A/C) joint by pos teroanterior pressure on the clavicle (for example) the routine is as follows.

Step 1 . P, Gentle, increasing pressure is applied very slowly to the clavicle in a posteroanterior direction and the patient is asked to report when pain is first felt. This point in the range is noted and the physiotherapist then releases some of the pressure from the clavicle and performs some oscillatory movements, again ask ing if the patient feels any pain. If pain is not felt, the oscillation should then be carried out slightly deeper into the range. Conversely, if pain is felt, the oscillatory movement should be withdrawn in the range. By these oscillatory movements in different parts of the range, the point at which pain is first felt with movements can be identified and is then recorded on the baseline of the movement diagram as PI (Fig. A1.33). The estima tion of the position in the range of PI is best achieved

Movement diagram theory and compiling a movement diagram

C

I

I

I

o

I �

.�

en

A

1

I

% Range

Figure A 1 .33

I

3;4

;AlC

B

Point at which pain is first felt.

by performing the oscillations at what the physiother apist feels is one-quarter range, then at one-third range and then at half range. By this means, P1 can be very accurately assessed. Therefore the two steps to estab lishing P1 are: 1. A single slow movement. 2. Small oscillatory movements.

Step 2. L

-

where

Having found PI the physiotherapist should continue further into the range with the posteroanterior move ments until the limit of the range is reached. The ther apist identifies where that position is in relation to the normal range and records it on the baseline as point L (Fig. A1.34).

Step Step 3. L

-

what

For the hypomobile joint the next step is to decide why the movement was stopped at point L. This means that the joint has been moved as far as the examiner is willing to go but has not made it reach 'B'. Having decided where 'L' is, the examiner has to deter mine the reason for stopping at L; what it was that prevented the examiner reaching 'B'. Assume, for the purpose of this example, that it was physical resist ance, free of muscle spasm that prevented movement beyond L. Where the vertical line above L meets the horizontal projection CD, it is marked as R2 (Fig. A1.35). The R2 needs to be qualified using words or symbols to indicate what it was about the resistance that prevented the examiner stretching it further; for example the patient may have rheumatoid arthritis and the examiner may not be prepared to go further (see Fig. A1.24) or to push harder than grade I V (Fig. A1.35).

4.

P' and defined

The physiotherapist then decides the quality, nature or the intensity of the pain at the limit of the range. This can be estimated in relation to two values: 1. what maximum would feel like 2. what halfway (50%) between no pain and maximum would feel like. By this means the intensity of the pain is fairly easily decided, thus enabling the physiotherapist to put P' on the vertical above L in its accurately estimated position (Fig. A1 .36). If the limiting factor at L were P2, then Step 4 would be estimating the quality or intensity of R' and defining it (Fig. A1.37).

Step 5. Behaviour of pain P' P2 or PI P' The AIC joint is then moved in a posteroanterior direction between PI and L to determine - by watching

61 1

61 2

Movement diagram theory and compiling a movement diagram

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Figure A 1 .36

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Figure A 1 .38

Quality of i ntensity of pain at L.

I

P 2 (intensity)

I

I

A

If4 P 1

Y2

L%

Range

B

Behaviour of the pain.

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Figure A 1 .37

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Range Qual ity or intensity of spasm-free resista nce.

the patient's hands and face and also by asking the patient - how the pain behaves between PI and P2 or between P2 and P ' : in fact it is better to think of the pain between p] and L because at L, pain is going to be represented as P2 or P ' . The line representing the behaviour of pain is then drawn on the movement dia gram, i.e. the line PIP2 or between Pl and P' is com pleted (Fig. A1.38).

A

Figure A 1 .39

If4 P 1 R 1

Y2 Range

;AlC

L %

B

Commencement of resista nce.

C

Step 6. R, Having completed the representation of pain, resist ance must be considered. This is achieved by receding further back in the range than P], where, with carefully applied and carefully felt oscillatory movements, the presence or not of any resistance is ascertained. Where it commences is noted and marked on the baseline AB as RI (Fig. A1.39).

Step

7.

A Figure A 1 .40

Behaviour of resistance.

Step 8. SIS' Behaviour of resista nce R, R2

By moving the joint between RI and L the behaviour of the resistance can be determined and plotted on the graph between points RI and R2 (Fig. A1 .40).

I f n o muscle spasm has been felt during this examin ation and if the patient's pain is not excessive, the physiotherapist should continue the oscillatory postero anterior movements, but perform them more sharply

Movement diagram theory and compiling a movement diagram

and quicker to determine whether any spasm can be provoked. If no spasm can be provoked, then there is nothing to record on the movement diagram. However, if with quick, sharper movements a reflex type of muscle spasm is elicited to protect the movement, this should be drawn on the movement diagram in a man ner that will indicate how easy or difficult it is to pro voke (i.e. by placing the spasm line towards A if it is easy to provoke, and towards B if it is difficult to pro voke). The strength of the spasm provoked is indicated by the height of the spasm line, SIS' (Fig. A1.41). Thus the diagram for that movement is compiled showing the behaviour of all elements. It is then possi ble to access any relationship between the factors found on the examination. The relationships give a distinct guide as to the treatment that should be given, particularly in relation to the 'grade' of the treat ment movements, i.e. whether 'pain' is going to be treated or whether the treatment will be directed at the resistance.

C

Summary of steps Compiling a movement diagram may seem compli cated, but it is not. It is a very important part of train ing in manipulative physiotherapy because it forces the phYSiotherapist to understand clearly what is felt when moving the joint passively. Committing those thoughts to paper thwarts any guesswork, or any 'hit and-miss' approach to treatment. Box A1.1 summa rizes the steps taken in compiling a movement diagram where resistance limits movement, and the steps taken where pain limits movement.

Mod ified diagram baseline When either the limit of available range is very restricted (i.e. L is a long way from B), or when the ele ments of the movement diagram occupy only a very small percentage of the full range, the basis of the movement diagram needs modification. This is achieved by breaking the baseline as in Figure A1 .42. The centre �ection can then be identified to represent any length, ill any part of the minimal full range. When the exam ination findings are only to be elicited in the last, say, 8° of a full range, point A in the range is changed and the line AB is suitably identified as in Figure A1 .43.

� A�------�A A I

F i g ure A 1 .42

.?:-

P l Y4

Y2

Rl

Range Figure A 1 .41

iAiC

%L

B

Strength of spasm.

Box

A1 . 1

A

Y4

Y2

Diagra m showing restricted range.

Steps taken in compiling a movement diagram

...-

Where resistance limits movement

Where pain limits movement

1 . P1 (a) slow (b ) oscillatory 2. L - where 3 . L - w hat (and defi ne) R 2 4. P' (define ) 5. P1 P' (behaviour)

1 . P1 (a ) slow (b) osci l latory 2 . L - where 3 . L - what (and define ) P2 4. P1 P2 (behaviour)

6.

Rl

7. Rl R2 (behaviour) 8. S (defined)

%

Range The last 80 of knee extension Figure A 1 .43

5.

6. 7. 8.

B

Modified diagra m baseline .

.en�

A

J

Rl R' (define) Rl R ' (behaviour) S (defined )

I B

61 3

614

Movement diagram theory and compiling a movement diagram

L

C

only two extra measurements to be stated: 1. The measurement between L and B. 2. The measurement between Rl and L.

Knowing that Rl to L equals 12° makes it easy to see that Rl is approximately 7° before Pl ' Because of the increased space allowed to represent the elements of the movement, the behaviour is also far easier to demonstrate.

A

CLINICAL EXA MPLE - HYPERMOBILITY '-----v---'

•

1 2°

Range knee flexion Figure A 1 .44

C

80°

Using a modified diagram.

I

R2 (IV++)

I

D

Y2

This example is included for the express purpose of clarifying the misconceptions that exist about hyper mobility and the direct influence that some authors and practitioners afford it in restricting passive move ment treatment. If the movement (using the same acromioclavicular joint being tested with posteroanterior movements), before having become painful, were hypermobile, the basic format of the movement diagram would be shown as in Figure A1.46.

C

P' (intensity)

A

I

X

)1

R 1 P 1 Y2 L

I

%

B

Range Figure A 1 .45 Range limited by 50%, shown on an u nmodified diagram (1 60' knee flexion).

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This example demonstrates that from A to B is 8°, and A to one-quarter is 2°, and so on.

EXA MPLE - RANGE LIMITED BY 50% Marked stiffness, with 'L' a large distance before 'B', necessitates a modified format of the movement dia gram. The example will be restricted knee flexion, a longstanding condition following a fracture. The first element is Rl and the distance between Rl and L is only 12°. Pain is provoked only by stretch ing (Fig. Al.44). lf the movement diagram were drawn on an unmodified format it would be as in Figure A1.45. Figure A1.45 clearly wastes considerable dia gram space and is difficult to interpret. With the same joint movement findings represented on the modified format of the movement diagram it becomes clearer and much more useful. The modified format of the baseline of the diagram (Fig. A1.44) requires

A

I

X

I

I

%

%

l AIC

Range Figure A 1 .46

C � ::J ro

B

H

Movement diagram for hypermobile range.

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-%

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A

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Figure A l .47

P1 hypermobile joint.

I

P1

%

l AIC

B

H

_ . . . _ - �-----

Movement diagram theory and compiling a movement diagram

If it becomes painful and requires treatment the movement diagram could be as follows.

Step 4. P' define (Fig. A 1 .50) C

Step 1 . P,

I

D R2 (IV+)

I

�,

The method is the same as in Example 1 ; see also Figure A1.47.

l

(intenSity .

I

Step 2. L

-

.?:

where

The method is the same as in Example 1; see also Figure A1.48.

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A

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l Y2

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P' - 'define', hypermobile joi nt.

Step 5. P, P' beh aviour (Fig. A 1 .5 1 ) D R2 (IV+)

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A

Step 3. L

-

The method is the same as in Example 1; see also Figure A1 .49.

Fig ure A 1 .51

Step C

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61 5

61 6

Movement diagram theory and compiling a movement diagram

Step

7.

Rl R2 behaviour (Fig.

A 1 . 53)

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Figure A 1 .53

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L

H

Hypermobility is not a contraindication to manipula tion. Most patients with hypermobile joints, one of which becomes painful, have a hypomobile situation at that joint. They are therefore treated on the same basis as is used for hypomobility. It makes no differ ence whether the limit (L) of the range, on examination, is found to be beyond the end of the average-normal range (as in the example above, L being beyond B) or before it (L being on the side of B). Proof of hypomobil ity is validated by assessment at the end of successful treatment.

R, R2 behaviour, hypermobile joint.

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joints. Journal of Orthopaedic and Sports Physical

Therapy, 2, 7-14

measuring passive lateral rotation of the shoulder in

Maitland, G. D. 1 99 1 . Peripheral Manipulation, 3rd edn.

593-601

Maitland, G. D. 1992. Neuro/musculoskeletal Examination

patients with shoulder pathology. Physical Therapy, 78,

Latimer, J., Lee, M. & Adams, R. 1996. The effects of training with feedback on physiotherapy students' ability to

judge lumbar stiffness. Manual Therapy, 1, 266-270

Lee, R. & Evans, J. 1994. Towards a better understanding of spinal posteroanterior mobilization. Physiotherapy, 80,

68-73

Maitland G. D. 1980. The hypothesis of adding compression when examining and treating synovial

Oxford: Butterworth-Heinemann

and Recording Guide, 5th edn. Adelaide: Lauderdale Press

Petty, N., Maher, c., Latimer, J. & Lee, M. 2002. Manual

examination of accessory movements-seeking R,. Manual

Therapy, 7, 39--43

Snow, C. P. 1965. Strangers and Brothers, p. 67. London: Penguin Books

617

Appendix

2

Self-management strategies: compliance and behavioural change

As stated at various times in this book, in many clinical presentations passive mobilization can be considered as a kick-start to active movement. Therefore manipulative physiotherapists will often suggest self-management strategies complementary to the passive mobilizations, once they have established the sources of the movement dysfunctions and the mechanisms of the nociceptive processes. Self-management strategies should reflect the clin ical stages and syndromes as outlined in Chapter 8 and may follow different purposes: •

• •

• •

self-help strategies to control pain and promote a sense of wellbeing prevention of new episodes of symptoms increase general physical fitness and normalize activity levels increase bodily awareness and relaxation rehabilitation of movement impairments such as joint mobility, neurodynarnics and muscle function.

The provided instructions, suggestions and exercises are especially relevant in the process of secondary pre vention of disability due to pain. Currently this con cept receives much attention in the treatment of spinal disorders as, over a period of two decades until the end of the 1990s, the prevalence of chronic disability due to low back pain increased substantially in indus trialized countries (Waddell 2004). It is suggested that psychosocial factors (e.g. fear avoidance behaviour, beliefs) as well as confusing information by clinicians are contributing elements in this development (Kendall et aI1997). In particular, a sense of helplessness, which eaSily evolves into hopelessness, may be an important con tributing factor which should be prevented in any acute pain state (Harding et al 1998). Therefore it may be concluded that it is essential in an early stage of treatment to guide patients to a sense of control over

their wellbeing with self-management strategies (Roberts et aI2002). An increasing number of studies incorporating variables with locus of control (Rotter 1966) or self efficacy beliefs (Bandura 1989) are being integrated in physiotherapy research (Crook et al 1998, Frost et al 2000, Roberts et aI2002). It is important to realize that the sense of control may change over the period of time in which a patient suffers from pain and restricted functioning. It is possible that a sense of helplessness increases with ongoing states of pain and disability. It is crucial that the physiotherapist discovers in an early stage of examination (see Box 6.3) whether or not patients (still) have a sense of control over their pain and perceived limitations of daily life and which strategies they employ to achieve this. Physiotherapists with their specific professional expertise have numerous possibilities to guide patients towards a sense of control over their pain or wellbeing, as for example: • • • • • •

repeated movements automobilizations relaxation strategies body and proprioceptive awareness muscle recruitment exercises other pain-management strategies (e.g. hot packs, cold packs).

COMPLIANCE

In the process in which the physiotherapist provides the patient with self-management strategies, the concept of compliance enhancement plays an important role. Compliance is described as the degree to which the behaviour of a client coincides with the recommenda tions of the clinician (Schneiders et al 1998). At times the word 'adherence' is used as well. However, both

618

Self-management strategies: compliance and behavioural change

terms are somewhat awkward, as they indicate too strongly an authoritarian one-dimensional patient clinician relationship in which the patient has to follow the orders of the clinician in a passive role (Kleinmann 1997). Within this context a focus on the change of unfavourable (movement) behaviours in daily life is recommended, hence taking a cognitive- behavioural perspective in which the term 'compliance' is associated with a more active role for the patient. Barriers to compliance

It seems that compliance to medical or physiotherapy interventions ranges from 15 to 94%, depending on the way the studies were performed (Sluys & Hermans 1990, Ferri et alI998). There appear to be different opinions as to why patients would not follow the advice, recommen dations or exercises of a phYSiotherapist. It appears that many physiotherapists contribute this to patients' lack of motivation or discipline (Kok & Bouter 1990). However, a profound study indicates several cat egories of barriers perceived by patients to the sug gested behaviours (Sluys 1991): •

•

•

Barriers to incorporating the suggestions and exer cises into daily life (e.g. exercises in supine cannot be performed in a work setting; lack of time to exer cise every day for 30 minutes; directive goal setting such as 'you should take more time off for yourself'; too many instructions and suggestions in one treatment session). Lack of positive feedback (insecurity as to whether the exercises are performed in the correct manner; no experience if the exercises truly are helpful). Sense of helplessness (the patient does not experi ence an ability to influence the situation positively). Physiotherapists and patients may have different opinions about 'non-compliance' to the instructions, suggestions and exercises. Patients perceive various

barriers to following the advice of the physiotherapist. which may be addressed successfully in an informa tion and education plan.

COGNITIVE-BEHAVIOURAL APPROACH

Based on these perceived barriers it is suggested that the therapist follows a cognitive-behaVioural approach to the education of a patient, with an information plan incorporated in the overall treatment plan (Sluys 2000). In this approach, focussing on the change of unhelpful habits in movement behaviour is recom mended (Harding & Williams 1995). However, frequently physiotherapists seem to choose a somewhat one-dimensional approach to treatment (Fig. A2.1) in which no specific behavioural or commu nication strategies are pursued. In a one-dimensional approach it is assumed that trust to move as well as the levels of activity and participation normalize as a conse quence of interventions with objectives such as pain reduction and normalization of movement impair ments. Furthermore, it appears that it is expected that a single instruction of an exercise leads to a lasting change in behaviour, in which the suggested interventions are employed at all the moments in which this seems neces sary (Hengeveld 2000). Within this context there is the criticism that phYSiotherapists seem to prefer to tell a patient how to move in daily life, rather than guiding them to experience this (Treves 1998). This may hinder some patients in regaining trust in daily life activities. HABITS DON'T CHANGE OVERNIGHT - PHASES OF CHANGE

Habits rarely change overnight and people will go through phases in which the intention may exist to change the behaviour, but distractions and tasks in daily life, as well as other habits, may hinder the patient from automatically and consequently incorpo rating the suggested behaviour immediately.

Unidimensional approach to management =

Figure A2.1

+

Understanding of preventive measures active coping

Not much awareness on communication strategies, collaborative goal setting, roles, 'art' of assessment and reassessment

O n e-d i mensiona l approach to treatment.

Reproduced by kind permission from Hengeveld

classical management in teaching (PT; Medicine; OMT)

and doing this at adequate moments

+

(2000).

-----.-.---- -

. -- - -- -. --. --

--�-

Self-management strategies: compliance and behavioural change

It has been postulated that people go through vari ous stages of motivation in a behavioural change (Prochaska & DiClemente 1994, Van der Burgt & Verhulst 1997, Dijkstra 2002) (Table A2.1). It can be sum marized from these models that a person goes through various phases before being able to successfully imple ment the suggested behaviours in daily life routines: • •

•

Motivation development Short-term compliance: the behaviour is performed as long as the contact between the physiotherapist and patient exists Long-term compliance: the patient maintains the behaviour after the completion of treatment.

discal problems. Education with regard to neuro physiological pain mechanisms may also be neces sary in this phase. •

•

•

Motivational phase •

In this phase the patient often needs educational strategies with regard to, for example, the positive effects of movements on osteoarthritic processes or

Table A2.1

•

In order to be able to provide the educational strate gies successfully, the therapist first needs to deter mine the patient's beliefs with regard to movement and to ascertain if the patient is receptive to new information. Further, it is suggested that the therapist follows an initial process of collaborative goal setting before starting off with explanations and educational strategies (Brioschi 1998). After the educational strategies the therapist should evaluate if the patient has understood and can make sense of the information (Chapter 3). Next, over a period of several sessions, it is essential to give the patient sufficient time to ask questions and seek clarifications.

Models of stages of change in behaviour and suggested interventions by physiotherapist

Prochaska a DiClemente (1994) Stages of Change Model

Van der Burght a Verhulst (1997)

Dijkstra (2002)

1. Precontemplation: in this

1. Openness:

1. Non-motivated: (in this phase a patient

-

2.

3.

4. 5.

phase changing behaviour is not considered Contemplation: change of behaviour is considered; however no concrete plan exists Preparation: plans are developed actively to change the behaviour in the short term Action: phase in which the desired behaviour is performed Consolidation: the desired behaviour is maintained and fallbacks in behaviours are prevented

(PT interventions:

Investigation of beliefs and

needs informotion and education with

expectations. Information on

regard to the use of exercises to enhance

usefulness of movement with

wellbeing. Patients need to experience

e.g. discal problems or

directly that the exercises contribute to

osteoarthritis)

2. Understanding and

wellbeing. Attention to the quality of the educational processes and reassessment

comprehension of the information: (often neglected in

of cognitive objectives is necessary-

physiotherapy: have the patients

PT wanted to explain?)

understood and do they consider the given information useful?)

3. Intention (development of plans) 4. Capability (having the capacity) The exercises should be simple and if possible give a sense of success

5. Action: change of behaviour with

i.e. has the patient understood what the

2. Consideration if suggested behaviour is

useful

(allow time for the patient to ask

questions concerning the information given in previous sessions)

3. Preparation (development of plan and

clear intentions)

Clear instructions

needed, when to do the exercises in daily

respect to incorporation of exercises

life, asking when it was possible to do the

and suggestions into DLA

exercises and when difficulties existed,

6. Maintaining behaviour :

continuation with the behaviour after completion of therapy

monitoring if the suggested interventions braught the desired results

4. Experimenting with the actions in

various daily life situations 5. Maintaining the behaviour Anticipation on likely future difficulties and possible strategies

Adapted from Prochaska a DiClemente (1994), Van der Burght a Verhulst (1997), Dijkstra (2002).

619

620

Self-management strategies: compliance and behavioural change

•

•

In this phase it is essential that the patient can expe rience that movement and relaxation may contribute to wellbeing. Perceived success and a sense of achievement appear to be relevant factors in com pliance to exercises (Courneya et aI2004). Reassessment of subjective findings and physical examination tests will contribute to a sense of success.

•

•

•

Collaboratively with the phYSiotherapist, the patient needs to anticipate future situations in which pain is likely to recur. The physiotherapist and patient discuss and repeat the behaviours which may be useful to influence the discomfort if the pain situation recurs. A repetition of prophylactic measures is often help ful in this phase as well.

Short-term compliance •

•

•

•

•

The phase of short-term compliance begins once the patient starts to experiment with a few simple exercises in daily life. It should not be expected that the desired effect is immediately experienced or that the patient per forms the exercises at all the appropriate moments in daily life. Often it is better to start off with one or two exercises and to check if they are helpful before other exercises are integrated into the self-management programme. Regular contact between the physiotherapist and patient is essential, in which the patient can ask questions and the physiotherapist may give correc tions or suggestions. The physiotherapist may need to motivate the patient to 'hang in' with the exercises, even if no results are experienced yet.

During the subjective reassessment in follow-up ses sions, the physiotherapist needs to find out if the patient has been able to perform the exercises and done them at appropriate moments. Patients may do the exercises at fixed times of the day; however, at those moments where pain increases they often stay in the habituated behaviour of resting or taking medication, rather than trying out the suggested inter ventions. It is essential that the physiotherapist does not consider this as a lack of motivation but as a help seeking behaviour which has not yet been habituated. The style of communication may influence this process of learning and experimenting with exercises in vari ous daily life situations substantially (Chapter 3).

COMPLIANCE ENHANCEMENT STRATEGIES

In order to develop meaningful exercises for a patient, the physiotherapist may follow an algorithm of actions and decisions: •

•

•

•

•

•

• •

The patient maintains the behaviour after the completion of therapy (long-term compliance).

•

•

This phase needs to be well prepared. It usually takes place towards the end of the treat ment series and is completed with the final analyti cal assessment.

Make a decision regarding treatment goals and interventions. In the selection of interventions, make a decision as to which physiotherapist-directed interventions (e.g. passive mobilizations) and which self-management strategies are to be employed. In the selection of self-management strategies the physiotherapist should consider the objectives of the strategies if the patient has to do the exercises for a definite or indefinite period of time. To those patients whose main complaint is pain, it is essential to teach coping strategies prior to the employment of interventions which should influence contributing factors (e.g. posture, general fitness). With these coping strategies patients may perceive a sense of success and control over their wellbeing, and hence may develop trust to perform exercises which they initially believed to be harmful.

Selection of coping strategies to control pain and wellbeing

Long-term compliance •

Find the sources of the movement dysfunction in examination and reassessment procedures.

•

The selection of coping strategies is normally based on the difficulties in daily life activities as perceived by the patient. In this case information from the subjective exami nation is frequently a more decisive factor in deci sion making than data from inspection or active movement testing. In particular, data from the '24-hour behaviour' of symptoms and at times the precipitating factors of the history may be very informative (Chapter 6).

Self-management strategies: compliance and behavioural change

It is important to know in which ways the patient is capable of influencing painful daily life activities. •

In order to be able to make a decision with regard to meaningful coping strategies, it is essential that the physiotherapist deliberately seeks information in the above-mentioned phases of subjective examination.

Based on a literature study, the following aspects of compliance enhancement are recommended to sup port the patient optimally to a lasting change in move ment behaviour (Hengeveld 2003): •

Example A woman who works in a factory at a sewing-machine develops pain in the thoracic area after 6 hours of work. Although in the physical examination she is shown to have a flattened thoracic kyphosis, her self management strategies to influence the pain are varia tions of repeated extension and rotation movements. Integration of the exercises into daily life situations •

•

•

In situations in which the patient needs to develop a new behaviour which influences wellbeing, it may be that the patient will need to employ this behav iour for a long period of time, sometimes for life. Therefore it is essential to provide simple, achiev able exercises which are easy to incorporate in daily life situations in order for them to become part of the habitual movement behaviour.

•

•

•

•

•

Unfortunately, patients are often taught to perform certain exercises lying supine, although the difficul ties they have with pain occur during working situ ations in, for example, sitting positions. In such cases it is possible that a sense of helplessness gradu ally develops, as the patient does not perceive a sense of success directly in the given working situation ('I have tried physiotherapy, but nothing really helped'). •

•

•

It is essential not to teach a single intervention, but to work collaboratively with the patient on modifi cations of the exercise, according to the demands of the various daily life situations. The patient needs to know that the adaptations are not different exer cises but are 'variations on the same theme'. Notwithstanding cases such as postoperative man agement, in which it is anticipated that the exercises only need to be employed for a limited period, the patient may be provided with a 'home programme' to which time is allocated in the patient's daily rou tine. However, if the patient starts to resume daily routines or returns to work, often it is useful to seek collaboratively with the patient variations of the 'home programme' exercises which can be inte grated into the busy schedules of daily life.

•

•

•

Follow a cognitive-behavioural perspective, in which it is acknowledged that habits in behaviour do not change overnight with one intervention. Respect the various phases of behavioural change. Beliefs with regard to the necessity of activities and movements in the treatment of pain need to be investigated. Follow an instruction and education plan, in which an awareness of all the instructions given during one session is necessary. Repeat the given informa tion over various sessions; give pieces of information, rather than everything at once. Collaborative goal setting and conscious communica tion procedures are essential (Chapter 3). One of the most essential goals of self-management strategies is guiding patients to a sense of control over their wellbeing (Harding et aI1998). If a patient believes that moving may be harmful when activities and work situations provoke pain, the physiotherapist may guide the patient with educational strategies complementary to passive mobilizations and other self-management interven tions. At times the physiotherapist may use the fol lowing axioms in the educational process: - 'It's not what you move, but how you move' (Sahrmann 1999). - 'It's not necessarily the work task, but the work ing style which provokes symptoms' (Watson 1999). Take time to teach the exercises, rather than telling the patient what to do in the last few minutes of a session. Allocate time for the patient to ask questions. Enhance positive feedback by performing a reassessment after the exercise (sometimes only seeking information about the sense of pain or well being - 'present pain'). In follow-up sessions ask the patients during the subjective reassessment phase if they have been able to perform the exercises and what the effect was. Pose the questions in such a way that patients feel free to say if they have forgotten the exercises (Chapter 3). If this happens, it should not directly be attributed to lack of motivation or diSCipline. Written information as a mnemonic may enhance understanding. At times patients may do this by

621

622

Self-management strategies: compliance and behavioural change

themselves. A 'pain, activities and exercise diary' may be incorporated (see also Chapter 10). •

•

•

Ensure that the exercises can be implemented in daily life situations. Patients frequently need to be provided with variations of the same exercises and should understand them as such. This is partic ularly important in those situations where a patient needs to develop a new behaviour, which may last for a long time, sometimes for life. Anticipation of difficulties: after the selection and instruction of an exercise, the physiotherapist needs to discuss with the patient if and where difficulties are anticipated. Certain exercises may be very use ful, but not during a given work situation. Collaborative problem solving for such a situation is essential and modifications of the exercise need to be worked out. At the completion of a treatment series, in order to enhance long-term compliance, further anticipation of possible future recurrences and their solutions needs to take place.

CONCLUSION

Before teaching an exercise the physiotherapist should go through the following steps and questions: • •

•

• •

•

What are the goals of the exercises? When should the exercises be employed in daily life? Have I explained the objectives of the exercises to the patient? Have I checked if the patient has understood? Were the exercises reassessed immediately after being performed? Did they contribute to a sense of success? Did I anticipate collaboratively with the patient if and when to perform the exercises should difficulties recur?

This appendix is adapted from Hengeveld, E. 2003. Compliance und Verhaltensanderung in Manueller Therapie. ManueLle Therapie, 7(3), 122-132, with permission.

References Bandura, A.

1989.

Perceived self-efficacy in the exercise of

personal agency. Brioschi, R

1998.

The Psychologist,10, 411-424

Kurs: die therapeutische Beziehung.

Leitung: R Brioschi & E. Hengeveld. Fortbildungszentrum Zurzach, Mai

University of East London

2004.

Exercise motivation and adherence in cancer survivors after participation in a randomized controlled trial: an

International Journal of

Behavioural Medicine,11, 8-17 Crook, P., Rose, M., Salmon, P. et a1.

1998. Adherence to

group-exercise: physiotherapy-led experimental programmes. Dijkstra, A.

2002. Het veranderingsfaserunodel als leidraad Nederlands Tijdschrift

voor Fysiotherapie,112, 62-68 1998.

Compliance

with treatment - an ongoing concern. Physiotherapy Frost, H., Lamb, S. E. & Shackleton, C.

2000. A functional

restoration programme for chronic low back pain.

Physiotherapy,86,285-293 1995. Extending

physiotherapy skills using a psychological approach: cognitive-behavioural management of chronic pain.

Physiotherapy,81, 681-688

j. 1998. Pain, Clinical Updates

Harding, V. R, Simmonds, M.]. & Watson, P. Physical therapy for chronic pain.

(lASP), VI, 1-4

1997. Guide to Assessing Psychosocial Yellow Flags in Acute Low Back Pain: Risk Factorsfor Long-Tenn Disability and Work Loss. Wellington, New Zealand: Accident Rehabilitation & Compensation Insurance Health Committee

1997. In The Spirit Catches You and You Fall Down - A Hmong Child, her American Doctors a"nd the Collision of Two Cultures,ed. A. Fadirnan. New York:

Farrar, Strauss and Giroux

Kok, j. & Bouter, 1.

1990. Patientenvoorlichting door Nederlnnds Tijdschrift voor Fysiotherapie,100,59-63 Prochaska,]. & DiClemente, C. 1994. Stages of change and decisional balance for twelve problem behaviours. Health Psycholo?;!), 13, 39-46 Roberts, 1., Chapman, J. & Sheldon, F. 2002. Perceptions of control in people with acute low back pain. Physiotherapy, 88,539-548 Rotter, J. 1966. Generalized expectancies for internal versus external control of reinforcement. Psychological Monographs (General Applications), 80,1-5 fysiotherapeuten in de eerste lijn.

Canada,SO,286-290

Harding, V. R & Williams, A. C. d. C.

122-132 Kendall, N. A. S., Linton, S. J., Main, C. J. et a1.

Kleirunann, A.

bij het motiveren tot en begeleiding van

Ferri, M., Brooks, D. & Goldstein, R S.

2003. Compliance und Verhaltensanderung Man!lelle Therapie,7,

in Manueller Therapie.

Corporation of New Zealand and the National

Physiotherapy,84,366-372

gedragsverandering bij patienten.

Thesis. London: Department of Health Sciences, Hengeveld, E.

1998

Courneya, K. S., Friedenreich, C. M., Sela, R A. et al.

attribution theory perspective.

2000. Psychosocial Isslles in Physiotherapy: Manual Therapists' Perspectives arld Observations. MSc

Hengeveld, E.

Self-management strategies: compliance and behavioural change

1999. Course on the assessment and treatment 22-25 August 1999. Schneiders, A., Zusman, M. & Singer, K. P. 1998. Exercise

Sahrmann, S.

of movement impairments. Zurzach, Switzerland,

therapy compliance in acute low back pain patients.

Manual Therapy,3, 147-152 Sluys, E. 1991. Patient education in phYSiotherapy: towards a planned approach. Physiotherapy, 77, 503-508 Sluys, E. 2000. Therapietrouw door Voorlichting - Handleiding voor Patiiintenvooriichting in de Fysiotherapie. Amsterdam: Uitgeverij SW P Sluys, E. & Hermans, J.

Treves, K. F.

ervaren bij het doen van huiswerkoefenmgen en bij het

Nederlands Tijdschrift voor Fysiotherapie, 100, 175-179 opvolgen van adviezen.

Understanding people with chronic pain

Topical Issues in Pain - Whiplash: Science and Management. Fear-Avoidance Beliefs and Behaviour,ed. 1. Gifford. Adelaide: NOI Group Van der Burgt, M. & Verhulst, H.

1997. Van therapietrouw Fysiopraxis,

naar zelf-management: voorlichting op maat.

12,4-7 Waddell, G.

2004. The Back Pain Revolution,2nd edn.

Edinburgh: Churchill Livingstone Watson, P.

1990. Problemen die patienten

1998.

following whiplash: a psychological perspective. In

1999. Psychosocial Assessment. IMTA Educational

Days, Zurzach, Switzerland

623

625

Index

description of

A

280-1

Abbreviation symbols

168, 244-5

Abduction

168, 244 441 extension/abduction 375, 375-6, 474, 495, 500, 500-2 for treatment of fractures 225 glenohumeral joints 311 hip region 455, 473, 473--4 interphalangeal joints 435, 435-6 intertarsal joints 556-8, 557 metacarpophalangeal joints 435, 435-6 shoulder 298, 301, 310-12, 311 tibiofemoral joints 504-5 with compression 312 see also Flexion Ability to move 156 Abuse 249, 256-8 abbreviation symbol

carpometacarpal joints

Accessory movements

1, 27 457, 460-6 562-3, 563 559, 559

principles of physical examination

18, 153, 159-60 183--4 514-16 tibiofemoral joints 504-9 Acetabular labrum, torn 478 Achilles tendinitis 565-6 Aching, chronic 176 selection of techniques

superior tibiofibular joints

Acromioclavicular joints acromioclavicular joint disorder

350-1 anteroposterior squeeze

291-2 332, 333

posteroanterior movement

selection of mobilization techniques

206 Acromiohumeral complex description of

280

330-1 290-1 rotation with compression 331-2 differentiation of pain

physical examination of

selection of mobilization techniques

206 Active functional movements

296-7,

366-9 Active movement tests

532-5 18 hip region 450, 452--4 knee complex 492, 493--4 of the hand 410-11 ankle and foot complex description of

153, 155-7 242 Active tests 153 recording

intermetatarsal joints intertarsal joints

333, 333--4

physical examination procedures

description of hip region

cephelad

physical examination of

331-2, 332

25, 79 49, 116, 120 Activity limitations 165, 490-1 Adaptation of techniques 178 Adapting, body's capacity to 22 Adaptive deformity 179 Activity intolerance Activity levels

Adduction

168, 244 441 extension/adduction 374-5, 495, 500, 500-2 flexion/adduction, elbow 376-7 hip region 196, 455 abbreviation symbol

carpometacarpal joints

317, 317-18 435-6, 436 intertarsal joints 556-8, 557 metacarpophalangeal joints 435-6, 436 shoulder complex 298, 300 tibiofemoral joints 504-5 see also Flexion Adhesive capsulitis 275, 341-3 Affective goals 94 Affective mechanisms 249, 251, 263 Algorithms 93, 152, 155, 179 Alignment 179, 295-6, 296, 296-7 Allodynia 249 Amplitude, choice of 191-2 Analysis, structural 144 Analytical assessment 1, 20-1, 53, 67, 73, 89, 106--9 Anatomy of the knee 488 Angulation 165, 184 horizontal adduction

longitudinal movement caudad and

interphalangeal joints

Ankle and foot complex active movement tests ankle distortion

532-5

564-5

214 526 brief appraisal 534-5 case study 566-74 clinical profiles 252, 564-6 deformities of the foot 541 distortion of the ankle 564-5 flexion 545, 545-6 functional demonstration 532 gait analysis 528, 533 history 530 introduction 526-9 isometric tests 535-6 movement 526-9, 539--40 observation 531-2 pain 540-1 ankle jOint mobilization

bones of the foot

626

I N D EX

Ankle and foot complex palpation

(contd)

539 539--40 530--40

passive test procedures pronated foot

451 536-8

selection of treatment techniques

206 530

special questions

subjective examination

529-30

529-30

symptoms

540-64 see also specific part of ankle and foot Anterior capsular insufficiency see treatment techniques

Anterior drawer test Anterior cruciate ligament

217 328,328-9 327-8,328 487,518,519-23

reconstruction Anterior drawer test Anterior instability Anterior knee pain

Anteroposterior movement

168,245 549,549-50

abbreviation symbol ankle joints

anteroposterior costal movement

338 craniomandibular complex

589,

589-90 386,386-7 195,464-5 inferior radioulnar joints 415,415 inferior tibiofibular joints 542-3,543 intercarpal joints 428,428-9 interphalangeal joints 438--9,439 metacarpophalangeal joints 438-9, 439 radiocarpal 424,424 shoulder complex 325,325-6 sternoclavicular joints 335,335-6 superior tibiofibular joints 514, 514-15 tibia 184,184 tibiofemoral joints 507,507-8 Anteroposterior squeeze 331-2 Application of forces 20, 166,169-77, 199,215,216 see also specific movement Appraisal tests 18 ApprehenSion movement 231 Apprehension test 327-8,328 head of the radius

hip region

Areas of symptoms ankle and foot complex elbow complex

529-30 582

359

1,20-1,53,67,73,89,

106-9 110-14 91-2 during treatment 89, 105-6 evaluation and reflection 161-3 forms of 92 general discussion 20-2 initial 54-60,89-90,92-7,97 introduction 90-1 joint 526 observation 526 pretreatment 21 progressive 22,90 prospective 107-8,119 psychosocial assessment 90, 115-21, 143 purposes of 92 retrospective 22,53,66-7,106-7, 109,119,143,246 subjective 118-19 the science and art of 6 see also Reassessment Assuming 48-9 Asterisks 179,238--9 Asymmetry 296,451 Athletic groin pain 476-7 Autonomic reactions 105 Autonomic sympathetic output 263 Axes of movement 528 and clinical reasoning

Brachial plexus lesions

communication

Brick wall

402-3,442

225,267-9 207-8,210,211-12 Articular disorders 260-1

Arthritis

Articular cartilage

534-5

ankle and foot complex

584

craniomandibular knee complex

492 153 275,302

principles of examination shoulder complex Bruxism Bursitis

577 341,479,489

c Cancer

96

Capsulitis

341

Cardiovascular system Carpal bones

96

403

Carpal tunnel syndrome

399

Carpometacarpal joints

441 441 compression 441 abduction

adduction

extension and flexion

431,431-3,

432,440,440-2 longitudinal movement cephalad

441 physical examination of

407,409 441

441

Case studies

519-23 226-9,394-6 heel pain 567-74 hip region 481--4 anterior knee pain

Balance

533

elbow region

Barriers to recovery Behaviour

233,249

120

Behaviour of symptoms

movement-related disorders of the

ankle and foot complex communication

530

temporomandibular joints

594-6

55-6

craniomandibular complex

582

359-60 448--50 knee complex 490-1 elbow region

352-5 Catching, knee

principles of examination recording

134-7

241

shoulder complex

288

442-3

490

Categorization of hypotheses Cauda equina syndrome

Behavioural parameters Beliefs

shoulder and shoulder girdle wrist and hand disorders

hip region

111,112

96

Ca uses and contributing factors

403--4,442 100-1

119-20

11,

93--4 Central core of the Maitland concept

6-7

48

Central nervous system

1

Biopsychosocial approach to treatment

490

Brief appraisal

rotation

B

Biomedical engineering

wrist and hand complex

284-5 4-5,7-10,35,72-3,78,251

posteroanterior movement

Bias

448

knee complex

analytical

96 400 Bone disorders 447 Bones of the foot 526

Bone destruction Bone disease

wrist and hand complex

craniomandibular complex hip region

277-84

Assessment

physical examination screening tests

Articular structures

73--4, 119-21 Bodily awareness 65-6 Body chart see Areas of symptoms Body of knowledge 71

583

Central nervous system mechanisms

78-9,112,125,133,144 115-16,251,263 Central sensitization 249,262 Central pain

Cephalad movement with compression

215

I ndex

Cervical spine disorder

415-16,

inferior radioulnar joints

579-80 583

alignment

Diagnosis

543-4,544 509-10,510 principles of examination 157, 158 radiohumeral 367,368 selection of techniques 167, 168, 213-17, 218-19 superior radioulnar 369 tibiofemoral joints 509 Compression tests 15-18 Compressive loads 218-19 Conditional reasoning 83 Confusion 105 Context 23-4 Continuum of movement 75 inferior tibiofibular joints

579 283-4

position and mobility Cervicothoracic spine

Deviation

416 patellofemoral joints

Change

98 measurable 100 phases of 618-20 within 24 hours of treatment 101 Chin movements 592, 592-3 Chondroblasts 207 Chondrocytes 207, 212 Chondrosternal joints 282-3 Chronic aching 176 Chronic pain 25, 393-4 Circumduction 439-40 Classification of joint signs 187-9 indicators of

Classification of

Contracted muscle tissue, stretching

31-2 Contraindications

mobilization/movement

165,

169-70

12,95-7, 112, 126,

128, 141

elbow disorders

112,116, 126, 144-5,180,233 Coping strategies 620-1 Core stability 165 Costal joints 293-4 Costochondral joints 282-3 Costotransverse joints 282-3 Costovertebral joints 282-3 Cranial bone mobility 587

hip region

Craniomandibular complex

Contributing factors

91-2 Clinical application 176-7 Clinical evidence 4-5,7-10,186-7 Clinical groups 179 Clinical patterns 113-14 Client centredness

Clinical profiles

564-6

ankle and foot complex

390-4 474-80 knee complex 516-19 shoulder 340-52 Clinical reasoning 1, 10,71, 82-4, 110-14, 126 Clinical science 36 Clinical tests of the nervous system

158 94 618 39,49-50,

Cognitive-behavioural approach Collaborative goal setting

18,156-7, 184 7, 39, 42-9, 73,95,

radioulnar recording

593--6

131-2,218 231-2

151 22,116

583-8 580-3

De Quervain's tenosynovitis

168,244 219,221,546, 546-7 intertarsal joints 558,558-9 Dupuytren's contracture 399,400 Dural pain 284 Duration of technique 175--6 Dysaesthesia 249 Dysfunction 11,231-2 ankle joints

399

Definition of the Maitland Concept

26-8 Deformities of the foot 541 Degenerative arthritis 269

6 E

manipulation

Complex regional pain syndromes

179 617-18, 620-2

Component analYSis with passive

159

Degenerative joint disease Degenerative osteoarthritis Dental occlusion

245 441

carpometacarpal joints

547,547 hip region 447, 465--6,466

Education of bodily awareness Effects, desired

580 447

579 577,579 Depression 168,244,336-8, 337 Depression of the mandible 590-1,591 Desired effects 25 Developmental abnormalities 583

Dental malocclusion

Compression

hind-foot

167, 168

25

Compensation

abbreviation symbol

selection of techniques

Dorsiflexion

50-3

Definitions of mobilization and

movements

369 368 245

abbreviation symbol

Comparable signs

Compliance

510,510-11 157

249,256-8 Diurnal events 357

Critical phases of the therapeutic

Deconditioned tissue

Comparable movements

564-5

Disuse

Combined movements Communication

shoulder complex

radiohumeral

D

207

299-302 296-7 tests 1, 7, 154-5,537-8 wrist and hand 413-14 Direction 166, 167, 192 Directive communication 65 Directive interaction 61-2 Disability level 112,126, 134-7 Disability, perceived 119 Disadvantaged joints 258 rotator cuff muscle

principles of examination

83

Collaborative reasoning

366-9, 411

330-1

patellofemoral joints

60-2, 99-100, 120 Collagen fibres

of movements of pain

15-18

460

Distortion, ankle

189

process

general discussion hip region

Distraction

management of movement-related

Crepitus

374

elbow complex

128-30 135 soreness of 180 stages of 180

subjective examination

Cognitive goals

534, 540

ankle and foot complex

severity of

587-93 577--81

physical examination

Differentiation

kind of

techniques

disorders

see also Physical examination 82

Diagnostic reasoning

Disorder

examination and treatment introduction

421, 421-3,422 76, 126,270-2

Effusion

65--6

25, 166

496

Elbow complex

226-9, 394--6 390-4 elbow disorders 390--6 case study

clinical profiles

evidence based practice

361-2

examination and treatment techniques

374-90

627

628

IN D EX

[ Elbow complex

(contd)

Expectations 119-20

flexion/adduction

flexion 301

Expert opinion 37

abbreviation symbol 168,245

functional demonstration 366-- 9

Extension

elbow complex 376--7

history 360-1

abbreviation symbol 168,244

if necessary tests 369-70

carpometacarpal joints 431,431-3, elbow complex 366,369,378-80,

general discussion 18 hip region 196,454

379

isometric tests 370 osteoarthritis 390

466--9,467 knee complex 502,502-3

440,440-2

injuring movements 366--9 introd uchon 358

hip region 445,457,457-60,458,

extension/abduction

intercarpal horizontal 427,427-8

pain in 284,366-9

abbreviation symbol 168,245

intermetatarsal joints 561,561-2

palpation 370

elbow complex 375,375-6

knee complex 494,494

physical examination 362-74

hip region 474

metacarpophalangeal and

selection of techniques 206

knee complex 495,500,500-2

special questions 361

interphalangeal joints 434,

434-5,439-40

extension/adduction abbreviation symbol 168,245

subjective examination 359-61

midcarpal 418,418

symptoms 359-60

elbow complex 374-5

pateUofemoral joints 513,513-14

tennis elbow 357,390,391-3

knee complex 495,500,500-2

plantar 558,558

see also specific part of elbow Elevation 168,244,336-8,337,341

hip region 455,474

radiocarpal 417,417-18

intercarpal horizontal 427,427

shoulder complex 297-8,308

End-of-range pain 165

intermetatarsal joints 562,562

tarsometatarsal joints 560,560-1

Ending sessions 52-3

knee complex 493,493-4,499-500

wrist complex 417,417

Endocrine system 96

metacarpophalangeal and interphalangeal joints 434-5,

Entrapment neuropathies 341,447

435,439-40

Epicondylalgia, lateral 357,390,391-3

Follow-up sessions 246 Foot bones of the 526

Ethical reasoning 83

method of techniques 168

deformities of the 541 patterns of clinical syndromes 252

Evaluation 53

midcarpal 420,420-1

Eversion 168,244,547,548,555,557

radiocarpal 419,419-20

selection of techniques 206

Evidence, clinical 4-5,7-10,186-7,

tarsometatarsal joints 560,560-1

see also Ankle and foot complex

306,322

Fractures 225-30,267,277,348-9,400

wrist 419

Frame of reference 1

Evidence-based practice 20,81,361-2

Friction 211

Examination clinical reasoning 10

F

Frozen shoulder 275,341-3 Functional corners 1-2,5,18,33

communication and the therapeutic relationship 52

Fear avoidance 25

Functional demonstration

contributing factors 12

Fear to move 105

ankle and foot complex 532

dysfunction impairment/disability

Feedback loop 44

craruomandibular complex 583

11 evaluation and reflection of the initial assessment 161-3 hypothetico-deductive reasoning 13 introduction 126--7 lateral thinking 14 movement potential 5

Femoral cutaneous nerve, lateral 446,

description of 7

480 Fever 96

elbow complex 366--9 general discussion 15,154

Fibrosed muscle tissue, stretching

hip region 450,451 knee complex 492-3

31-2 Final analytical assessment 22,53,67,

overview of examination procedures

153

89,108-9

pathobiological mecharusms 11

First carpometacarpal joints 440-2

shoulder complex 275,296-7

pa ttern recognition 13

First rib syndrome 282,282-3

wrist and hand complex 400,404,

planning of the physical

First sessions

examination 143-8 precautions and contraindications

assessment Flexion

Functional movements 155 Functional oestrogen receptors 580

abbreviation symbol 168,244

12 prognosis 12

ankle jOints 545,545-6

source and cause of the source 11

carpometacarpal joints 431-3,432,

treatment/management 13

see also

442

see Assessment; Initial

Physical examination;

Subjective examination Examination and treatment techniques

see Treatment techniques; specific region/complex; specific technique Exercise 212,243-5,621-2

G

440,440-2 elbow complex 366,367,369,380-2,

381 flexion and quadrant 308-10 flexion/ abduction

Gait analysis ankle and foot complex 528,533 hip region 452 knee complex 493

abbreviation symbol 168,245

Gastrointestinal system 96

elbow complex 377,377-8

Gate control theory 78

knee complex 502,502-3

Genetic predisposition 255-6

Index

Giving way of the knee 490 Glenohumeral joints abduction 311 differentiation of pain 330-1 flexion and quadrant 308, 3 1 0 glenohumeral instability tests 327--40 glenohumeral movement with compression 214 glenohumeral osteoarthritis 344-6 lateral rotation 313 locking position 302 longitudinal movement 1 9 7 medial rotation 314 movement system impairments 277-80 physical examination of 289-90 posteroanterior movement 197 selection of techniques 206,225 Gliding adjacent joint surfaces 168, 245 Goal setting see Collaborative goal setting Goals, cognitive and affective 94 Grades of mobilization/manipulation 165,169-70,171,172,184-5, 599-601 Grip strength test 404 Grow1d substance 207 Groups,clinical 179 Growth disorder 580-1

H

Habits 618-20 Hand 206,252 see also Wrist and hand complex Hand position see specific movement Hand-behind-back 168,1 98,244,298, 315-17,316 Healing 33--4,105 Hip region active movement tests 450,452--4 case study 481--4 clinical profiles 252,474-80 differentiation tests 537 functional demonstration 450,451 gait analysis 452 hip diseases in childhood 447 history 450 introduction 445-6 isometric tests 454 movement disorders of the hip joints 446-7 movement of 446-7,457 muscles 446 nerves 446 observation 450,451

palpation 450-1,456-7 passive test procedures 457 physical examination 450-60 screening tests 450,496 selection of techniques 206 subjective examination 447-50 syn1ptoms 448-50 treatment techniques 460-6,469-80

see also specific part of hip History ankle and foot complex 530 craniomandibular complex 582-3 elbow complex 360-1 hip region 450 identifying movement-related disorders 252-3 knee complex 491 principles of examination 137--41 recording 56-8,241 selection of techniques 221-2,234 wrist and hand complex 404,442 see also Natural histories Homeostatic facilitation 25 Hopping 533 Horizontal adduction 31 7,317-18 Horizontal extension 168,244,318, 3 1 8, 562, 562 Horizontal flexion 168,244,561 , 561-2 Humeral head, posteroanterior movement of the 2 1 8 Humeroulnar joints 363--4 Humerus fractures 277,348-9 Hyoid see Craniomandibular complex Hyperalgesia 25,32,264-5 Hyperextended knees 451 Hypermobility 230-1,249,266-7,580, 614-16 Hypoalgesia 25 Hypotheses categorization of 111, 112 deduction and introduction 111 expressing 143 hypothetico-deductive reasoning 13 making explicit 162 physical examination 144-7 subjective examination 128,129, 132--4

Identifying movement potential 5-6 If necessary tes ts elbow 369-70 knee complex 494,495 shoulder complex 275,302

IlioinguinaJ nerve 446 Illness 2,96,113-14 Immediate-response questions 39--40, 47-8,99 Impacted fractures 225 Impairments 2, 144 Inclination 165 Indicators of change 98 Individual illness experience 71,112, 126,141 Inferior instability see Sulcus sign Inferior radioulnar joints compression 415-16,416 longitudinal movement cephalad/ caudad 416-17 physical examination 405 posteroanterior and anteroposterior movements 415,415 Inferior tibiofibular joints 30, 527, 541-5 Inflammation 32,105 Information phase 51-2,54,118,127, 243-5 Informing,body's capacity to 22 Initial assessment 54-60,89-90,97 Injuring movements description of 2,15 elbow 366-9 principles of examination 157 selection of techniques 231-2 lnsidious onset 255-8 Instability description of 249,266-7 of the knee 490 of the shoulder 341,346-7 testing 158 Instructions to patient 243-5 Interactions,shaping of 45-6 see also CommW1ication Interactive clinical reasoning 83,110 In tercarpal jOin ts horizontal extension 427,427 horizontal flexion 427,427-8 longitudinal movement caudad and cephalad 429,429-30,430 posteroanterior and anteroposterior movements 428,428-9 wrist and hand complex 406-7 Intercostal movements 293--4,338 Interfaces 275,285 Intermetacarpal movements 408,433, 433--4 Intermetatarsal joints 561,561-3,562, 563 Intermittent minor shoulder pain 352 International Classification of Functioning, Disabilities and Health (ICF) 76-7

629

630

I N DEX

I nterphalangeal joints abduction 435,435-6 adduction 435-6,436 circumduction 439--40 extension 434-5,435,439--40 flexion 434,434-5,439--40 longitudinal movement caudad and cephalad 437-8,438 physical examination 408-9 posteroanterior and anteroposterior movement 438-9,439 rotation 436,436-7,437 Intertarsal joints 554-9 Interventions 94,243 Intervievvs 92,117-18,126 Intra-articular disorders 261,445 Intra-articular joints 206-19 Intracapsular dysfunction 579 Intravenous drug use 96 Inversion 168,244,547,548,555,556 Irritability 125,135,145-7, 166,176, 191 Isometric tests ankle and foot complex 535-6 description of 18 elbovv complex 370 hip region 454 knee complex 494 principles of examination 153,157 rotator cuff muscle 299-302 shoulder complex 301, 302 vvrist and hand complex 413

J

Joints assessment 526 disadvantaged 258 diseases/disorders of 260-1,400, 580 intra-articular and periarticular 206-21 joint movement 1,27 joint signs 25-6,32,187-9 joint stability 487 lesions of 447 locking 267 pain in 271,393--4 relationship vvith muscles 285-7 relationship vvith nerves 287 restoration of 29,578 sources of symptoms 144,205-6 stiffness 390-3 stretching 29-31 subjective examination 288 total replacement 269

see also specific joint Jumping 533

K

Key vvords and phrases 99 Kleinmann's notion 120 Knee complex active movement tests 492,493--4 anatomy of 488 brief appraisal 492 case study 519-23 catching 490 clinical profiles 252,516-19 differentiation tests 537-8 flexing 453 functional demonstration 492-3 gait analysis 493 giving vvay of knee 490 history 491 hyperextended knees 451 if necessary tests 494, 495 instability 490 introduction 487-9 isometric tests 494 movement diagrams 497 nerves 488 observation 491-2 osteoarthritis 489 pain 487,518,519-23 passive movements 492 passive test procedures 497-8 physical examination 491-8 screening tests 492,496 selection of techniques 206 special questions 491 stability 487-8 subjective examination 489-91 svvelling 490 symptoms 490-1 temperature 496 treatment techniques 498-519

see also specific part of knee Knowledge base 126

L

Laryngeal joint 585 Larynx see Craniomandibular complex Lateral chin movements 592,592-3 Lateral epicondylalgia 357,390,391-3 Lateral femoral cutaneous nerve 446, 480 Lateral rotation abbreviation symbol 168,244 arUde joints 550,550 glenohumeral joints 313 hip region 195,461,461--4,472, 472-3 knee complex 503,503--4

radiocarpal 426 shoulder complex 298-9,300,301, 312-14,326-7,327 tibiofemoral joints 508,508-9 Lateral thinking 14 Latissimus dorsi 340,340 Levator scapulae 339--40 Level of disability 112, 134-7 Life problems 117 Ligament lesions 400 Ligamentous injuries 488 Listening 40, 45-6, 121 Localization of forces 166,169,215, 216

see also specific movement Locked joints 231 Locking position 168,245,275-6, 303--4 Locking, knee 490 Long-term compliance 620 Longitudinal movement glenohumeral joints 197 hip region 194,194 Longitudinal movement caudad abbreviation symbol 168,245 acromioclavicular joints 333--4 ankle joints 551,551-2,552 craniomandibular complex 590,590 elbovv complex 382,382-3,388, 388-9 hip region 462,462--4,463 inferior radiouInar joints 416-17 inferior tibiofibular joints 544 metacarpophalangeal and interphalangeal joints 437-8, 438 patellofemoral joints 512,512-13 shoulder region 318-22,319 sternoclavicular joints 334-5,335 superior tibiofibular joints 516,516 tibiofemoral joints 505,505-6 vvrist and intercarpal joints 429-30, 430 Longitudinal movement cephalad abbreviation symbol 168,245 acromioclavicular joints 334 ankle joints 551,551 carpometacarpal joints 441 craniomandibular complex 590,590 elbovv complex 389,389-90 hip region 465,465-6 inferior radioulnar joints 416-17 inferior tibiofibular joints 544,544 metacarpophalangeal and interphalangeal joints 437-8, 438 patellofemoral joints 512,512-13 sternoclavicular joints 334-5 superior tibiofibular joints 516,516

- --.,-

---

--

-

--

- - --

_

. ._ .

-

I ndex

tibiofemoral joints 505, 505-6 wrist and intercarpal joints 429, 429-30 Loose bodies 231, 267 Lower limb neural tests 168, 245 Lumbar spine 455, 496, 537

M

Make features fit 259-60 Malignant disorders 133 Malocclusion 587 Management 13, 126, 141, 146-7 Mandible 587 Mandible depression 590, 591-2 Mandibular development 579 Manipulation definitions of 26-7 desired effects of 29-33 grades of 172 techniques 5, 19-20 see also Mobilization/ manipulation techniques Manipulative physiotherapy, art of 73 Maximizing movement potential 5-6, 26, 34 Measurable changes 100 Mechanisms of symptom production 251, 262-6 Mechanosensitivity 79, 151 Medial rotation abbreviation symbol 168, 244 ankle joints 550, 550 glenohumeral joints 3 1 4 hip region 1 94, 1 95, 469-72, 470, 471 knee complex 503, 503-4 shoulder complex 301, 314-15 tibiofemoral joints 508, 508-9 Medial transverse movement 426-7 Median nerve test 371, 371 Meniscus testing 497 Meralgia paraesthetica 480 Metacarpophalangeal joints abduction 435, 435-6 adduction 435-6, 436 circumduction 439 extension 434-5, 435, 439 flexion 434, 434-5, 439 longitudinal movement caudad and cephalad 437-8, 438 physical examination 408-9 posteroanterior and anteroposterior movement 438-9, 439 rotation 436, 436-7, 437 Metatarsophalangeal joints 563, 563-4 Methods see Application of forces; Treatment techniques; specific

technique

Midcarpal extension/flexion 418, 418-19, 420, 420-1 Middle ear infections 583 Mirroring 40, 46, 65-6 Misuse 249, 256-8 Mobility 487-8 Mobiliza tion / manipula tion techniques aims of 182 ankle joints 214 compression 217 definitions of 26-8 desired effects of 29-33, 182 directions of 167 evidence-based practice 35-7 general discussion 5, 19-20 grades of 171, 599-601 method of 166-7, 168-77 rhythms of 174-5 role in rehabilitation 33-5 selection and progression 7, 180-235 tibiofemoral joints 2 1 4 see also Treatment techniques; specific

technique Mode of thinking 2 Modification 610 Momentary pain 202 Motivational phase 619-20 Motor mechanisms 251 Motor representation 399 Movement active 153 ankle and foot complex 526-9, 539-40 combinations 27 disorders 3-4, 250-4, 446-7, 593-4 dysfunctions 94, 112, 151 grades of 169-70 impairments 126, 132, 231-2, 276-94 movement continuum theory 75 movement diagrams compiling 7, 610-14 depicting 599-601 description of 2 general discussion 18-19 knee complex 497 principles of examination 153 teaching, communication and selflearning 601-3 of the hip joints 446-7 paradigms 77 patterns 488 potential, identifying and maximizing 5-6, 26 responses 263 sensi ti vi ty 79 system 2 types of 2, 18

Multicomponent movement disorders 445, 447 Muscles and joint relationship 285-7 and nerve relationship 287-8 around the hip 446 disorders of 261-2 muscle length testing 153, 339-40, 340, 454-5, 496 sources of symptoms 144 spasms 176-7, 187, 189, 202-4, 607-10 tests 450, 454-5, 492, 494-6, 535-6 Musculoskeletal joint pain 271 Musculoskeletal system disease 96 Musculotendinous lesions 489 Myofascial disorders 261-2 Myofascial pain 581

N

Narrative clinical reasoning 83, 110-15 Nasal airways 579 Natural histories 249, 254-60 Nature 166 Nature factors 125 Neoplasms 583 Nerves and joint relationship 287 and muscle relationship 287-8 conduction tests 158 cutaneous of the right upper limb 286 entrapment 390, 400, 480 knee complex 488 root pain 284 root signature zones 285 superficial 411 supply 446 surrounding the hip joints 446 tests 370-1 Nervous system 96, 158 Neural conductivity 105 Neural disorders 262 Neural movement 28 Neural structures 284-94 Neurodynamic tests 153, 158, 455-6, 538, 587 Neurodynamics 28, 32-3, 144, 496, 538 Neurological examination 157-8, 538 Neuromuscular structures 285-93 Neuromusculoskeletal disorders differential dia gnosis 270-2 mechanisms of symptom production 262-6 movement-related and non movement-related disorders 250-4

631

632

INDEX

[ Neuromusculoskeletal disorders

(con/d) natural histories 254-60 prognosis 270 recognizable syndromes 266-70

selection of techniques 1 8 1 , 186, 222

structures at fault 260-2

see also specific disorder Neurophysiological mechanisms 133, 144

New use 250, 256-8 Nociception 26, 32, 251, 262, 263 Non-movement-related disorders 254

Non-prehensile function 399 Non-uniting fractures 225-30, 267

o Observation ankle and foot complex 531-2 general discussion 1 5 hip region 450, 451 knee complex 491-2 principles of assessment 1 2 1 principles of examination 1 52-4 Obturator nerve 446 Odontogenic pain 583 Opposition 441 Orange flags 1 1 7 Oscillation 1 74-5, 1 9 2 Osteoarthritic arthritis 225 Osteoarthritis clinical profile 475-6, 5 1 7 degenerative 447 elbow complex 390 general discussion 269 glenohumeral joint 344-6 knee complex 489 pa in relief 32 selection of techniques 223-5 shoulder complex 277 treatment of 79 wrist and hand complex 400 Otological disorder 583 Overbite 577, 587 Overpressure abbreviation symbol 168, 244 ankle and foot complex 534, 534 description of 2 general discussion 1 8 hip region 455 principle of 156 shoulder complex 299, 299, 300 Overuse 250, 256-8, 390

p

Pain 96 ankle and foot complex 540-1, 567-74 as a dynamic phenomenon 79 attitudes and beliefs about 1 1 6 central 115-16 choice of technique 176 chronic 25, 393-4 dimensions 357 dural 284 elbow complex 366-9 end-of-range 165 first rib syndrome 282 increase of 105 inhibition 1 80, 189 jOint signs 1 87 knee complex 487, 518, 5 19-23 levels 49 mechanisms 2, 112, 262-6, 263 momentary 202 movement diagrams 603-6 musculoskeletal joint 271 nerve root 284 onset of 1 46-7 pain-relieving techniques 578 periarticular 220 present 15, 153 processing 357 relieving by using special techniques 32 responses during the application of passive movement techniques 1 05--6

revolution 78-80 role of movement in the treatment of 79-80

severe 190, 217-18 shoulder complex 277-80, 283, 296, 343-4, 352

sources of 1 1 2 sympathetic maintained 26 systemic joint 271 through-range 166 see also Clinical groups Palpation ankle and foot complex 539 elbow complex 370 general discussion 7, 18, 59-60 hip region 450-1, 456-7 knee complex 492, 496-7 mandible 587 of nerves 158 of the first rib 283 of vascular pulses 158 principles of examination 153, 158 rotator cuff 299-302, 302 wrist and hand complex 401 , 410

Paradigms 2, 71-2, 73-8 Paralleling 40, 47, 99 Parameters 99-100, 1 26, 128 Parotid disease 583 Participation levels 120 Passive mobilization 34-5, 226-9, 295-303

Passive movements abbreviation symbol 168, 244 elbow complex 371-4 general discussion 5, 1 8 hip region 451 in clinical practice 28-9 knee complex 492 oscillatory 27 pain responses during 105-6 physiological intervertebral 168, 244 principles of examination 153, 158-61

principles of mobilization techniques 166 recording 242 selection of techniques 212-l3 wrist and hand complex 412-13, 442

Passive test procedures ankle and foot complex 539-40 general discussion 7 hip region 457 knee complex 497-8 Patella 206, 519 Patellar alignment 494 Patellofemoral joints 489, 497-8, 499, 509-14

PateIJofemoral movement disorders 518

Pathobiological disorders 446 Pathobiological mechanisms 1 1 , 76, 112, 126, 222-31

Pa thological disorders 488-9 PatholOgical mechanisms 112 Patient-centred approach 3-4 Pa ttern recogni tion l3 Patterns, clinical 113-14 Pectoralis minor 340 Pelvic tilt, posterior 451 Periarticular disorders 260-1 Periarticular joints 219-21 Peripheral nerve injury 284-5 Peripheral neurogenic mechanisms 133

Peripheral neurogenic pain 251, 263 Phases of therapeutic process 50-4, 118, 127

Phenomenological approach to the movement paradigm 77, 77 Phenomenology 72 Physical examination acromioclavicular joints 291-2

Index

acromiohumeral joints 290-1 active movement tests 155-7 ankle and foot complex 530-40 clinical tests of the nervous system 158

costal joints and intercostal movement 293-4 craniomandibular complex 583-8 description of 1 25-6 differentiation tests 1 54-5 elbow complex 362-5, 365-74 findings, recording of 241-2 functional demonstration tests 154 general discussion 14-18 glenohumeral joints 289-90 hip region 450-60 identifying movement-related disorders 252-3 initial assessment 58-60 isometric tests 157 knee complex 491-8 Jines of investigation 148-51 observation 152-4 palpation 158 passive movement tests 1 58-61 planning 52, 119, 143-8, 1 49-50 reassessment after test procedures 161

screening tests 157 shoulder complex 289, 294-5 special test procedures 157-8 sternoclavicular joints 292 wrist and hand complex 404-13, 442

Physical impairments 144 Physiological movements description of 2, 1 56, 1 58-9 mobilization 27 of the hip 457 principles of examination 153 selection of techniques 1 83-4 with compression 216 Physiotherapy diagnosis 76 Pillars of carpal bones 403 Pisiform movements 430-1, 43 1 Planning of sessions 162-3 Plantar flexion 168, 2 1 9, 244, 545, 545-6, 558, 558

Poor definition of the gluteal muscles 451

Position of hands see Localization of forces; Treatment techniques;

specific technique Posterior capsular insufficiency 329, 329

Posterior drawer test 329, 329 Posterior pelvic tilt 451 Posteroanterior movement abbreviation symbol 168, 245

acromioclavicular joints 332-3 ankle joints 547-9, 548 carpometacarpal joints 441 craniomandibular complex 589, 589-90

glenohumeral joints 1 97 head of the radius 387-8 hip region 1 95, 464, 464-5 humeral head 2 1 8 inferior radioulnar joints 415, 4 1 5 inferior tibiofibular joints 541-2, 542 intercarpal 428, 428-9 interphalangeal joints 438-9, 439 metacarpophalangeal joints 438-9, 439

radiocarpal 423, 423-4 selection of techniques 218 shoulder complex 322, 322-5, 323 sternoclavicular joints 335-6 superior tibiofibular joints 515,

Psychosocial assessment 90, 143 Pulmonary system 96

Q (2uadrant 1 68, 245, 276, 305, 305-8, 305 (2ualitative research 81-2 (2uality of movement 156, 180 (2uantitative research 81-2 (2uestionnaires 1 1 7-18 (2uestions additional 121 asking 65-6 first 54 follow-up 129 purpose of 48-9 special see SpeCial questions style of 46

515-16

tibiofemoral joints 506, 506-7 Posttraumatic arthritis 225 Posttraumatic lesions 447 Posture 451 Practical reasoning 83 Pragmatic reasoning 83 Precautions and contraindications examination 12, 126, 128, 133, 141, 145-7

hypothesis categories 1 1 2 selection of treatment 95-7, 233-5 Predisposing factors 140 Prehension 357 Present pain 1 5 Pretreatment assessment 2 1 Principle o f overpressure 156 Procedural clinical reasoning 82-3, 1 1 0-15

Prognosis 12, 113, 126, 233, 270 Progressive assessment 22, 90, 1 06-8, 109

Pronated foot 451 Pronation abbreviation symbol 1 68, 244 elbow complex 367, 368, 384-6, 385 intertarsal joints 554, 554-5 radiocarpal 425-6, 426 radioulnar 368 tarsometatarsal joints 561 wrist and hand complex 413, 4 1 4 Prospective assessments 107-8, 1 1 9 Protective deformity 180 Protraction abbreviation symbol 168, 244 of the mandible 591, 591-2 shoulder complex 336-8, 337 Psychiatric disorders 96 Psychopathology 1 1 6-17

R

Radial deviation 422, 422-3 Radial nerve test 370-1, 371 Radiocarpal movements anteroposterior movement 424, 424 extension 41 9 flexion 4 1 7, 417-18 lateral transverse movement 426 medial transverse movement 426-7 posteroanterior movement 423, 423-4

pronation 425-6, 426 supination 424-5, 425 Radiohumeral joints 363 Radioulnar jOints 364, 368, 369, 415, 415-17, 4 1 6

Randomized controlled trials ( ReT), 26, 36

Range limitation 614 Range of motion 3 1 , 156, 488, 533 Reasoning, clinical 1, 10, 71, 82-4, 110-14, 126

Reassessment after test procedures 1 6 1 art of 101-2 balance in subjective and physical parameters 1 00-1 change 98, 101 cognitive-behavioural perspective to 102-4

communication 53, 98-100 conclusion 104-5 description of 90 objectives of 109, 1 1 9 procedures 97-8 stages of 21-2 subjective 62-4

633

634

I N DEX

Recognizable syndromes 266 Reconditioning of tissues 34-5 Recording active movements 242 asterisks 238-9 conditions 239 information, instructions, exercises and warning 243-5 introduction 22-3, 237-8 of follow-up sessions 246 of physical examination findings 241-2

of subjective examination findings 239--41

of treatment interventions 243 retrospective assessment 246 written records by the patient 247 Recruitment patterns 494 Red flags 95-6, 128, 143 Referred pain 271-2, 277, 278 Reflection 53, 106, 111-13, 143, 1 61-3 Rehabilitation 399 Relationship between joint and muscle 285-7

Relationship between joint and nerve 287

Relationship between muscle and nerve 287-8 Relationships see Therapeutic rela tionship Relieving pain 32 Research 80-2 Resistance 599-601 , 606-7 Response to treatment 166 Retraction 168, 244, 336-8, 337, 591, 591-2

Retrospective assessment 22, 53, 66-7, 106-7, 109, 119, 246

Rheumatic disease 96 Rheumatoid arthritis 224-5, 390, 400 Rhythms of mobilization/ manipulation 5, 1 74-5, 185 Ribs 282-3 Risk factors 95-7, 115, 1 1 6 Rotation carpometacarpal joints 441 hip region 456 metacarpophalangeal and interphalangeal joints 436, 436-7, 437

patellofemoral joints 513, 513 selection of techniques 1 83--4 shoulder complex 336-8 with compression 3 3 1 , 331-2 see also Lateral rotation; Medial rotation Rotator cuff muscle 285, 299-302, 330-1

Rows of carpal bones 403

s Sacroiliac joint 496, 537 Sacroiliac provocation tests 455 Salutogenic perspective 72 Scaleni 339 Scapula, angle 296 Scapulothoracic movements 282, 293, 336-8

Sciatic nerve 446 Screening tests ankle and foot complex 536-8 contraindications and precautions 96

hip region 450 knee complex 492, 496 principles of examination 157 wrist and hand complex 404-5, 413, 442

Secondary gain 1 1 7 Secondary prevention 5 1 Selection o f interventions 94 Self-efficacy beliefs 105 Self-management strategies 63--4 Sensitive practice 49, 91 Sensory and motor representation 399 Serratus anterior 340, 340 Session ending 52-3 Severity of disorders 126, 135, 145-7 Shaft rotation 26, 27, 1 94, 218 Shin splints 525, 566 Short-term compliance 620 Shortened muscle tissue, stretching 31-2

Shoulder complex brief appraisal 275, 303 case study 352-5 frozen shoulder 275, 341-3 functional demonstration 275, 296-7 glenohumeral instability tests 327--40

if necessary tests 275, 302 instability 341, 346-7 intermittent minor pain 352 isometric tests 301, 302 movement system impairments of 276-94

osteoarthritis 277 pa tterns of clinical profiles 252, 340-53

physical examination 289, 294-5 shoulder-hand syndrome 341 symptoms 253, 288 treatment techniques 295-327 trigger points 287

see also specific parts of the shoulder complex Single instance case studies 26, 36-7

Sinuses 579, 583 Site of symptoms see Areas of symptoms Skin disorders 96 Skull 579 SOAP notes 237 Social environment 120 Soft palate 579 Soft tissues 144, 447, 488-9 Soreness 1 80, 198 Sources of dysfunctions 141 Sources of symptoms 1 1 , 144 Special questions ankle and foot complex 530 craniomandibular complex 583 elbow complex 361 hip region 450 knee complex 491 principles of examination 141-3 wrist and hand complex 404, 442 Special tests 153 Splints, shin 566 Spontaneous onset 491 Sports injuries 33 Sprains 231, 258-9, 400 Squatting 452, 533 Stability of knee complex 487-8 Stability tests 497 Staccato movement/ rhythm 166, 175 Stage of disorder 180 Stages of tissue healing 76, 112 Starting position general 1 84, 199 patient 166, 168, 215 therapist 166, 168-9, 215

see also specific movement Statements-of-fact 23, 39--40, 47, 53, 99, 104

Stationary holding 166 Steps, getting up and down 452 Sternoclavicular joints anteroposterior and posteroanterior movement 335, 335-6 general discussion 281-2 longitudinal movement cephalad and caudad 334-5, 335 physical examination of 292 selection of techniques 206 Steroid use 96 Stiffness 96, 1 87, 199-202, 540-1, 614 see also Clinical groups Stress-related bruxism 581 Stretching 31-2, 578 Structural lesions 151 Structure impairment 400 Structures at fault 260-2 Structures, movement-related 251 Subacromial impingement 276, 285, 349-50

I ndex

Subclinical arthritis 224, 267-9

sites of 130--4

Subjective assessment 1 1 8-19

sources of 144, 205-6

Subjective examination

Tibiofibular joints

Synovial fluid 208-11

ankle and foot complex 529-30

Synovial membrane 208-11

craniomandibular complex 581-3

Systematic reviews 26, 36

description of 1 26, 1 27-8

Systemic joint pain 271

elbow complex 359-61

inferior 30, 527, 541-5, 542, 543, 544 superior 489, 498-9, 514, 514-16, 515, 51 6

Tissue healing, stages of 1 1 2 Tissue mechanisms 132-3 Tongue 579, 587

findings 238-9

Torn acetabular labrum 478

general discussion 14

T

Total joint replacement 269

heel pain 567-8

Transverse movement

hip region 447-50

Talocrural joints 545-53

abbreviation symbol 168, 245

history 137--41

Talocrural transverse movement in

and rotary movement of the

identifying movement-related disorders 252-3 kind of disorder 128-30 knee complex 489-91

dorsiflexion 30

laryngeal and hyoid joints 593

Tarsal tunnel syndrome 525

ankle joints 552-3, 553

Tarsometatarsal joints 527-8, 560,

craniomandibular complex 587-9, 588

560-1, 56 1

peripheral joints 288

Tearing 199

purpose of 52, 54-8

Techniques of mobilization/

gastrocnemius 3 1 patella 28

special questions 141-3

manipulation

symptoms 1 30-7

manipulation techniques;

Trapezius 339

specific technique

Trauma 33, 96, 390, 400, 541, 579

wrist and hand complex 401--4

see Mobilization/

patellofemoral joints 5 1 1 , 511-12

Subjective reassessment 98

Teeth 587

Subluxating patella 519

Temperature , knee 496

Traumatically induced arthritis 269

Subtalar joints 527, 545-53

Temporomandibular joints

Treatment

see also Ankle and foot complex

Traumatic onset 258-60, 491

distraction 29

general 7, 13

internal derangement 580

interventions 243

Sulcus sign 329, 329-30

introduction 578

movements

Superficial nerves 411

management of disorders 593--4

of bodily awareness 65-6

Superior radioulnar joints 364

patterns of clinical syndromes 252

planned break from 108

Superior tibiofibular joints 489, 498,

physical examination of 584

planning 60-2, 94, 126

Sudeck's atrophy 399, 400

selection of techniques 206

499

Supination

Tenderness 497

see specific movement

soreness 1 66 Treatment techniques

abbreviation symbol 168, 244

Tendinitis 476-7, 565-6

elbow complex 367, 368, 383, 383--4,

Tendon lesions 341, 400

elbow complex 374-90

Tennis elbow 357, 390, 391-3

hip region 460-80

384

ankle and foot complex 540-64

intertarsal joints 554, 554-5

Tension 105

knee complex 499-5 1 9

radiocarpal 424-5, 425

Test procedures 148, 152

shoulder complex 302-27

tarsometatarsal joints 561 , 561

Tests of the nervous system, clinical

wrist and hand complex 4 1 1 , 412, 413, 414

Swayback posture 451 Swelling of the knee 490 Swelling, general 496-7 Swing movement 453

158

wrist and hand complex 413--42

see also specific technique

Theoretical reasoning 73-8, 82

Trial and error 26, 37, 114

Therapeutic process, critical phases of

Trigeminal nerve neurodynamic test 587

39, 50-3

Therapeutic relationship 40-2, 73, 94-5

Trigeminal neuralgia 583 Trigger points, shoulder region 287

Symbols , abbreviation 1 68, 244-5

Thoracic spine 455

Trismus 577

Sympathetic maintained pain 26

Through-range pain 166

Trivial incident 258

Sympathetic mechanisms 251

Thumb joints 409

Trochanteric bursitis 479

Sympathetic outflow 250

Thumb movements 440-2

Trust 120

Symptoms

Thyroid area 584

areas of see Areas of symptoms behaviour of

see

Behaviour of

symptoms

Thyroid cartilage movement 593, 593

u

Tibiofemoral joints

classification of 146

accessory movements 504-9

Ulnar nerve test 370, 371

identifying movement-related

lesions 489

Unstable disorders 112, 125, 158,

disorders 252-3 production, mechanisms of 262-6

mobilization of 2 1 4 passive accessory movement 5

221-2, 266-7

see also specific disorder

questions about 137--41

passive test procedures 497

Upper arm pain 283--4

reaction to 156

subjective examination 489

Upper limb neural provocation tests

reproduction of 494

treatment 498-9

(ULNPT) 357, 370-1

635

636

I N DEX

L Urogenital system 96 Use,predisposition through 256-8 Uses of glenohumeral instability tests anterior drawer test 328 anteroposterior and posteroanterior movements 333, 336 anteroposterior squeeze 332 apprehension test 328 longitudinal movement cephalad and caudad 334, 335 posterior drawer test 329 rotation with compression 331 scapuJothoracic movements 338 sulcus sign 330 Uses of treatment techniques see

specific technique v

Vascular disease 583 Vertebral collapse 96 Viability of nasal airways 579

physical examination 404-13, 406,

w

442

Warning at end of a session 243-5 Weak link 180 Weight loss 96 Weight-bearing 452-3 Welcoming phase 5 1-2, 54, 1 1 8, 127 Whiplash 579 Willingness to move 156 Wise action 180 Work-related upper limb disorders

radial deviation 422, 422-3 screening tests 404-5, 413, 442 selection of techniques 206 special questions 404, 442 subjective examination 401-4 symptoms 402-3, 442 treatment techniques 41 3-42 ulnar deviation 42 1 , 421-2

see also specific part afwrist and hand

400

Wrist and hand complex case study 442-3 functional demonstration 400, 404, 442

history 404, 442 introduction 399-401 isometric tests 413 osteoarthritis 400 palpation 401 , 410 patterns of clinical syndromes 252

y

Yellow flags 40, 115, 180