ijlTITE~"QRn,
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MAITLAND'SI .. mmmJ
Vertebral MANIPULATION Edited by
GEOFF MAITLAND ELLY HENGEVELD KEVIN BANKS KAY ENGLISH SEVENTH EDITION
Maitland's Vertebral Manipulation Seventh Edition Geoffrey D Maitland
MSE. AUA. FCSP. TACP. SASP Mapplsc
Edited by
Elly Hengeveld SellPor
ltac~r; Int~rMrionol
Kevin Banks
MSc, BPT. PTOMT. SVOMP, IMTA Memb" Maitland T~chcr'sAsS<.lcior'on. Obcrcntfcldcn, Swiller/and
SA. MMACP. MCSP. SRP. IMTA Memb"
Cho~~ Ph~or~rop;sl ROlherlJom,
Kay English
UK
Dip Tech (Physio), Grad Dip (Adv
Mn. MMPAA, MAPA
Privott Proc1itiOflcr. Mtdind;t, South Auwoll(r. Australia
ELSEVIER fIlrrn;RWORTH
IlU"u., ...""
EOINBURGl-1 LONDON NEW YORK OXFORD PHILADELPHIA ST lOUIS SYDNEY TORONTO 2005
ELSEVIER ",;,r:~~~~"
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Bn.15lI Llbl'lll')' C.tlIloeuin, inl'ublkation Data A ......"""'" ~ r.... 1bi< boo/,. I. fn"n ,he fln,c'" bllrary
i."......
I.lbnlf)· 014.:_11.__ Ca'OII"'J'llnit In l'utlllc:o'ion I)a•• Acal.Ilus"" =-Idl f«1!u> booI.. I> " .... lmlc fn\lll the 1Al<..,. orCon:='
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Contents
Prl'fac~ 10
11.
the seventh edition vii
Prdace to lhe first edition Biography ~I Glcssary J('(
i~
Introduction
The lIoctor's role in diagnosis and referral for
1 17
O.A.B,e~rtOt1
4.
AnesSmtnl 53
5..
PrognosIs
Eumin.tion
ttthniq~s
~lccljon
9.
Application of tcchniqu($
111
of techniques 183
213 willi 0 ('OIIw!Jutioo by B. C. Edwards
CCr'IIica! spine
2. Clinical C:lilmples of ~mtflt 459
moYelTl(nt dillgf1llms 97
8.
10.
Apptndi~
AppendIX 3. Examirution
85
Principles of
Examples of tn:atmcnt 413
diagf1lllTll;
wirh 0 conui/)cjtiOll bra C fdwunJs 7.
15.
Apptndi~ 1. MovclMnl diagram theory and compiling a r!lOYf'mcnt diagram 445
23
wieh Q contribution l:Iy J. Graham
6.
Silcroiliac region; sacroiliac jei...I, syml'hysis pUbis 401 rcgioos 411
manipulaliW' phyo;iolherapy
Communication
lumbar spine 337
13.
14. Sacrococcygeal and intercoccygeal
1.
2.
J.
Thoracic spme 301
12.
229
,dinem~ts
and
46S
Appendix 4. Oinical lips 469 Appendix 5. Physiot~rlIpy for animals with 0 contribution by r 1. Ahrm Bibliography 481 Index
487
475
vii
Preface to the seventh edition
PhyS'Olh(-r~pislS ..re being
calii'd upon II1creasmgly II...
medic.. l praet;1I0ners to t•..-Ip I''''..,n" llUI\"er from
t>pi!iOd,os of uncompliCil.loo
l>I"
~ln'rle/rnechanic.>J.
~pinal d,sonl,.,... Manipu"'li,·.. Ml)'liiotherapy, il is de-.u,lus an Important role to pta\ Wllmn!he recm'~ and ~Nbi'ilationproceso>Tk ablbty 10 identify and "leal" Ith s..--grnent.>! mobili!) U!V"inncnl, ni!UlOOyn.utuC d)'Sfuncti and musoele ,mlxlL1nc{', for .,...mple, "-'quires finely hml-'s bl.'t.'ll 0I1C of lhe con"-.,-ston<:S of rnQr\( will "nl"" how mUch 1)1{)UI~ht "nd detail goes mlO Ii~' .\pplication of each individual k'Chnique of examll1ation, rllQbilisatioll or ",a'u!'u]atic'11, H,wing thp npporlunity t(l Seol and pra<:ll<X' !C'dlniq""" JX-..-furTTl<.'£1 in an o.pcrl wa...' can onl} sen"C In hdp an} clinician 10 und and appl}' n",mplllat"e phnio!heTapl methnd~ mon'dfocb,"el~II' lhecluuc.l setlIng
sr,,,,,1
Wh,lsl le,lbooks can ne\'d" ~titute the- rcal-timo.' acquisition of lIlo1I1ipu1l.h\"C skU]", they l;M :\bllI~~J.uW>" although hal'ing cxacth \hie ....1TM' teotosr'.lpl'os and a DVDshowing \id«I dIps or aU rdc\OUII !I,'Chrnques_ 1lus shoukJ hdp the n'ilder I"see and appl~ mon·d.:arl} asf"-'Cbof '-"'<:h l...Jmique sucft .... sWrtln" ~'lJun>, 1oc.l.l"""lIon 01 lom'!I and "pphc;d>on of fum", II th""" dmamK additions allow srud''nb of m,lOipw3tin' ph}>iothc.apy \{) enhance ,heir skills Mld e>:perls 10 check and refinc their skills and in hun appl), such skills clinically to help maximi'" p.ltie"t ",'Co"I'<)', then the aim of thi~ rev;.;ed edition will ha'"e oc'\'n "crue' 00. Elh I-k'llge,eld - Obrre.,f,'/J("fl. Ke-"in Bank$ - RI>rnm""fl. Uk
5"~I;:nIa",f
;.
Preface to the first edition
M"l>ipu!Jtion (It the spi"e i>, aS6(ld:llro so oft"" with fa~ diagnosis at\Cl 'hit or ml~" methods 0; bruh' force. ~a!i§OCiJll{l11S h.a,·c rnulk'
gl.'flt!er procedun"'<. Thef-e Me m'o war-; of lIMImpulallng the
c~;ous
p..~lknl. 11le first, bo.oU",r thought of as mobilQ,lnon, i, the gentl", C(~l"Lng of a mOYCml'TIl by p"",i,-" m} thmk,ll oscillations performoo within or at the limit (If the range; the sc<:ood ;s the fmcinl; of .1 mOn'.." "nl (rom the limitofU.... range by a .uddcn thrust The difference between ~ 1"'0 technique- IN.)" '"l'eIJll"ll'7'ilisiMI' "·!-.... comp;oring .. stronglv apphl."d moblli/..lhOfl ...lh a GOOtle manipulative thrwot, but ~ i!; an Important d1h~_ "The patient ("In .. lw... ~"S It;,bllt1<' mobil17..ltioo1 if It ,"",>uld berome too painful, wht'n'.lS tho- suddenr>rSS of the forcrlut milmpulahon preo. ...,,15
any (()Iltrol by the p,'l",nl TI,e prncli<:al appru.~ch lu th" ",.., of m~njpub,jon is I" rdate treatm""1 to Ih"patj~nl'.~ symptoms and siilns rather Ihan to dia"noses, Such a plan "Yoid, bolh the amfusion ,,",u§«! br diagno5tic litl~ calling to mind dilkrenl 5~ mplums 10 d,f{("l\'nt people, and (on-
me
troHr5y .......... pathology. lmieN, 11 i5 often impos..-ib.... 10 In...... ..-Nt the In1<' patholog). ;, AI60 " "Ill be a~ lh.at und.....,. the umbrella of one dlo1gnostic ti:lt>. fol' ('XiImp...., 'disc ~ion', ; from I"" occiput to thl" ,,;,crUZll arC discU5!led in this 1xx,1:. ""d !hI' k~t hM been planned lu 111"d Ihe reader in logical
each col> in the final (Npl(>r. II should be undet"5l00d tNt .. II ~a!ml.'nl in mis boo!< when dOllll." b) physiothc-..arbt, is.,ruyC"amed out on rrw!dical n-il'rral To the m.my propl.. " 00 M."l" contributed 00 mudl roward, Ih... final preo;enlalion of lhis Iloool: I .:1m unabl.lu "~press m~ grahl\lJ.. i1dequatdy. Will'"ul the con_ .Iruct",~ help of tho,;,: co,><:emro wilh the Iypin!l ",>(1 po,i0!l for Ihe di,'gr~ms, my work \\,,,,,1<.1 h"ve D..--Cn much more difficult P"rhculJl people Well' asked 10 undertake 1hI' t",1: of mildmg and mliazing the m"nu""ripl m d..ta,l. so lhat il mighl m<'t'1 11, IlNn}" as po:s,.iblc lhe 1lC'C'd,. fur w!tich II Was undl'ft.llen, and I am!>Ure that the} "'ill boo abl<' 1O>ol'C how iJ'\,ah..ble their ,,-utdance has been. In partlCUl,u I "'1Sh to "~Pll'SS my ";n<:....-c ltunl<s lo )lbi \I J. H"mmOl1d, ,\UA, MC5r [Teachers
C"rt.), Mis, 1·-\1 Gam~, MCSI' rr"..chers eerl), ~!I.\oS M. Marhn-Jonl::>, MC5P(T"ache .... C""I.). Dr A w. l:"Hlwl!. D Ph}. Med. M", H. S. Cul,h"w. 8", Dip Ed. Mr Lansell Bonnin, MCh (Orth), FlK5 ,1I1d Dr Bry,ln Gandella. \10, BS (1.ldbl, \iRACP{Consult.ilnt Editor. Austr~Ii4.11 /('1 ...11I1 of Pll'l"-ii.'l/lffllpll). T"hcsI' persons by their indi' idual comments and crillos.rn!> ~ .... ronsoderab~ guid.aoce conammg d,ff~""1 ~ of the work. oarnt.~J tht' tcadung of ph}"-';lOtherap} >tuoi<'n!, medlnl .K'Cq)IoInce and compos'llun. \t) lhank", al'l' du.. abo tOutr,,-ife .. hoso pairblilklOgly rrnducoJ all the dr,l,,'iog"I ;lm most gratdul for the murt~y \·~tended to me durin,!; •• =ent .tud} lUI" in Greal Urit,lin.lhc Unitl"(l 5t.lles of Amenca and Cm\,.da Adelaide G. D. Maitland
Biography Geoffrey Douglas Maitland
MBE, AUA, FCSP, FACP {Monographl.
FACP (SJ>e{'ialist Manipulative Physiotherapist!. MAppSc (Physiotherapy)
G. D Maidand (19U-J, \\0lSb(lm inAdel.lIde,A....trallol. tTaiN'd as a pfl)1o.otheraplSl from 19-J6 to 1949 .. fleT 5CT\'U'1g in the RAAF during the M'Cond ~\orld W,]T In Grt'~l Imlain. His fi~t job "'Mallhe Royal Adclaid" Ilosp,t,,1 and tl'le Adelaide Children's Hospital. with il m~in inte~1 on Ill\, trealm('nt 01 orlhopi>l.,lic and neurological disordl'N;. Later he oonlinuro working part-time m the hospital and p"r1-hme on hIS 0....." pri' "lccllnic. After .. fe.... )~'il~ he b«-a"l-.e a parNIm<' pri' at" practitioner and part-time clinICal tutor at the School of I'h~~o lh<.'ra~ in IhcSouth A..slr"JWl (nst1luleofT~'Chnolng~~ nOW the Un;"('I"S,I) of South AuslralJ.. lie continu-
corresponded with in IhI> p.-..cl'ding \~",rs. In London. Groff h.>J ,"~tin$; lunchtimt' climea! SleSiSions and d~ions With James C",""" .. noJ hi~ staff From this tour G D, \-laltlilnd ~"blishcd a friendship with Gregory P Gri..,",~ tron1 1110.. UK. They had t'~tens",,, correspondence about Iheir dmic,11 ('xpctiencl's and this conh"u<'d for !l1,.ny y"ars \-faitland d~1i\e,,::d a p.lper. in 1962. 10 Ihe Physiotherapy SocIety of AUSlralia enlliled '"The ProbIMru. of Tmdting \'t'tkbral Manipulation', in which he p"'"
Barr-Smilh tibrMj' and the exceU"nl library 011 the Ml"dic,ll School of the Uni""n.ily of Adel~id" He immediatdy showed ",n intere;l in careful dmICaI {':\.aminalion al'ld as;es;m....' Ilt of patJenb WIth """,m-
.....nl<'
m,~dtSttdeTs.lntha;edil}''5~and
physlOlhl'rapi5ts;
ously stud""l
,,"J spent "',If a day Neh w''''k ill the
movementS "'~"" un:amino1lilm and a~~1 He slirnula~ Siudents to Wn:e lIeal· Ill(.'nt raords from the "e-ry bt'ginning.. as he- fetl 1....1 'one Of'('ded w comnut Ot'I\.'jlolf 10 p;lpet' to an.al~-e WMI one is dOIng' In 1954 he- ~larted with mampula· the Ihc.apy leachjnG <e:>sion~. I" 1%1 he ~e'\"l'ctors, mecbcal doctors .,nd phvsiotherap\ fflileagues "'hom the)'lwd helIrd and read about and tr'eo1tJn('n1 by
li"X'fw:
p""'in~
""'" rrr....ll.v .\Iol'IJ.U1J•• pIrysa."~Fl>tJrom A"SlmJiIl, /fa- Mn e1frpl~/1g"J'I.°III~ thru~'" oJj J/'<M'r /millmcy !mlll'I/lr mart' ,'rr'lglh Mind II~'",. TI1eI/ a"ollot i,lemiclI/ l.·itll III<' /lwb,!i;:ms I.-.:IIIII'/,I<'S tlml O,I"Il/Mlh, ,,1i,.WHlf 'IIrlicoll,rlro,i", I10r lire Ilory rt.' jrrkv II chiro"rllclol'l" I'''-s..
/lOt
tmlllJl'y QrI'''
poirt.1,t'II tndtni.J" got< au! OJ hI) """ Iolar-'.
11r. .",.ttml.'Su"""lslIlld '''''',,1><11,11.. prllrlical rffi>rt of malllp"lat'Oll 11r,' ""IWII j, ex<>mi"",f rrl frrquml i/1lff"iwl, dHr;'l~ Ill/' 1il'S.'lClIl, t(Jf"~H~ Ih,' llUwjlm/alnr 1<1 a,><,:;S tit" n':'l1ll '111i, trcnlmC/I1 50 ~r. Heron/m,,'" or allers hi, lce/""''Ila in IXcordfllCt' ll'i/Il
lklcdeJ
,h,remlsr, IN a/J«'ICfO!dl/lll,l:f,
~ ",ohJ~J<mScJCQrly
p"",i,k 1M
r ':~ -'-'-",-"-'-' '1i-'d-' '-;'-' '-'-fu-'_- ' i- - ' -"d-'ho~'-n-"'-~-'-"P-"-"-"-"-P-"-"-.-" '-"-'-P-Y-(,-k-O -" MtllOpanlic ftlnf""lJ~ a",I-I"'ft,'I' ~fjll, u'ill,.OJ ;"Irrxf"c/i<m II) ,I,nll. Sll~ smIJ, rmifiIIicn.~nn;Jall,
umdon. P"S'" -10-11)
G. D, Maitland I:>o!c.",., .. subst"",i,,1 contributor 10 th..
<"f PI'Y'J",/IWl1lj'll ..s ...,,11 a~ to other m..-di<:lol an.! ptl\'5olothe1ap\ joumab ""OfW" id.. On the instigation of Monica M/lll MIl"'I"" Inrum in 1%-1. whIch w~s 10110\\,('(1 by J !'oC1 c'dihon (If I'c~'wh,'ral Mo"ip"lalio" WM published in 1970, in "hid.. the famVIb 'm"'eml..... r di.lgram' wi\S inlrodw;OO . .." ..a,lic... co-producrion ..-ilh Ms}ennikr I liddifls III 1965_ 0.''-'' all tho:' rurs of Ift:turing "nd publb.h.in~ M...tLmd kepi tINting patients ill> thto clmical "OJ~ ",mallled hl~ m.l1n SOU= of learnIng ..nd adaptu'8 ide" •. Geoff tre"tlod pati('JllS in his pri"M" prM'h«1 for ~ yean; Jllli although h" doscd hi, pr"clI,,' 111 1965. "" r<:maintd Jcti,'e in treatingp.lti"nt> unt;119'I~ In 1965, one of M.. Jlbnd'ji wishes Came h11..; With the hdp 01 ~h 0 ...... C.......a..'Y, Hei\d of !he PhHlolhcrap> School South A=Ir..i...n In',,ululI!.'' of Techno!· OS)' and thl' South Ausl1'lIli<'In Brandl of the A""trahan 1'h~."".u..'I p)' ... ~tion, the fiN titrel.' ITU\lhs OOUI'lll.' on M"llIpu!.>tlQn of tll.. Spi...• was n..ld In AdeLudc. In 197~ this cvur.;e d",e]"I"-,<1 Into tne Oil" ye,lr p<.n>t· sr..duatl'oo""ativll 'postgr,;Ju.Ill'diplom... in marupu' br;v" phyi the Workl Conf.xl.....• at,,,,, of l'hysi"llwlOlpy (wei'll Only in 197~,,, hilc tl'aching one oi hi!; fi,."t ""uN'S in cuuhnental Europe in B"d Il:aga~, S",uerldI1od, llid he ~ , through d~on ....· ilh Dr £Inn. lJ'm>o:tor 01 !he MedKill Cli..... and the P<Jo"IgradUoll<' Studv Cenl", in D.ld Rag.oz. tlut in f.."lC1 IUs work and itk>.. s ......".., iI specUJ(: COllCl'Pi of Ihooghl and <'CIi<>n ~ather than a methQd <.>f appl)lng lJIolnlpulatke lech· ruq\ll-'S. T..... MaitlM'Id C<'>llccpt of\lallipulati\'e Phys.othcr,lpy 'IS il!x-eame !.:nown emphiiSILCS a "P"Cifi< w,ly (II Ihmking, cQT1rinl>Ous c\'ah",li"" .. nd i1,;,;e,.~ml"'" AII!>/",t.", j'lIlr>l1l1
0\-'"
..
wh.."" how lInd whl~h k..,h"iqll~'S to pcrfonn. nnd a,J~pt th.-'SC to tile individual situation of the patient') and .. total (ommitm.. to Ihe patient. M.liUal1d 1\.;>5 held " ~ .md ""h...ui...· comm,t" ...",llo , .. riou:; prnfCffiion.,1 lIS.'lOO.1hOf>S:
'n'
Austrnlian 1"Y"'oolh".aM' A-.ci.Jlioo {APM whcft, he "-015 on IheSlate branch comnunec for2~ \'t.\1J'li in \ ..OOu5 cap.1Citi<.." ilnd iI Stat.. OI,"-,*,t" to Fed!'ra! (",neil ior II ye,lrs. In cuuf"nclion .... ith "thers. he was rcspon..'ibk for the "",,-,ion 01 the stitu!ionofAP/\ in 1~1%~ In Im,hepul fo.ward. submi:>sion f>?golrdingSp«ulizahOll in \I.""puLtt"e l'hysicothefilf"; a<.V<'lC'q)r ..-hich ...... .,..b>equ.,mly acr<>plcd in n>odifJed lonn lnaugUlall'<esld""t 01 U",A"",ualian CoIkogc of Ph\~oIh<:rar"t:s fors" )'''U"S and a " ....-mlx... . o/lhe Cl.,,,ncil fora furth<.... s;",p,"''S. Member o( tI~ Ph)"'iOlhl'rap~' ~cl>l.lrallon Uoord of500.lth A~trill;" fur 22 Wilrs Chairman ,>I rhe &pt'M I'anef for 1'h~l'i<.>IMilpy for Ausl... I~", Examini"lC CoullCll rorD-..........s I"'} .......therapbt5 IAECOP) lor 11 )'Nf$. Austrilhan d,4"'!l"1e to IfO\tT for fi\e )·""<5aOO a m<."n'lbcr ofl~aCJd"mic "bndardscommitf('(' for
.111".her fil'e
r"MS
For hlJ; work he
w~s
hon.)u .......J wilh
.,.,\er~1 aWilrd~
Mem""''''~Order.."
!he Brilish Empi.... in 191\1. FtlJo>,-,;hip .." I~ ~U-i1h..n College uf Ph)...iotherilptsts by I-1<.>n<.>gr..pb in 1970, ..-iII1 a furl""," Fello"-"hip by specWizAtion in 196-1 IioooraJ}' ~reo.-' uf Mas'l'r of Applied 5ctencc in I'hysioU\('r~py1m", Ill<: University "fSouth AI.l~traTi~ '" 1986_ tiooorilry rdlow of th"Ck;'r1"n..xl Serlet}' 0( Phvsi<.>therapy (CD) J-iorIor~ry II(e ...emb"nlll!", ui the Se.•J1h Ahirnn !'oc~ '" Phr"lCJtho,np~.including the Group 01 \bnipulab ..,(' Phy-srotl\eQp~~ M......pulab\'t' rhv.wthc..apy Association or AustQ.l1. (~1PAA), Sw,ss A""'-'Ci~linn o{\1anlj>ulatiw I'hysioth"r.lpy (SVO:\l Pl, (;(>nlla" A,..)('iMi,m of "1an unl Th<:mpy (OVMf) and Ih" American l't1ySiC.l1 The,apy A»ociation (APTA). tw "",.,.n.,J ..., a\"".d lrom IFOJ.,IT in app"",;"tlQn 01 hl$ .......-~;u>d I..~dcf'ship from;1$ foun,btion \llIdred Own Award b\ Ihe World ConkdcT-atioJ'l 01 Ph\"Sica111'lo:"<~py (Wc:rn for his life's work in 19'95'
-
in 1M '" Zur.wch, Swlt~l'rbnd, the 11l1"m.,tional Mulland T,"..d ....-no' A'>SOC;i1l1on (l:\IT,\) .....as found...,j,
810graphy
of .... hkh G. D. \laitl,md is a founding member and inaugural President A1Ithis w(If'k w(>uld f!N M\e l>een po;>;oJl>le" linout the kwinS ~uppnn 01 Ills wife Anne. thl.. rnotheT of Ihcir Iwo chikf"-.... john .. nd Wench: Anne did most of t..... graphic art;. if! MdJlbn..l·s put.licdlion", l"J'I ""te<, rna<Jt. manllo of the M... itlands, who an' pracl1t'ally illSt"parable SUlC\: II.-') mel in England during :;aund World W,lf Anne wilS aw",rdcd prulocI"'less of the Dutch As5ociation of Orthop.-.cd1C M..nipul.1I"·... Ther-..py (' VO~Il). M"itbnd's work, <'!lpeciall\ through I"'" mod.. thinking lind the pl'OCt.~ of conlinuo"," ,l5'ieSo""-'rlt, has l
m.:-
or
Within this conl<'~t it S('\'ms suitable 10 conclude with a q""h.' f""n1 Pn.J(~wr L,nce Twom~', Vice eh,"'cdlor, Prtlre~rofI'tly"mtherapy, CurtLll UJ1I' l'r-
sily of Te<:hnoloflY, l'i'rlh, Australia:
PH ;'Cry.areful and Ci''''I'I'f'llrJ'5il'<' ""'mllma/i,m 1~lIdi'lg 10111"I"''l:i"" 11!'I'I~,7Jt"JJ 'iflr(l1lm",,1 by m01't'mmll1nd foJlolr'/"li ill IlI,n by lI'fll_
n.uffll riillieo/ IIPI'roWell, TillS b l'robIlbly'hdlN' I' 1Iu' ,;n,~11'6c nll'lhcJ 11>'' ' po1>;,/['/1' u·;thin tilt di,fi(nJ
,..odin' c{ Jt/:l/~IC'l/IIh/'raI'Y ulld ...~ "" If mMrl1'll' oil," ~1«Uf/llmbof II.' prP//'5
Eatii"r in 1987, TImml'\'. ha\'1n~"uHb'CSledMaitlaoo ,,'rill' about hIS WfItnbuhOfl s.ud:
~tlO\Ild
/11 myl'ito1'. thl'A-1JJit..llIdtq:pnlIlfIllOlll'flll'lt'T" di'frrsfron' "t~, "d i>1 tI", IntdldPll('S iffl. I«J",iqlli'. M,I r,~111T III IF, 1lJ11"TWdllc Ill.' IVUrIll alld his l'dltKTl!4r /'TC'NrolI. l,-llraffmlllln Iotktllil ii' tTJnO.Ii,ra'i'I''1, Ir",11IlI"ll Il"J rr..pt}fN i~ "/Jill"'" in pI'lf"lUl/ fl>mzl"f /uw /l'(iic';" .. UVrlll spclllll;( 01/1
ill
1/1(' dm-k'V,.1<'tf1 i:" lfl)U' 0111''1''. if _'rmll IIJld ImlTr'lml;
tIl'llT 1'~!;tm<1' ('II
",,,,,,J fi.",tJ.lI. 1I<'oflolsK
bioIogicul b,.~~·/.,,f;(...;
iI,e 'r«rs':;llffo, l,i;;11 I.· ."" ,t! slil/. rftl/f","'....pto. II JIJ mll w,,'t:' I"
tr,,·n.'t1ulum
.¥"" fllllyJrn'/0I".J /"" I~ If linus IIJI"';. d'"1~IOJ'i"lI ""J nkll.l",s; II", IJff,'S,illffi" .Id'Iilt'd i'.m'IIIJ1,III"" mId for the I'.",m""d iOl'l/m'I"'ml/r" .....mmilwlio'IIII'I''''''r!'
TI,i, u,,'/I i.< 11'C11 1<'orll, "("y <,,'mi,I,'mN,' '11I"lIriOlI 1t....·<1tN·. 11'1'1". ili~tl,e''S'' ..I!'''''lf'/I.1i11l1,IIl.r' 1\\T.ml'\·, L 1. ~nd T~\'lor, j, K (1987) 11,1' M~illand O>nn'pt: As:;essml'fll'. E>..1D\inaII0l'l, .1nd T",alment by I'as:;i,'c ~lo\'CmclIl. Ed~ PiI.lf.'iml TIK'nlI'Y of II... Lou..., Burk Churchill Li"ingslone
t'JI}' H{'flge,·etd Ka)En~
Ke\in BanI.,.
xiii
Glossary
ACCESSOIO' MOVEMENTS. (a) [>~ssi\"e ae
<.ot,1"Cl".' of symptoms "'hen rnO"" Ihan one joint or "truclure is ul\"oh'oo in a mO\'\!lJll'f\1
costal n'o,"errw.'flIS, PAICM.
DISORDERS. Beca~ a Spe"CirK diagnosis IS an a~ of d"lo>nnination which is In!o:-.. m the led of Ihis bolllk. The .....-...on fOJ" u_mg such II term is dclib=l~ ,t IS m;,>,lnt [<) ttw ,.,ad.".'. nund fTt"e to "bsorb the ~ oSsmtl..ls of the """""",ted IL':l.1 The .. tlen1ati'e is !II ta,k in dIagnostic tenl'll>. bUI Itus can oc'COme counterprodUCII'!, b)" clouding lhe ,mpocl of lhe relatLod lext thu" losinS the key of Ihal rel,'IOO le~1
ASSESS\1£N'T This term Iw; three defllUliorIs:
1. A!i5CS6mmt 01 the lindmg;;oilhl!eummilbonofa palJenl"1Udl g;,..... 1hc L""ul.iner lilt- informal.,., Ie) rn.:aIoc- a diagno>is. Some (O\.Illtrie!; use the term [V,\I.UATIO:-.l f;;w Ihl> aspo.'Ct
l'l."lUln!d
2. AsseSismmt of the change.. wtuch lake pLoc.. as .. !>!Suit of the us.: of a t«hnlqU", to prO'c Ihe clfed of the te.:hnique on til<' d,>oroL"" al"" to dC'lcrmi"" Ihe <"fll'Cl of the Ircalm,,'" hxhr"qul'S and th.. treatmenl Sl.'SSiOll> on the disonk•.
3. ANALYTICAL asS<'S,nK~ll j, ,," il-<,,«menl made durin);" Ir(>illme"t or ilt the rontlusio" of t~lmeT1t. It take!; into acrount all d.-t;ub of th,- patient's pil.S1 ilnd pre5Cll1 history. IN.> di.1l:n.l
hi,...,
ASTDUSKS. The use at ~ ;1' !he n=rding of each palll!fli se.=UnabOf'l findmgs ,,00 m.o"-o the thl'filPlSt quickly ........... of ....senlIilJ romts ...h8l milkirf;
..
~_
COMPRESSION. This is Ih"al'l'r<)~Im.ltion of OPpoli-
Ie",..
[VALUATION, This term is not u:>ed in Ille 1".\1 of Ihis book. but it ;s understood to mean a form 01 A~So.'S<->menl
(see A,se-smt'nll
GRADES OF MOVEMENT, 5.,... M.,"e"'''T1t HYPERMOBILITY. Sec lT1stabllity. Hyper-mOOlhl)" I~ ,In ~,"-""S" .. rang~ of mCl\emC'1lt (e>."mples bein!; hype"",IL'1lSioo of th....lbo" Of ~..,) for which the.... is romp"'te mUSClJLuronlrol thu~ prO\idmg~tabilitv" li\STA8IlITY. This lenn is USt'd onl) 10 meao oCulolrrontrol. IRRITABILITY. Irril1bi!J~' means lhat a btll.. acti.·") causes" lot of pain that t.ake;. a relalL.-...I}' long bn... to Ol'1lle" In mill')" cases this is an lndk"tion thai <:iIUIioo ;~ T\.'quired dUTlng ......,lUllolhon and t.-mIn"",1 p-~
ing ;oi"l sUr!:t<es, either in a positiun or duri"g .1 m<)"eml~lll, 10 asse,s the .>ource of '1'1l1plorns and to IJ" used as a lreatmc~11 !<-'Chni,!ue
1. Its 5usc'-'plibi]jl} 10 becomi! p.1i"fuL 2. How painful II oc'l:ome<. 3. Thl.' k'T1gth of timl.' this 1"'"' takL'S 10 reco"L'" ($<~'J"'1gesS. 116-117).
DtFFEKENTIATION. This arplkos to examination assess which joint or ~lruClu", is Ihe
JOt NT. This word rd'-'n> to all lllol intra-articular slrue· tur('<;, tilt- capsule ,,00 all Ill.. nOl'-eOT1lraclit" t!.'>,UC5
p~ures Ih"l
xvi
GLOSSA~Y
!h.>! move during "'''''ry pas.siV"dOO dcl,,,(' mO,'Cllll'nl. 1'-TRA-ART1CULAR refcrs to llw.'slfUeture(S) (f1) from thc~bchondral bone to th<> subchondral bone of ~dj~· a'lll joinl surfaces, .nd (b) including e'n~""1!ling ",ilhin the joint spac~. ,ncluding th~ innl'f c"P"u1". PERI· ARTICLlAR ref...... to 5lructures OU~oi' tIlE' joint. act....enol 10 ,..ld mduding tho! au",," rnpsule LATE.'\lT PAIN. s.,.. I'"in.
LIST.
~
J'roiol'di"e I:lI'formil)".
MA~lruLAnON.
l1li5 term is
~
in 1"'0 dislilld
"J}'<;:
I. II coin be w;<>d 1oo.s<>Iy 10 refer loany kmd of 'p.lSf;I\e lno'emenl" U5O'd in e""lll'fldhon (W In~ltlll,'nt (",. J',,,.,j"l' \lO\·"m,~,!. and Moolli~ation).
2. In a restricted definition, it is u~ed l
MANII'ULATtVE PHYSIOTHERAPISTS This term 111c11111es m,lrlll;llthcrapists, c1,nlclan, ,'nd thcr used in ;;()IJU.' EngIisb.-spcaking countrios. GRt\D£S OF \IOVD1EJ\,T RHITHMS or \10VE.\I[NT; fhe:!,e MO ter=; SoeI'\'" <>nI~ one purpost', thilt ~ I~' d,·"cribe mol.. ~bbre'\·iotk-d form the qUilhty of p;>ssl'" treatmenl lIlO\"mrot hems u>ed. 11ll' h.::1"ITlll are not essentLilllO the pr
of quick l'lX'Ording .u'od c~unk .. tk.n.
MOVE~I[NT DIAGRAMS. The!;e;are txpl.o,no:d in deMiI,n t"" .ppmdices. Th~~,., nul l...~tialto the pr;>('l,o' di"m ilnd .. n",ans .)f communicalion.
NATURE OF A DISORDER. This rder. to '''JX'Cts "r " probl ..m IhJI "'quire consider.. tion in n,lmi'I.'!,on ,md t",.. tnwtlt pmc,'du,('!;. It m.. y io(lud,' th" p.. thobi"lvgkal rroc,'S.><'s und"rlymg the dborU"r, Wl1tribu· nnl: f..Clon; such ..s o,teopomsis, stagt of healing, sLlge Jnd stdbility 01 the diwroer. iln
NEURAL MOVEMENTS. This 11-,"" is!lti1J nolell'llrl)' d<'fined, and 15 .1n unfortunate term boxau;;e it can be misunderstood and prtl"ldl' fud for the disbehe-ers It refers to ner'''' and thl'lr ,nfmstruclurcas "Til as to the connecti,'t' tISSue llul support. them and th.......gh which ~' pas5; I. Vcrtd>ral (,lna1 a) duT;a h) other mminges 2. Folamin.o.1 canOll 3. Pt'npheral t1sBueS a) neT\-.'$ h) lIlM'shh..II.-...s c) support"·,, h....Ul....
d) osseofibrous IUnm'!s, <'Ie 4. Up!"'r limb Ic.nsioo Ie L~, ULTT Thi.~ is the eommonl)' uS<.'Cllcrm. but on beconfused wilh other ,Irudu,...;' 1t.... I, ,m''''''mg m"VL'TllL'Tl!>;, AI this stilge ,t would be !x:lter .If..:l mo....' ilCco>ptf'd by medic.. l pmcl,hon"N if 'upl'"r 11mb ne"ral mOH'mcnt tests' or'''PI~r limb neural t"sts', ULNT, "'''''' llSL'Cl, OVER-PRESSURE. Every ~litll has a J>ds it.. ach'l' range. Further nor· mal mO\em""t c..n be addL'Cl to thil; pilSSive rangl' by a stretching applkatiOll of o\'eT-pn>ssu~. This O\'crp"",,"ure rilng" ""11 Cau..,., " dL'g"-.... of dis<:omfort or p"in. iloo should be dSM.'S6<.'d befOf'(' de<:laring a joinl DlO\en\el\! to be llOI'lTIil! PAIN. ThIS IS ..-d ill this Ix:lol to ~ t many kinds of ""in and L.......... indud"" oth..'T scnsatlOnS such "" discomfurt, aWilrcr>£'SS of. lIbnorm.alit., tr.., i""""" etC. L-\.TE'lT PA1l\, of"hich lhcreare m.:in y prt'Sf.'flblion;; ('"" ""Ses 166, 167. 190-19:!1, refers to ""in and tile other S<.'flSIborls which do not rome 00 imrnediatclva mo·cement occurs. but ",ther ocnu ~t "arymg t~ aft~ lhc InO\cmenl, or after a position is sustained. REFERRED 1'1.1:-'" ;am pam. discomfort or other sens.otion which ill f<'tl III II place whidl isdt>tIlnt from its SOUl'«'. RADICUl.AR PAIN: Ihis il; iI h.::rm r,.]atoo to .. rcfcrn.'tl P.~1Il "hich is &eno.,.ally recognized (rightly or wronj:ly) to be a clearly defined "rea related to a l\CI'\'C root. THROUGII-RANGE PAIN' this is,' pain which is fi ....t fcit vcry corl)' in an av,lilabl" ran&, of 1l1
G1<»>a"l
performed acth'ities in an unfa"uurabll' manncr, the p;>tio:'nl may l10l "'" a"aIe of;1.5 h.wing any effeo::l BUT ""ill know all aboul it b:o·tl>o.' follo... ln8 mormng. PASSlVE MOV£MENT. An)" lr\On;:mmt of a mobile whIch i> produced by an~ mroll5 otho!!" thdn the pdrlicuLlr m~ ~lated 10 tlt.ll pdrlKu\.lr Slog· mcnt's mo'-em.... 1 is a p.1SSI'-;> ITI(l,'cmenl. It includl'5 both mobiliLllioo and m.anipulahoo,
~mmt
PHYSIOLOGICAL MOVEMENTS, TI>o.'.c a.... adi,,, and pa""i,;> funclional mowmenls. P,'>oS,,-e physIlr lo~ical inll'rverlebral m""cmem (or inlcr-segm""I,,1 movemcnts) is lIob....."i.1'"d 10 I-'I-'IVM PROOUCEfRErRODUCE. '01.1' aim of physical ">:aminatllm is Iv provoke, with lest mO"eml"llIS, etttler an abronrm.'] I\.'tipol'L<e in an appropriate ~i'e or. whcn ~"Ullcd to lllI! diso
PKOTECTIVE DEFORI\UTV. A ('Ommon 'pmteo::ti'"e in tho! cervical!ip1I1e'~ the 'WRY XECK', lumb.~r ,!,,,'lot" is a 'SCTATIC SCOU(})lS·. C;CIAnC SCOLIOSIS I!! an ,nexact tcnn beau"" lhe «olio!>i$ (protectiw deformitv) (;lin gcrur without 'so· alic' p"In. Iletter kTIIb are LIST or SHIFf (str P"80 131-132 ,md 350). do.>formih~
",nd m the
RADICULAR PAIN. ~ I'ain.
REFERRED PAIN. Sco.' I'"in. SCIATIC SCOLIOSIS. 50...: r"'I<'(!ive Deformity. SI:VFIUTY_ A .ymptom 1S elivil)' 111", Caus<:'> th~ pam n",-ods to be interrurtcd and ~'0l'rro lx-'(:",,~ of the intensily of the rain In many (,1'><'5 this is an indicalion that(aulion is ne«ic.'d wllh e~MlUnahon and tre
&..: Protectll<' DI,'!onnll)'
xvii
Chapter 1
Introduction
Dealing with problems of diagnosis 'BRICK WAll') 6
CHAPTER CONTENTS ~mov~m~nt
3
Manipulatio'> 3 Mobilization 4 Manipul<Jt,w: Ihffapy 4 ~
relationship bctw«n
ILdence . ~~~
"ppropria(~ wording 9 listenif'g 10 wmmation 11
lech",qu~ and
R,lat'''9 m .. tm~nt to the history. symploms and !>19m 12 ~~llt ..lId anatytj(al ilssesment 12 Two mher~nl capabiliti~s of th~ body 13 Summ~ry: the 'C(mccpt' 14 _
4
asscssrn~l
T(c~niq~~
5 mode of thinking. the primacy of cJini<:al 6
MunipllL1lion is NOT as man)' \\'lIulJ II,.,,' u~ 1.>1.']jl'\'~, an '~mpincal' t"",lm.,nt. Thi~ is largdy duo.'10 ad,aoclS in mockm tI.'dInoJogr. particul.:"i~· "ilh th<> capabilities ol' mod..'m rompulet'S.- Although mo~1 authors on tlw ~ dt5Cr,bc ll'Chmques and technique! only. lhe 002:1. of this book is .digno.od ""th UIO: foUowmS'luot1lion:
err'
Dt$p,u ,r~ J.... ,~ pflnr /vmg <.,'IfIU'lhing U; Il '/>*t wx', ,.mdl,-"'l ~.J.lm-t~ lfilnwlr rlrli,>11TSS. MtJIlIJ7I<J~litt' t""""p~ lm...!ly~!hI lMllmnll ,>{ktu·!lIKt p.;in bv~"S r~""lptJ1~ (~""""~OI'~J
lth~
Th«>. ,
t~'bJarlbox'
n",."a..q..ny
,mJ MrlJt<.;J;.-"Uyai¥yi"i tlmr -.t,ll. flJll'u/,'- to bri".~ a"-'tlt _jrr...-..mllJ/roll/ro".... TM ".~f'1Il~~
r!Ju""lllmpI_"'" m~ I/Ii' 'bl""t /lux' M"C"1l"' I~ mf'lvlJI r.TcrpI III /rlOO<' IIls/al/,n U"k'" rrli"blr ptl llk1IO:S'C'IIJ.'"niols
(!mi' &"'k I'~"" Prn",,,ri.m, Tn'Mnlwl, R""'rl,..h SYIIII~)silllrl, The /IIanipulali\'C I'hysiOlhempis15' Association of Australia (MI'_\II), M.lrdl, 1%4)
Although Ihis book is ori..nled
~lmust ~"li,.,ly
10
trnlmcnl by m.nipulalion (i,e, pass;>', mo".. m~nll, il
J
doct not mean thai thdl rn""illuldlion is 'Ihe be all d"d end all' in the o\'f'rall mdna8emcnt of pal;e"l. wilh ,'ertebr
....,,11 .lppll.ooaled m many doctor- <100
physi~
dpiMo. II ;,; important, therdafl.'. tnat "",n;P"I~lion ~Id be gi\ "" ""ITa emrhOl5is so Nt the dpproprbtI,' ~ders, the ~~r.!' and lhe U!lll't'5, will use maniJ'Ulanon III lis propt'T conlnt and to it" fullest ",,1<-,,1 ~t.uupw..tion i5 not lik" S"me of l;OIf (Fig"" I,ll when! the pLty~ Ux'S a tKhmqlM' to h,t;) batt III III<' dU1'C'hon hl' wallIS it tu go. allhough most poop~ lmd to \b(' l<-'Chniqu"", of m.>mpul~h(ln in thIS .... ay. r. L~lnpulahon is """" like ~ 8"1l1e of..:hl'ss (ri,'U1l' l.2) "!wI" d,ffl'R",1 'p,("«"<' can b.! mowd in lNnrdiffclUll and sp«ific wavs, and where plolllS an.' made and t!e:;lrovw and changL>U unli) tho! l\o,a.l ~ achieved An even better analogi' is Ih~ game of Conlra(1 Bndge (FiKW'1' 1,3/. Here (tlmmlluicatim" in Ihe 'bidding', plays an import."'t mil,', a~ abo dot'S the a,S"Ssmenl of whe", importanl kc" CMOS are hkel)' 10 lx" In lhe ga~, th.. technique of plal'ing the cards requires
e---------------------
2
MAllLAND'S VERTEBRAL MANIPULATION
Fog" .. 1.1
Figu," 1.3
Thrte~hni~ueofgolf
,o",idl'red. thoughtful pLuming. E;,(h facd is UllpDrtant 10 the whole_ and ,,~[h nl"l.'ds to be integrated with
the others with knowledge, skill
~nd
experience
The 'conc<->pt', as it has come to "" known, of m,lI\;pUlati,·.,trc"lmcnl embraced in Ihis t"xi is ba5ed, sllbj<.'C1 of COlliSE' !" wa!7'""is, up<m tJx, symptom response (its slle, its qUQlily and its bch,w;our) to mr",cm~nh; and positi......s, It is the mo,-em'-'f1I!I",in response that is half of the wnQ'PI's keystone. the olr..,r half tJ(,jng "n"lytica1 aSS<'SSJl1L~'t. It is tl.., analvtirul u>Sl.,;smenl that ,.,,,<'als thl' ch~ngl" in the pain!mmemcnt l"e;p
t"'"lmrnt. Kcyston~> 01
the 'conctpt':
As~sment
M=m~nllll"in f(SpOnSe .nd i~ adaptation in trcatm~m to thr patknt's current episode Sr>
(onl"."t
8rid~
The ",rowlh and expa,~,ion of manipulation wilhin roulin" orlhodox m""';cal care is mosl cncour,'ging for th<.- p",ierot, particularly ,os goveITLrnL'f1t-nccf'l'(litt.-d postgraduate wur>;Cs are conduck>J in manipulative phvsiotherapy. al1d also as there is [lOW a 'spe::ialty quaU/ieation' within the physiotherapy profession in Ao,lralia_ hen the wort.! 'mampula!i",,' is accept..:1 by 0'01'<.' medical practitioners. This grenter I1Wl1nmess "f the pl;>ce of manipulation wilhin the con,cn'.,tivc nwnagemenl of P.'hl~lts wilf. roeurolnllsculoskelelai dborders has wme about by a growth in the skiHs and the applicati<m of them, togdher with a growth in the ability to ",late the prognosis to the d<'gl"l'C of the pat;e"t's disability. There ,lre thn::c m.lin fc"tures about the ways in whkh manipulation is pcrfornwd today Ihat h,we made for its more ready acceptance: 1. The realizahon by tlw medical professiorl of the
emphasis the manipulmive physiotherapist plaa.'S on lh~ wnl;nuous analylkal a..essment before, during arid ~ftcr the application of e~ch lechnique during e~ch lre~lmenl session, from session to session Ihr(n,!;houl trcalmerll, and Whl~1 I"'J 2. The gentleness of the inilial 1"',1tment lcchniqucs, wilh stronger k>o;;lmiquC$ ~ing us<-'Cl only wI",,, lhe inili,,1 ted",i,!u(,,; h"ve Ix",n proglL'S.'Wd gradually and judIciously. 3. The demonstrable effecl of such t",,,tmenl and the rdinl>J information it can provide in terms of dif· ferenlial diagnpsis and prognosis.
Introduction
TM
l_a~1l§I
Kttplancr '"
mar PI> al
Conlln~
IINIytJaJ a~enl Gtn\ tnei6 ",fin;w' rr.:.tmCrlledln~ Et'ttU of &e rr.:.!J1ICnt ",lid nn 9~ ~.ntmmt tel d,ffertnlial diag"""s aTd proll'lO!oK
The go.'1M:ral a(cLl'lance of manipulation has nt'\,('rthc-Ie..;" bet."Ilsluw, and Jnanlpulahon,~still far from "'-oing: US('(! 10 ils full"'l potenl;a!. There are IWO reason,;. for Ihis, Firsl, Ihe diagno:>lic litl('~ u;;ed b}' sum" mhould bo:' ~n m their nghl conw..1 Toquot" Brewerton (l~):
another person or pieeO' or eqUipment. Pass;\/, rom'l!IY\('flI rna\ ref...- to the ,01ll1'S.o«essor)· mov~lS ~ II!; ph\<,ologkal fI\O\·cmcnts. Physiologic... movemfnl~ are tho5o> """""'<MIS that patients can perform Kti\·e...· br t!I.l'm5el\'ol"); K(K50ry mcn-nnenbii af(> tho5oe IT>
I'I-ss~ m~me"1 ft'Ia\I ~f.,
tell". pnls' acrnsory Of
ptly\iolo~;cal ff'~nl
Ch'sp'tr ,Itt ~ of 11_ Clt$<">, t/try mllst br ltJ'l i" P'l'PI""iot'; Ii lYT II ~ (1(10 ........ Dun'llJ ,111$ N1V IIrnr ........ 16 (.lX} _';ipII&iIOO lI'1lrt",s rrgu14rly .... rhUIJ be rd~J
upon to Mtmi""lt.lr "I JtusI nl~ rr«t tDdI dar;; 1Ir..f Illb lWlilJ "",""11 illrrJrnu(l( 1 III 10000000 ItID"'J'ull1",ms. More 111.'11 40 }·..a~ OIl, IIti.> I> >lilI ",IMi\'('I~" unchang<-d D,....slers C,lI' be a\'oided by adhering 10 the lollow_ ing three rule> 1. COlllmuOllS ~n~lvtical as;('Ssm"nl mu~1 be carried oul during Ihe ~rform"n<;(' (Of a Il'(hnique and lhroughoul treatmenl 2. nu, in;tial ~pphcaholl of a Il.'<.hmque must be
g..... tl('. l. The SYPII'tomaotic~. both during Mel aIti'" apphc;r.1ion of tn>atment, m~t bt·aSo5C"..ro and anal\-sed beftm.> ~g There musl bean awal'l'f"lCl6 of Lllenl """"""Nliooru.lhal were not
idePI al the time of the JOllnl consultation and must ~ clanfied befl:R seloe
t'\
"""""""
s..>f"re L'Illbartting on the 'concept' 01 manipuLoti\... lrealmt"'t. \\hich lhis 1>001< ~,ms to dC5CTibO', tl>ere are I"rm_ related to thO' word 'm,lmpul"tIOil which requ;n'dMilicalion.
PASSIVE MOVEMENT Pas~iy" ",o,""menl meanS any movemenl of any part of one person which is perf"rrfl('(1 OIl Inal persOn bl'
MANIPULATION l1w word 'm.lJUpul.:lt>on' can be> usN ;n man:" wa}"$. \lC,hCd.l~, il can be used loosely 10 mO'an ~\(' m<:'\'.. menl vi am lind. 1here are English dicti<>n.~ry dl'flO;IIO£IS or manipulallon. and medical dictlOf\,lry dettnilioru:. Medic-al dclin;lion, ""1)" ffUm pTad"")I"ll~r lorr,lClilioo<-r <md from ochooll05dloo1. "lampulahon.. moblli2dhon and pa*l .... rn("'em~'IlI can be, and of len MC, ".,..'<1 synonymoush'. t'e\'erth.. less, the manipuJaI"" phrSLolherapi,t is in a ).'OSllion 10 ,U&;e.l prcci:,(' definitions for lernu usN. In lh;~ bool<, Ihe "'oret 'manipulation' will be u-.ed in IWo ways As a gene,al I"rm 10 row, any form of pa~il'e mm('ffi('Tl1 tedmiqUl" 01 any Siructure as" form of lre.olnte1,1 for l\I!W'Om1.lXUlosleletaJ disord<'r5. In Ih", \OJ;(':t wiU {O\'er ~ll formsoipas>o;\'" ......·erncnl lblN abon', as "'cU as the <J"-"OflC defin,hOkn place before the JX'I'lOn on .. hom II is per.
2. ....
formed is ilh.., 10 preH'1I1 II ~ a mom'l'ul~li1-'r h:.>chmq"" Such h!chniqu~ aT\! often !,flltle, .. IWa}lI in ,ange. and .a... l\ forceful (Oft" P....i"'" 10 for,1 Edihon).
~1Tld1l
Th~ l~rm mJnip~IMion embrace:; 0111 kird~ of ~'Sille mOVl:m.nl, Of can be viewrti more $p<':C1fically as a :>m.11 8mpliwde manip~lalive thfLlSt le<:hn,qu. perfOlmrti ""Iln speed
J
4
MAITLAND'S VERTEBRAL MANIPULATION
MOBILIZATION MQt"h~tkw1
,s pass"'.. mO"ement perlormed in such
.. m.lnTl('l" (rartirol.lrl) ,n ,...I:>t"", to tho:' ~ of lhe mU"'Im.",tlthdt ,t '5 al all time;; Wlthm the .. blhty of I~ p-,tM'fl1 10 p",,'enl the mon,."..,,1 if he 'II'" ''''-'.10 d\OOSe$ («< PTe!"'ce to Fil"5t Edition).
lI!obzal O'lS~re performed ,n such ~ IIlinntr INI lheyan lit: ~t(lj bv tile poItJmt
Tho:' IWO type.; of mobilization ..n>:
('(InC\.'" r"""'"
THE RElATIONSHIP BETWEEN TECHNIQUES AND ASSESSMENT Marupulal,,·.. lrNtmenl c.ln be di"ided inlO four ""''''
I. ['"S.
functional mO\emenlS. TheSl";l1\' o.f two kinds: a) t'assiv" ~I1d), smoothly or sla«alo. with sll'U\1l or lo1l)1"."'plilude, "nd ,'ppHed In "ny p"rt of Ihe 101;11 range of mo\'em,·"t. Thl...• mO\',·ml.,,15 ~ !",rfunned wlule lh" )Oint ~urf~(t.'S ~re dislr.lCtl'Cl Or compre,,-~>d_ \)i,traclion i< Ih" !K'parallon of opposing joint surf~C("S and com· pre%ion i5 lhe .ppro"imalion, or squ~/ing logl~hcr, of Ihe opp'",ing joinl surf,lCt'!> hI Sustained slretching p
""'y
2
group of !<.-..:hn'que>o. II I~ I>«llU5(' of this mlSCl:>fl«'Ptioo lholl 1hi5 irltrodlKtorv chapl""- S<.'!S oul 10 ""plain til<' enL w,th lhe tccluUq....'S and their itdap"'-bilil)' koiOl; 1;1\"" lheirCOl'Tect relationship 10 the ...-hole. In tact. the greal emphdsos on pam and other alllCd s),mptoms. This ('ffiphasls .... eXrLlmed. 10000000hl.. wllh the other aspo."C15 of It\I' con· n-pL Wlder the ~ ...Itl h<"admg5 thai folio».
l'lb>i'e mo\ l'lnl'1ll!; perfonned for II>.. ptlrposo> of maintaining a funct>o.x\al raoge of mQ\emo."rtl in palu'nts "ho "'" WlCOnSCiou~ or who ""n'
MANIPULATIVE THERAPY Who:-o po.",p'" LlI]" aboul 'manipulaliw IfI.'almt'''t' it seem,o; impl)5Sible 10 avoid lheprobJem 01 their putllng ,nordi""l" t'mph"sis on In.., I""hniqu~,:" compM' in8 thost.! 11S<.>d by different practitioners .lnd l"picr"n' of, treatm..nl conc<,'pt, r.,,,,, 'ur· ,-ey5 or ~Soearch projects wmetimes miss the point wh..'rt Ir} ing to weigh up the "alue of a p.,rtK:ular
t"'"''
partS 1. 2. 3. 4.
hami""hon of 1h<"p
Otmthng tilo<" 'mode of thmking' [MIl al lhts st<;h is nul l"'lul\·.llenl, E\'ery manipul,,· liw ph~"Sioth.. r"pist must always renK'ffibt>r tho,1 the /><'sr treatm('nt c;,onOI be gll'en ""thout p<:rkctly p',rformed ex.:>rnilli.ri....., and l",atn",nl lectmiques. How",·..r, lechniqu,,, an'the k.:.Sllmporlanl of all lite p..rIs. Continuous an.I)'lk.1 aMeSsmenl he.'l,·ily out· ....eighs tne olherti. Those who SO:!'l.. .. to copy ao)' particu· Lar person', lilChruques, lIlI:"'-"y 10 u.-.e lho.'1lI on lhei, p"tienlS. ha~ a Iotalty wrong ide.t of "",nipu"'b\~ m.almenl, and .n)"onc~ondL>ct"',ll.COUf':iCS thai consl5I lI\iIinl} of locc> to each oI"'-'r, M.:>oipul.>ti,... In';llnK'rt1 should ....wr ..., admme>teMl "llhout .accurale (";lmmJllon (,,-turn mvolves both ""-... 1,,1 ""d maoual .killo.l. Withoul acruulc ""aminabon, pree;"" as>CSO'~1 is nol ~ible. Ass"ssmenl irlvolves e,·"luntm); lhe chang"" in Ihc pal;"nl'ssymrlums "tid mo,emenl signs lh.Jt occur ,IS a result oj lhoc lre;IIn1.~nl 1~'C""hlue(S), ,md it IS this a>O>eSsmenl that IS Illc thdr ,·ffl"<:I""nes.s in Irc"lnwnl "nd thciT ",,1"10 ,n m"kJnf\ pt"ll!;nn,;.,,;.
Inltod~~tlon
phb>U'lhcrapi'>lJ>' lJUIlds mu:.t bo.' 50 ope!' thai Ihl.')' tht... r I......h rnq...... until ttl~1 ocm.,,-e !h<.-ir int......
mod~
1101\. ll>ebasK:trealmo.'f\ll"'Chnoque mll>ol indudcC"ery mo
\oj;Jco1l mO\:tments ...-.d the ~ n\O\·............"'. plus ASSESSlilOO T_Toclwuq.....
_ _ lOknoorlloor
Tne~a1pftlrm."lI_ tecI'~,
_1n_ooI>c1t~
"!lurr ,,~ Jhe ~I~t,.< imp<>
TECHNIQUES Tr'Nlm~"1
tlXhniqueo; are d ~ UI rcldlion 10 their
Ina'
Import.>~. MId l<.> tho;> fa<1 <;(>Ill(' ill"'a~~ looking 1m ne'" It'Chniques ralm
poopJe aft' than undeo'sl;mdinK Ilc:w.. and "'hen thl'\ should be modifit...d and USoL.... f',,>:"fI' I," d""""""tr.lle lno, ...,I.",~ of techni<Juc'> In n!'IallQlllo tho;> lotill con<:q)I of treatment. T~'ChnlqOl"...s they .. pply to the oont:ll'1 p~ in thisbook,..m' m.'H'I'cndmgand th~"l' roc' .... "'ill h,a,." an "nding So Ioog as palit11ts P~'II1 ""ltIl dllfen'llt srrnptorn~:\nd ,,~am i""tion ~lgJb, th..'rt' "'ill h.Jw to be chang~'" m l«hniqlk'S to fR.'t' lho'! p.. tients or mUSt' ,}mpl"ms. Cyriax (1"78.,) ~id that Ihe m()l:>ili~.ltion Ic'Chniques inciudtd in lh" \l.'xt of this book W"I'\.' fi ..... t pracHsro in FranC\'(",'C:ami~'r, 1&'18j,and
it i~~"rt,~jn thatlhe 'boneseIK'1'S' of !X'nturie; ago (Cl'ri.. " 1Y7Si» 11.1> (',,!so praeli-....t t....,,,. \\'(' mu,1 al",,,}"!; a~ln('lwledgelhal'~ is no ",""" thm~ undl'rthe ,un' (E«le:.ia~n.'s 1:9), and thai
all "'" do IS ',",'uk ,he ro.od mao.. b)' cf,bed ..,~.. tho;> cl!fllunes Wen!: pll.-d ~ atop anot'-, the ho...¢'1 of It-.. pile "ould ~ l$tounding E,'en 1"","- "II tht- possibilities would I\Ql tw,e been exhilu~1ed Th\"I'l'h; an 'ffiIIlo<'aSUI'ablcnumbo>r of d,ffurI!fll t«hnoqu<'5. and each Of\(' 005 un ,nc.>.I"'u.>bble numbt.'f vi '-,In,,lions 'I h~s !iUt\>o."i;n,,-,,> been SOlId during ~ demonstration 1"'.. ln...." 1 .... f a f'l'hent, 'You dldn', ~ach U5 Ihill IlXh· "'que 1
;ill poosoible cumbmatiorb. When it CDIIk"S 10 st'I.',:tin); the lO.'dIruqu<' for b'l""tmcnt. IllS first ~<}' Iu 1o.ncMthe F""",,-e mo'~b Or f'OS'llOnS th.>l pmvokt' or R.~il... e th<' patient's symptom~. Whft, lhe symptoms "n' "a.,ll "1'roducoo. the l~chl\iqur chos<:-n '""y be ",thel the mO,,"-'fTler\1 Ihal ~l~'eo; the symptoms or me rrK)\'emt"t that 1'00\'0...... th.' s}'mplnm,>- 1 his ch",i,,. d~,X'"ds on ~'" 'nalu",' of lhe di-.on.!<'r. the '''''''Nit}'' nf lhe .ymptoms and Ih" 'i,rit
A technique is the brainchild ~ inC','"',"'C"'---_ _ Th("I'l' .. re no """ or imari.,bl.' tlXhniques; sIdlements su~h a' 'H>U mu,IIU'i'n- do it til;" ".ol" or ')'ou muSl nr.w do INI' haw no pI.>« in our thinking or te4d1 ,~ llle ('lr11v ML-Sf is that tI'to: lochmque />lib' doCh""·,, its "'l(''''IOI'I. roth "hilt! it i, bcil1g pt"I'formro and whc:n tl has ~ J1""'formed Therap~ mmds must "I"ay' Ix' Of'"';/.." 1H,,;l1ItnT btd<>s_/i,. rnm,1tI1)_ the 'coocq>t' demancb kno....ing ho'oo.- to n:wlc It><, ffi,thm,. u...- >f"l'<'d, the position in t/w, rang:. thP amplilude and the stren~'1h or II><' lo.'dmique to the examination findings.. 1lolc.1\l5elh..>st} I" or mo,emt"llhal can boo osed a~ a Ire.umenl 1~'Chruq"e C
n~ """"nti,,]
fo, three I'\.'a!".>n';'
I. n",y form Ihe be-l b",i.l"r 1~..,chinJ:: ~nd
c"mmu",,,,hon 2, 111,,) fon:c the m"",pulalor 10 think in much liner detail about lhe It'Chniq,,~'I,,'ml) performed 3. Thev form an e:!;......"ri.allflC'lhod of at!bll!'.-iation "h\.:" AXordmg lr'NtnwnL Th.~r mt.'sa'e.lrn......nd 11><':.- .:ll-o. I]l fon:ing!hl' milmpuLthw ph)'SiotheT-apm Iuromm,1 tho;, k.'dutiq.... 10 P"P", mill.o.o d>e tt-o-"pOst MWI) ~ !he bed'wUque mud> rnon' cleml" (l~ of ~
a
m""tII'tnt 3~ =not al
ba~
fu' 1<>.d1i~g Ir>d commun,calron thinki~g abo~1 lhe IrctlOlqur 3ad fo,
For ~~Ia-I~
IS~ng p,"g'~s
In rrrordirg
I~at",.nl
THE RH'l'THl\1 OF THE TECHNIQUE i, ,onotlx-r loclor to be C0T\5rdere
5
6
MAITLAND'S V£RTfBRAt MANIPULATION
I",alment lechnique. rv. lhe palient who ha~ a "erv pamful disorde., it i5 likely Ih"t physical e,mmi""ti"" wIll ""'",,1 a pai.... thrt>ugh-.anl;" situation Lnder Ihese circurnst1lnce>,. thlo tft:hniquc wIll 1M.'<.'d to be p.:rfurmed;
sl<»< 1\' and smooth" p.ooabl!, in t',t:hcr the painl.,..., Tang" a,ailable, or taking the mOVl'ml'lll inlO only a sln.,l1 ,kg"-'" of dbcomfo.l, l"l-'l"I"inl}' nol into p.un. brin~ us to lhe nl'XI f""'lm" l<> be cort5lden-d in l"IILlhon to a trdmique Whrl"ll >hou1d the ~Io\", 5mOOIh te;:hniqu... be performed? If w(' roru"dcr IIv:- "cry pamful di50rd('f, II should unlJ.illh be p;> a Tan!;" of mon:rrw:nt a, is possible \\"thout lhe pali"nl bdng abl... I" I~'el any di~(lmfort ""h~tsoe'·e'·. Alliwother~'tldof l!>e «all', if Ihe ralienl h;>sachrooic di:,t)n.Jc." hkh is ani!, pron,ked b, mO\crTI"nl at the end-of·ra"8'!'~tretchpo>oition. il "ill probably ~uin1:1. siretdung. <'Od-(lf-rang;>. small ~mpliltJde men""",,,l, I"l""fnnnep~, as a ,Iacc.lto rl>ylhm. The mm',.'''' ml"t would bf: ronsider.'lbly fasle. lhiln Ihe smooth" slo\\' lechnique sugge~led abm .... This ml....ns that Ihe Il-cllniqu", ("I",tIlL..- a p.,lpaton' t\"pc of di.~""1 t~-'(;h' niqut! 0. an ioo""",,1 Ilocalized]teehmq",,) would aim 10 b!.' fast enough to It\l'" ;.piN! SIlwno-"'t bl..ng In... tl'd reach its end--of·range paslhoo bcfOf'l! the ad,"" O'flt sc8~'" bogin thl:lr mlr.-cml."fll.
This
...u..
whjc~ Iht I~dlrllq~c i~ ""rto,mtd 1$ ~U(nti~1 10. tI't qu;llily of t~c Icc/lnlll.x· It may .... 'Y fnIm 'gentlt-smaoltl' to )trddo ~1-stKQIO', deptndi~9 I)!'l t!'.c d ,"alCOftd!lOtl 0' t'le pn~nl
Tht rhythm in
Wh~n perfollrllng .1I'y t('('h"i~ue, manipul"t,,·(, ph}'si".. tht:.api5ts mu~1 t>t:ronl(' ," inlimatelr iIwol~ed wilh "hal lhey' are doing as do w!0i5ts pl'"rfonning with an ~tra and Il:scondU(lOr'~inlE1l'fetalion of meron' Cl.'l'tO, which I5lhr b.."ndlild oi the rornpost.. .
THE MODE OF THINKING: THE PRIMACY OF CUNICAL EVIDENCE DEALING WITH PROBLEMS OF DIAGNOSIS (THE 'BRICK WALL') "The prohtl'1lts associ"loo \~llh dia,,'"T\OSi~ a"oJ diagnO!l' lie lilk'S a", difficult problems wIth which 10 come to I"'tn!>. I,xen within medIcine. many diagnostic lIlies a""lome"m~'S madequale, inrnrrt'Ct.OI' may br ""'rei,· linUd with palterns of symptom.>t<dogy; they mav
,-"'en be b,,'lC'd on
supP'-):iiliun~. In Il'latiun 10 lre~t· m~~ll, many m,\lJml Ill'alments are mitially administen."I:I empiri(allr; onl~ L1!<'T. as tht!scienn:oi me.licu'" ulCho "'1" dOl", lho>lheory be«Irnt' known. \\1t1un mt.odiolW todolV Itv.rc i~ much tNt ... ck:...ly I<no\o.·n and undef5l00d T1ten' ~ abo much thaI jo; being disco>t:I'(od by day as SCIt'l1Ce l'rogl'tSSeS, and Ih"", i. still milch Ihftt i, a. )<:1 unk,,,,,,,,,. AI",. IJ""n:;'; .. n,I"I ..'ll f.. el'l that mu~t be rorlSidl'rl'tl then' ;s much we n n:-:K we know; "1'1 i>'> mee'pru"ed "rQltg. A petft:.c1 example of this IS tlte changing knc>w k'dge of lho: neur(>-physiology of pain. as IS .... td... ><:ed lnlhe 'galt theory". Anolhera..... of difficulty IS IOdlG>tl'd in eMy'> A,,~'''n'!I'
dar
tlu'rld"ilc,' ,,,,,·I,,,,,i0 1tlJ.",,1
"''''''''y j"Ji"id,,,,j j,,;J1/S .>flll
III",,,.
lb."",' facl5.aklni.' dt-'INtnd thaI,..' -.hould nol be dOS' mal>cor riSId ,,,~>n<:'s th,nking when e.;"mimnj;,. tn.... t ing, or making ,udgl'fTlL"flts aboul palimts.ln addlllOn to the l"inFl~ we Iu-..)w ,lI1d lho.' Ihings we Ihink we kl\l"lW, tl,,,1"tC a'e thing§ alx>uI whkh w"cun make sp<Xu, lahun§l>r SUgj;'.'l;ta hypothesi>. In ~ummal')' th~"" 1 1lIt:'re is much we do know 2. There is much t~e Ih",~ we know. 3. The", is much more we dn.ooI knuw 4. We can J11ilke "/lI'clllntkm, 5. We can propose I'''IIQII""",,,. l1Ie four
m.>U'l
are"" of mrdic,.1 I<no\o.ledb"C thai .Ire
p;>rtlC\llarly applicable 10 1re:t11Tll"fl1 hy m;o.nirulali,e phr..olhcrapy are omatomv, ph\"sooIOffi~ biomechanics and pathology. In all of these, sclenllf", invI'S!lgalion conl"'''I'-'' Il' milka' disco\·cr;cs. AU vf th"' fo". an~1S of medical knowil'dge coIlI,';n dements uf knowns and unlnowns, spt!€ulation~ and hypothl'SCS. A diagnuo;lS is arriwd a' by rdallng the dinical (.,;amin.t!ion of ol pam...' to lhoc knotvltdg... in ~ four main an:01S oi medICal knowlc<Jge. II LS somehlTlt~ difficull 10 n.'L11C a r.aric-'nr~ 1I"....ry and the eX.lmllMhon findings to a precise> and ,....,,In· ingful dia8"0,is, as well as arriving at a de,.. under·
standing of both the sl,'le and slage of pathologi...1 ch;>nj;('S and lhe ",k",nl b,on>l'Ch.lnW::.. 1 implkanons. An example of ttus is giwn br );lacnab (1m). Of 842 patioenb opo:..at;.>d 00. for disc pathology, 68 w~...... found dunng Sill'gl(all''q)lorahon to lome <1i>cs lhal were not abnormal in Ihe way anticipated. A•• of Ihis Sl:r;l'" of palienl~, fi,'1-' T\:,'sons other 11I"n disc hl"''';,'' lion we ... del~rmin~"I:I for lhese p<1tK:nts' s!'mptom>. TIt", ~'<.lmp~ me""" ...... t a paho,tt who on. clinical f'x.tnu.... tion preo.ents with a .5l1 of s~mptoms and
..,..,,!l
IntrodlKtlon
bble 1.\ Asrtlgk cl,mcal Stvtriill diagnostic ttle->
p~nlat;on
r=f have
Table 1.3
clinical
Division of IhJnklng in di~9nosis and tht to tilt ph~othtr;ptSt
~ntation
r1tf'Otcr'caI/JptrrJf~rivt!
Ont·,M< h.. niallon Macnab two W.cnablh"t I.'I.."bfou' lI.l1ml1blivt
""'"" " Table 1.2
chn,cal
)
-
IJiSIO
A single diagnostic tItle may me..n
he,n,ation with nt"'" root irritation'
Thoognt
•.
.~
8~chIonfC'i
""-
\j! ~~'ffon
II:
in H"tory
+
SymjlWt"S
"iSign,
Sprotiltion
HypntOds
~riiI
pr~lallOrlS
.~
A"~tOolT"l
"'",-
Syrn~lom, (S) and Signs lS)
Known
Thi::n> are ~ imporLmI rt"awT!, tor employmg Ihis reat"re of l',,,.. ; :ompartmcnl thinking:
" ,"".
,," ,
ev,,,,
1. It cnabll'S manip\lI.ltj"c lreatn",,,ll,, b.. ""od, illhe di,lgno,is i, nl,t prI'Cisc, pn" Idt'd it is ktl<1wn thaI thesymptnm,> Me ansing In)lll a neuromU5<;Ulu.kell"toll dN)rUl.'T ..ad not from SCllO\b patholOJS} 2. II males r<-ibl., the use of nwupulanon and analvlical~tto..,;,;istdiffl'«'ntillld;~
signs indic:ahng
nt........ mot Imullen ma), ha... a db...
order with on<.' of at least six dif~t di~gnostic htles (T4b1t'111_ The probl..m also occurs in It", 1'\" ....... order. Th~t ~. d patient who has a disorder th.l1 is dia!;rl~'d as 'diS( herniation with n"r"" ,oot ",ilatmn' mar prtsent c1imcally with on... or many dif(crenl sets of s\'mptoms '\lId signs and wIth Olloe of many p.1ttems of (\11.'1<."1 or the S\'mptoms (T"foj, '_1) It b«ome5 .ppumt that if lIOt' 1S to ro><: t..... lmL"t on d:.l.gno;.t" alon... one must be '''ire of the real dCfi· nllti6.lS5OCiared with makmj; It p""ise and t~fo... meanIngful. So, "'hat can the ph. <;iothcrapbt 1\'1\ on? It IS u~ually pos:oible to detennjo,: th.,t no r/i",,,><, pnxL";:; IS lI1\'Qln-d, and ..... hetl"', Ihe is a ph}~ic~1 !\elll'(lmusculo-)kclet;ll l",>blem rn ~1t Ihal m.l)' bo,> .uit~ble ior tJt:"lment by .. physiotlw,.apist u~n~ p/lSoSke mm'em'~lt Within du, (ontt-d ,he manlpulati' e ph,·siotheraplSt. ulld('rstand,ns lhe patholog,c.-l MId biomo.,<:hamGlI
change; that IN)' be p~t,;s ~ to base m"illm('nt IlXtUlI'lU<'S•• nd subseq"..!!lt dwtgt.'S 10 lhccI, on a"... 11'1;01"1 ~mcnt of chanS'" In I..... palient'~ symptom:. and signs. a..... r"18 thIS III mend, whM also .....m('mbl"ring Ih(' limItations of our ",,;"ntific know.. \Lodge. it ;s hdp(ul (or the ph}'siotherapist tu .plil the thinklllg process into Iwo collll'mlm"l1lS (TolM,' I J); thaI IS, Vile p~rt NI11l!~ und('r the general he~ding. ·Il>\!.. orctiClll aad speculati,,,', and t..... other under the general he<>ding 'llistor~ and c1ink.1 presenbtion'.
3. II enables till' ref....ring doctors and !he ph~'..>otht-r.. ..rilit. to discuss thc.'ir ideas on "",,, rnarupulahun
,\Corks, "ithout the 'i"-"O'lahons or hypoilleso?s being interpn.'1l'll as dogmatic certainties. It is ~nliai lhat the..... should "IW,'y, be unrestriclL'd a"enllCS for di"c\lssion. This will lead to !x-Iter Sl,r.. ,·...vs and re:;earch progr"mm~ beilllllUnduct(.~i. The I,;oil<)ll ","tween the 1"'0 C()mp~rt""-"ts. lhe chniC41 comp.ortmml and Ihfo lheordic;o/ comp;ort.. rnent IS .itIJ fOf thl.' growth or usefu.IIcnow~. ClImc""", IIW)' ;r«ul"te and h)'flOlhesize, while lheon!tical practitioners Me often too f.u remo...~d frum the clinical situ.ltion to assist thL'l1l.1tGln ..1-.0 be h.lrmful "hen clinicians helre--e theIr hrpolhegelI dogmarkaU}. There is consider~t>le space for ...rrur in the tht.'Orcl" JCOll compartment. ,dIe",... there call b.. no ermrs 111 the chnical compartment other th.,n ttl<'Se caused by the e~amlll"r's lack of kilL Seldom do examination findmgs behe thepatlC!l"s true ph~'»kal condibon. For a ~I s""~ment 10 be corTOCt ,t mu"" fit til(> clinical SlIuation- II it doI5 not til .t IS the lheofttical ~atem""t thai mUiI be wrong bfoc"'use the dinicaJ pr\.':>eflt.llion cannot be "1'Oflll. nllS ~ .. raling of one's mental pf'llCC»><.'S into two lin~ed romp~r1ment! is wmmonly rdl_,",-'\:i to mctaphoricall: ~> the 'symbolic semi'p"rme-able b,,~~ l\",'il' Tht" dividing hne be!>..."" the 'th,-~)",li«li/sl''-,(;' ulati"e' compartment ind thoe 'c1inic.I' (omp.,rtrneflt ., the 'brid. wal1'. It is not a solid ,,·all; it has rna"y
7
~AnLANO'S Table 1.4
VERTEBRAL M A = O " " - - -
The 'pcfmCiiblc brid wall'
op;."fWl9 kI aJk"..,·lhough15 to tim,- from ...... (ompartmentto ~ ~ (T;;LW I.':).
THEORY T~bfllJ Ilh,I"lrate< ,he relationship bctwem t/lelh."-"hear kOO\ ",,~t feature of me conc~pt 01 this le~' Il'!>t!i "'Ilh lilt> ~1a1..' 1n... "t, 'V.c must not gel di\erted by the !heo~al aSfX'Ct5 of .. patient's dISOrder such thai it is to th.. dctrinK,U of the clinic.l1 aspect', ThffI';< ~1111 an ..nor· mous amount ..cdo not know, and till' fhcoory m\l.~1 be ~'t.~1 In a b.,lnnced way. 1\"0 ltxampll'S follow. "The first c"ll'h.ui/.c!l ex""",,," .. attention being fOCllsed on the racl"'l;"'phs a"d not rel"ting the"e findmgs to the his-
'marked osteodrthritis' SIlo: certo,nly d,d ha'e gl'OOiS joint char>gl'S, .. hieh wen' ob",o"s both chnimJl}' and radiologically. Physically. she h.td. 35 I"'" cent redllC" non in r~np', p"in on Sllrtch,nl/- and considerable rainless d".. CI'll"tus dunng .tel;'"" mo'"emenls. When mo, 00 passnely with the j;!mohulTM'.... 1joinl surfiK~ c«npres5ed, cnepituS inc~ and dlSa)mfur1 (not "",in).,.as plO\"okd. mar to ~ot of l>} mploms 6 ""«"ks rn-'YiousJv, although she me.-".>he n"d an arthritic shoulder, 5hl! did not ronsidt:l'.;he lud any reaJ dil>abililv. The 'majlv su'}:l'n" option ""itS b.osed on the radioklgic:al findinp .. hid\ ........... inlerprded ~m;call\·. It would be unroiIli:
w'""
t""
lory of a \\'on"'''', symptoms (6 wwks). The SC'Cond eX,lInpl" dcmom;t",tL'S how the theoretinl Implicatiol\~ of a c<',vic.11 radiogr.lph may not fit Illc dinkal
siluJli"n
He 'svmbolic ~",;.~,meablc bfick walr 11 a model thai gu~es phy"':lIhr'i1pisls ill tM· ",od( of t~jllki", In t~i~ ",ay t~(y all k(l'~ tt!(" tt>ouo,~", r((\cd,()I'lS ,"'~11!SSOOtlS. ~,,"d
Imowlnl'l" ill two ~r1t(
bllt '''dtpendml mm,,"nrr:en~At tt!e SiI'ftt ti..,( info,...... ti()l'l ~Id ~ ff(l' to 1Io.....om 0"" l.oCl( to 1M otIln 0.,., COII'jIaf'!ll'ffit ~id ttlf'tain 3 ' lhco-ctiarl illfor...:lttOn" ~nown .nll spttal>ltiw:. 'no:/ud"'S tM ptU3ulions iIIld ~b1( ronlratnclJcalJOm for llNt'l"Oe'l Olr orllft C'OII"~rtlnml.ta.JdCOIIta'n l~t d'NCllI ~ [hr.tory. """' nd ~IOt'lSIIO ~ .asscwd ...... rvalualr
a'
Examplt B - ctrvical spine F'gul"(' l,.'i~hows th" radiograph nf lhe cer"kal spine of a woman aged 73, l'ilrs. who hlld neck symptoms fol1m, ing a Ian 3 " .." '\Q; pre' '''u>ly. Sh" hod not h.,d an)' ll<:'O:k symplom,.......t 0'....."11 o~ day of ....'Ck stiffflO'S». prior to this incidl."I1t. She alro l\." S{'''',,' symptoms ",Ihout .... ,~ng any rad'<.>!ogic"l ch.J,'S'-....
A ptfYlfl <:.n have 9'0\6 laddogN;;ll cha"9l" but h;m, IlOpa,"",,~tM~'S*..otruo:
Tho> <:eIYical splI\i! "'-'pllrt wos ",. folio... '"
TlIt' ~/ !!1m... i!. ttm"f'll 011"....-10 I/r r
a'
Elample A - shouldel A 7-1-H>,u-old hc~lthy woman, bcGlU>e ()f '~houlder wc~k;;"'S5 and dJ...;coI;,fort'. had ul\olble either to tt>rnb h~r hair or Il'ach fa, eI1OUj;h behind her b.1ck to do up he, brn»iere for 6 wl."'ks, She IV"~ h;>ld dUlIlhe only ,~)ti",J..~ vpcn to her were 'm"jor surgery' or to 'put up with if, She n~fuse<:l S,nter}'. prdernn~ to put up with it. 11<.'(.1""" her si,tl'r, who 'had had e:>'(lCtly the Mille I'nobk'm', was 'cu,,-'Cl by physiothl.orapy'. shol prl'Slll.-.l fvr the So,m" I'\'.llmenl, The d,"/;nos,~ "'liS
be""
:rill! .;J'g/,I Qulmor $JI/!I'l)aI;c>tJ t1{Cl 0" C5. WIUI j10:iOll/!J(" it; ~1.s<J IVilerNr wbl,,;mIw.1 alC)Q" C4. Tilt'" is "nrmrl'mg of111/ II... ;l1lmnlrol1l1 dISC SjJ
Introduction
figu,,", 1.5 RadI09'" 0' =-iC3 ,:>in~ itl Exo... ~ B.. CcnO
~"d
rl... curl..I",,, 11I11".~m-;ad spi,,~. lmp$<jort
Xn-rr th).vtlrnrtrrlt' c/~', ...> e; in rlr ~r"""""l.pf""Il!' tlrsnj~>l
\\",7< r/!,rrIl'Il/ prtrivu; in'''1)/1
phras.s ",,--.I "hoen "''''.:lking o. "-"COrdmg in wriling. Tht> phraseolog:.· on(' uses dean) lhoe way one is thm)..mg.. and Iherd,,", If, for e=mpJr.>. !he :>polen phra:>e:<; aao wHaled "rongl~. the lhinkins behind IIwm Must ... Iso be wrong.
sIlo,,-,
APPROPRIATE WORDING It is tumtial to KI~11~e apP"lI'riale wo,d'rl!I. as t!1IS will ir,f1l,1tnct tilt t!1 nkirg p~ of ttlt pnysiotherapi'l
To s/'<'/lk or UTiu in llTlHrS h."f1l1S meart>. 10 ""'11; In ll'n'lIS It'l"fIl$.
11", plan of rl'lo1llng 1l>I"O",tiul knowk'db'" '" a p"ticn!"$ presentin;; ~y"'pl",n;; and ~;!lns plnces """ther dem"ird on the manipulati,,, pll)";;;olh",.'p;;;t. who mu;;1 employ a ~pt'C;al pattern of IhinkinK "hi~h ""lu,l"\"5 "cry can>iul oeleoction of the \\(1rds aoo
A
""'rle .'>.ampl" rna"
Ima~il>e
help to make mi. point c1eu. a physiothcTilpi.>! pre5
9
10
MAlflANO'S VERTE8RAL MANIPULATION
,1t a chn,c,11 :'l<-'Illl1\"r. Til" p;lhl'Ot, on bdng ;,,""-od to d"monstr;,t.: h,s ~re~ of p~;n, pl"Cl'S hi, h,lnd o\,('r the &acroili"C ;olllt. l1lt' ph),lliolhL'l','Jlist may, in ensuing dl5CUSSion, .d"r 10 Mr X'" '",'cft),h,t<; p."n· To be ITU" to lheconcept - thai'" 10 be IfU(' to lhe St'f'draled 'lheoretical/~pecul~li",~' dnd ',Ii"ical p",-~'lllilllon' comp.1rtmeJlt,;-s,,", should So'}' 'p.1in in tllis/"m'" hill' J"lllor>:;tralin~ ..... ""r U"on bod)' To h,"e.......:l the won;b 'sacroiliac p.lin' indicales thai she COUl.D bfo Ihinml; th"t I.... pdill IS cdu,,-od 1:» ..onM' di:'iord<'T of lheSolCTOili.ocjoinl. CJbo.iousl)· ,t doesnol nM'an tllat,"" MUST be lhinking thio way, but It docs mean that she COUl.D, and is in fact h,ghly li~ly to. be thinkmg lhi5 w.w. If, OIl the olher h"OO. ~ nrll'J"5 to 'poin in this area'. it is qwre impossibloe lOT her to ~ thinking thai the pam IS cau:secl by.l d~r of the 5ilCfOiliIK joint. And this is the imporu.nt elde \\,Ih care and '" ith ItI<' ngllt pauI,'m in mind. tllo.'l'I the thinking pro:xes must be ngfll.•'\nd when this is >0, thl' whoM: ~ of """mln.'tion. 1n.'atrrw.",1 and Interpreta"on m1J:'it be the best that is possible A ~ e:.ample conc:cms • student being ~ honed b)' hoT h:'acher foUowmg tho: student', eumlll..lion of a patient The stlllk'flt has found thai the patient's left hunod< and ~I;,roIall'filllh,1th~ a~ p<m'ol<.>d by \cfllateral fl,,~,on and ..~t~.and lhal on foO\ an! fleuon ht.- R.'llis an arc of n'<'traJ I:>i>cl< pam ....ith d s;mullalll'UUS arc of conlralalc..... t Ibi In the standing po5ition. the 1..-(1 butlocl pain ,~ ll"pmduced by rotiItion oft.... trunk 10 th.; Iefl"ht>n" is perlo.med in a Jl'OSIhon of roughl\,)(l of lrunk f1ex'on. 'The r.. ng of bolh st ...,gnl kg ra,sing and tile ~Iump lest ,'n." normal••",d tllene ,'n." nn ~rologkal dlangiS. (A",lI" PA pn.."",ure on bolh l.-t and L5 pro"ok" det'p t.al back pa,n One of the qu<'"'''ons the stud""l may Ill' a$kN b)' lhe It'acht'!" i" 'What do you ttunk is wrong'" ,th the patient" If tilt:' I<"""hing is ori('nted .. round diagnosis and p.llhol""y. thi! an",,'er might bo' ,,,m,'lh"'I\ iii... this' A I. l1lt' IA/~ ink"",td,.,.11 di"
A2.
I wpuld U"'ITI()"L~l1l'nl,to try to Cl'lllr,llil~' th" disc lesion lind ....duce the bult::e.
If tl", Si,m" '1l.1CShon "en' ,1skl'd of JI1 ,,>ponl'lll of lhe 'concept' of Ihe te,t, the .tod....nl would ,lnswer '11 lhis fashion 10 question 1. AI.
H.. has Tt'fer~ non-radicular pain in his left buttock lind postL'f'I.>lateral Ihigh, whICh is linked with /tis arc of cootralatcrallist on fo.ward flexion.
And the IIO:.W(" 10 que-,I,OIl 2 w"uld be
u""
A2. I would inil..ny pain~ pas6I\'1! mD>1!menl t~UC5 in an rifort I(> hnpro-.e h,s ..rc on flexion, and impftwc rangcs of I('ft 1::11eral /le>;iQn and rotation At IhI! ,,'me lime I "ouki hope Kx a l\.'d1lCrion in the ",,'enty of Llw rclcrred pain. ConlinUilI ~I will prm'ide me with the aM""<'T If my ! ....... ghlSo in relation to tile phast- and pre;ent sl.lb,lity Of the daJfdet are corn.
LISTENING It '" exlraonhnary how oI'ten doctur5 and pll)'SKMhcr. aplSls {in fact aD ~ "-00 dea.I with peorItl do not listen, nor listen c.uclully.".,..~ nor \;,;"", "''I>Sltl\'dy enough. nor listen al sufflOl!fll depth. 10 thell pabents.
ii..,,;,//. of rou~,.".rl,
111111 is rllrl'f! il HIVrillS Iii pawt't'; lis/millS islJdirr.lkan,,'Il' IS "rro/lllll"ry; lislt1l/1'S dnrUl'W; .lfnl!;"". HrIlrm!: is .Ullund; lis'mUl~ is u;/rni"K
.:tftr'sfrrmt~!J "" tJO{l,irrrJ
""'""'Il'
Jisd,,,,,,,,.
(The- Ag«, 21 Aug.... 19S2.)
11IeIe 's;;o much 10 \e.lm about l)'lt,enl:<' prohl~m5.
onl)' we ",ill hstt.'J1 11"s is
~"ClaUy
,f
rete',l11t when ,I
is belie\'ed thai I.... p~til",ls' bodies (an tell them Ihlllgs lhal we can onl}' dl5Co"er by li,~t\ir'l; to their
COIlHT\("I.tS. Our nllnds h.....• to be fn..'I:' nowlIlg. able to be dinxted. n'directl'd or innuenad by sublle comm,~t~ lhal I"" patient may m~k~ as a pa"lIl!; remark We must be good lis!(~\Crs. ,,"d "'" must bdin.,. patienl" subtle comments o..... m~rks. Also. lV~n such a remark has OC'L'J1 made, which innUenCl'S our !lul\k'O\g, the l\!l~vancc of th" n'nl.1rk mu51 be COIl· firmed by asking othe. related questions. It is lotally unfair to pati""ts to make academic judgements on ",h,ll should be do"" to help Ihem, III prd"rl~"e to making a clinkal j\,dgement ba><:d on bctual infoTma' lion from th" p"ti"nls and t"",pering this with what h known "cad,)mi",ll)'. Ob,inusly, In \ish'" itwolvl'S communication of both Ihe "etiMI and the non"'erb"l
Introduction
lind, picking up 'kC)' .... ords· and kno,vmg how 10 .".tabllSto good rapport. This subfect i5 d~a.ll "''1th in dclail in Chap«'1" .3. ~t and underslAnding M~ ~;;i.;:1el.... mg that Iheu body a.n inform patH!nts aboul aspocts of their disorder that caru..>! ~ fuund by "uminabon. ~OI" ~pk: ~the thlllg that is wrong~ "hl(h i5 sore, or '" il Just ~ from my treatmen,r
1. 'b II
'1\.<>, it's nol a silly ql1C'oti"n to ~S" wheth~r your b.1(k problem could hal'e any CONll'Clion wilfl h~~daches, IVhat ha"" y... u nOlked Ih,,1 g"'('S you lhi, r"cling?'
a".. .",
3, 'We both th.1t your mO"C1T\('nt, look better, bul you obl'iously feellh..! your S\'mplomS men't llf\Y bo.1lcr. Ale you able to ""y Il~n( 'I doesn't f~ bt.1t~'T, or on "hat "ay il ,sn'l better?'
lnIorm.lllon gained b> such qllC!>I1OJ'un" can "",·e.. 1 'n'i1h..... ble mfonnalion.. W~ '''list I,,,,,,,, . .,... m.. . .ftlI W<' 1ffl<j/ brim,
EXAMINATION G"... ler dct.lil and d'-"P'h of e.umu1allon is demand.'lI by this conctpt than thai ,,'ith whICh 1110..> ""'jori~ of c1u>iclans ,,"" familiar Fo< e>:ample, in the foIIO\\'Hl~ li,r of aspt'Cts imporlanllo e""mHl.ltion. t....o (number< I and 2) Me not cvm",only u>l'd to tho!ir fullest ,'a!ue,
Sometimes the only 5l~ lhal can bf, found 011 e~m,nabon a", palpation ~Igns. "'lule- all pb~io klogICill.lnd functiIo,""""nt d,agrams hne bcm ....eluded in I..... lext of this boo!< itS an appendiX r.tther than as a particuLar chdrte< of the book. TI",; Wil.'i dont for the p,,-~ n'ason thaI mo,'nnenl dia ,.rams shoukl nol ~ ~ as a m.mdatory ..x",· else for lhe marupulallvl.' phYSiotherapist. H~\'er. t'VI'IY e.fcellve milnlpulator goes through thl' pI'OCl'':'li!I of mm'emenl diagram •• although this may be done quite inSlinctiHI}'. In reachin" Ifle concepl lluIl tt", book portrays, mm'ement d"'gram, lx'Come an ~""""n' tial part of Ihe leaminl' pnlCWS, Th,s le,m",,!; I'fOC~'SOo 111c1ud~"S bolh a lNeI",r tcetmrnl 1.'Chm'iOJeS "hen apphed 10 a pat,...,!';, ~ling ~\ mplOm!o and sign,., II'" a mandalory rule thar in lesting ~ mo"emenr of any lind, r..nge plo~ its symptomatic respon!iO' "'list alwa"s be relatoo: ,~....:<
t. The precis<: site and kind of l)~h"nl" Sl'mptmns
thin" of rang"" Jlho"t Ihinking of
~ympt{Jmatl( rL'Sp""o;e
(which Can "" (lfte" inJi"at" fr\lln ",hich structures the o\'mploms ue NCTf c{~nll\g, as .... ,.\1 a, "ice
1'\1"."< think of 'rmP'om~ withoul thinking of range of mo,'emenl,
1~1),
r"l1ction~1 movtmtnlS that l'at,ents C"n demonstrnte to repnxlua: tnrir S) "'ploms, 3. Tht Jtandaro 'C5'f nUl\'eml'1lt!>of J01Il~3nd \erl.obrill canal and nt'Urill ~truct,,~, 4. Couphngd,ff.......1 'no'.-emlffllS. $l'CjU{"f\Cl'S and
2.
po!>ibom.
S. D1ffl'l\'tltWlti01lIe5ts «>determine \\ltich structure or mon'mcnl component IS in\'oko.'lpallon fUldinp (the t,ss....,. and joint mowmmts) that ha\e.In eft«t on the S}'mptoD\.'>. 1he It\3rl1pulah\e ph~"Siotherarist, during and folio,,· inl; c\~minati""" t~11 h..., the 1M\.. of col13ling Ihe ",fOrmal,on galhered on eXaminlllion 10 make il mean· ingful, This informalion C,1n Ihen be uS<.'· lion {'Xa mlt\al'OI' as ,~xpoul1d.~ hl'rei"
t.C'Vtl' t!"nO:: of pilin ""f~out tl-inklng of ",n!l'l', Ntva It' 'It of ..nge wiltloull~,"k11lll at p;IIO
..... lkto,led eJ<Mninalion
cN.ng<'5 in
~
10 r,",:eal the sm.ollesl
the beiloI\iour of the symptoms and the
n51St':ll"Ice "Ith l"ilCh dlr«bOl1 01 mo"emrnl. FOt'
.......mple, a.n pam or discomfort be relt throughout the
,1\
11
12
MAITLAND'S VERtEBRAL MANIPULATION
t'U-min:lrion findings cn1aln Irl'.llrnenl !<.'dlniques sIloukl efft.'ct 'You 1"",,1 as g~II}' ~ y(lU can but ~ h.ud illS Ihe d,SOfd"r "''''I.uin.>s' fEI jenth, 0., unpubli>J>ed observalic:w'ls). This is~, but rnany manipuL,. hI'" phYSlothcr~pi.lS do not apprerie;.lhe fourteenlh hole III a round of golf His standard of gulf i. t1wn n.'ho thill arc ,,>00 who...... a J"'S'Sil-.:' I,.... mon-..nenl, uwoll-inl; s;m"llll.1ot'OUS n"", ~I of ..I ""'~t two joml> or <Jth,o,r m(t\'e"""'I COffipont..... ts such CnI b prodllCt'd in one of Ih.' two componenlS involH'd \\hile at lhoe s<~me tIme the mo,"em('Jlt is r(·dllceJ in Ihe 'llh"r component. rh" t"st is then performed in the !"CI·cr,." marllll'r. Th,~ syn'ptomalk n"'ponse(i.l'_ n'C......,... Jl'Crc"se) confim15 whkhcompon,'nt I~ al f'lUlt (,..,. 1'1" 162-163 for .. c1ar· ifying e~ml'l(').
RElATING TREATMENT TO THE HISTORY, SYMPTOMS AND SIGNS tnfOfmallon Irlm<"llb, while al the
Solme timt' ~nK the clfecl olln"'II""",1 ba..<ed on in the pall'-'ll!'s syml'tonl$ and signs, is a pn_ mary lealu", of thi~ concept oltr('almenL Ass<'ssIDo..... I 0/ eh.ln~ effl'Cted by a tech."IiqUL' is made in CdCh of the diffet"\.'llt ph)'tiJ..,l nmlponents of a patient's disorder. The ·ioint-mon·IDenl/p.~in-,,--.ponse' compollenl, the mu>;<;l" spasm compon,'ll!, :md t.... =tnctf'(! neoral movemCnt c"mpo""nl .11'(' ~"ch ron,id"rlld ""parately (.". Chapter 4) cMn~
Kro,","'dge ~bolJI ~Iholog'j' helps IN Ih the 1~le,p"Ia~ rion of tht l:Nr~ in \'j'mploms ~1'Id loign, 1~.I
A p \\-1!1I ~ It:> ~ following In'atmentIS c ..... r-<:ul, positiw iniorm.~lion Ihal fomlS the prrmelMslS for lle"\mI..,,,r by Ihis method. E"en hl1\""''' u:o;ed Ih" wnrd 'rain' ..... tricts its import.meO' \.x>c""se mmy paticnl§ do not hal'e what th,'y call f",in, so tll" wmds di,r:tmrj,Ir/, an
t""
ASSESSMENl AND ANALYTICAL ASSESSMENT A'SCS,m('rll ha< always be<''' the ~"y.rone of thi. le"t. ","ell durlllg the ..... riling of the first edition in 1962. '\SSCS5ll1e"l "'ill al"ays be 11..-:. kcrstonc 0( rrogl"CS6loo.
l~troduetiG
figu.t 1.6
Tht 't .IM: ;mp"'l.ntt of
,"".Iy:ICOII~tf't.~tnt. 1,",_~1 t«"ln
ql>tS alld tQ""~
o' 1b~ 1"111:"1
.".5s<.,:;/;mo.',,1 d"mllnds of ""'" m~nipul~lil e phl'~lo lherapi5la mmd that is'
"P""
1. A~il,' ,md tu ,.,.;:"we mform.. lion. 2. 1'1;'~lk and ",n",~t,,·~ In the analy,is of the
info,""lllion
l.
D;sciphn~d. methodical
and logicdl in ils usc of
infornMt,on WI1\' l.'i th"", a 11<'«1 for '~ssessm<'flt' and 'a"alltical a.~mE'nt"'Al'l:'11't they the Solm,,? No,lhe)' are d;/bl'nt alth"ugh Ii'll'} Me bOlh ,ls:se;"n"".l. While a<..... Sml'nl ",milt"" p .... ,,'inS Ihe lalu... of .. te-chniqul', dJUh'licill ,l.S6eSSmentcoH....s . wider field of im l....I'g;onon and ~sing {Fisutr I 6) and Cdn b<' wn"id,'n,d under~ go.......... II1<'.adi"ll of'lTh1king r..... NIl'S fit. \\ hm 1""1 do not fil it i~ ~. 10 hunl lurt~, .nd re~lf\gre.lrerdctaiL .
~ " L If
f"'lu,o:l; do nol fit. ntt1kd
4. Other tr'-'.ltnl<'nls Ihal might be u.ai: deciding that because sucf\'and'>U<:h 1;1 hnpp..'fljn~ wilh t",,,tm~nt. an mIra-articular into,.'Cli,Ml, f"r (·~~mpl." m1ght Sol'" CIhP i",ticnt lxolh'r, S. TIw ...ltd-n>;.,,11 of l,..,atm"",l: making S('TlS(' OUI of a ,ornpromiseend-~ult, de-ciding wh"tOO mmnlcnance lreatmenl ;,; indiclh"r the "rmptoms and signs mdlch "';lh eKh other and with the whole ston- qf the coUlplainl, etc.
The .........1.:11 prlX"e"-"'" In' oked In 'alloll}'lKal .ossessmcnt' .. re sunpl" Ih,nLng !f>:;:iol/1v, Illoullh lhe)' mmk.. vertical thinkmg ancllaleTal thinking (DeBono.
19S01. inducti,e:h:nl.ing and dNun"e thinking II IS '~Il!''' manopul.:lll\"e ph,.--siotherdp'~1 s/uJle>. As ,u, sla~ b, Hunkln lunpubILohN ob.-...n-a~., "'lour i>CIue\-ernemsare limited 1>\. the ..",\enl of ,-our latMai anclloskallhinl.ing ~ in th15 a..... th.11 the
11.<1<;"9 felll~,ts fil ii.n mJIO'1Hll5p<"Cl of I~t IS II5UiIlly
not ",hie'..ed, dOO ",h, " mO"l'Tl'lent or symptom doc'S nOI impron! ",hen il should han' in ",l~ lion to other m"H·m,'nl~ or symploms whICh lultOf' ,mpfOved
furt~ .~r:
In Sl'fl("Tlll !l.'rJlI'. il _ ... no; makmg 5e1l5e OUI of "'holt tJ... p.tI'C!n1 i~ .blt> to Sol} .md demonstrale about lho.>
TWO INHERENT CAPABIlITIES OF THE BODY
dGorder. 1 h;"llpph"" to:
The: body"s capacity to adapt
1. Th" hislun m,.I<mg the onsel of Ihedisorder Ill. or lJ,;, ,l(cl."pIJble or ",~sonab!e. when rclilR'd both
fl)
thL''' II}S Ihe dis()rckr affects I"" p"lient, ..nd I" lhe physical c~~min.llion fiaJinp 2. The e~anlln"tion: "",king all of the (;nding~ coml1"tible wilh e,lCh other ~nd ~l>o with til<,' p~!icnt's disabiJiti~.
3. 11"'ch.lI1ge5 that t~I<e pl~ccdurillg tNalmenl: "'orl<· "'& oul ,,11l' lrealmen! prediclions ore "Om('lime,
illS aSlonishing kI rc;ili.;ce rhebodl"srnpacit) to ·ad•• pl to chang,,;;' forced on 'I bv rong,~"LII db""rma"I,es. Irauma end lifelong h....w) "'nrk. Knowing this to be d {,loCI hdp. u. to pul our eXaminMion findings into a mon: preciS<-' conte,r ",hil~' m~kinS m;s<'Ssm""t>;, I" other ,,"o,ds, it a p~lil... t h~, h~d "II ~(cidcnl nr disease '-',11Ii,-,r in life, lhe body's Cdrability 10 compenoale tor the damage can be.o compklc Ilmt the< ~bnlllrnJllind· ,ngs rna\" ha,-e Hltle 01 no bt"aring on Ihc l',..,..,nt;ng dl-onl"r.
13
14
MAITLAND'S VERTEBRAL MANIPULATION
--
THEOflEllCAI. KNO'.',\£OGE . .
•
TES'"TNGOFLr.£SEs
1
The body's Up.ilcily to inform
SUMMARY: THE 'CONCEPT' se...WJn:s
S'9'"
T...,.....,
"d T~or. o:ds. p. 1<100. Owrtfll Ljyi""l.t
s..·.:ondly, p•• heo.ls' b,xlirsrnn MIl""'" things r",btl'CI to their d,sonll.'r that "I' can ne"'!" de\<:'Ct c-.cn b)' th.. rnO!oI thon)\Jgh phYS1QI exami...~ho", Thl'loo-' are 1ft-'" qucntly ~ublle mc<"'ges that patients m".\· cnJnlllenl on, ,,,w.! Ihl')' c.'" be rricc\cso;, n..,,,nly way the m~nlru· I.,tivl.' phy.,,,lt'crapbl 01" elicil th,'",· ,ul'lIl'hf'S 1~ by Jislmlllg tn IJI1IIC,,15, and by cnwur"ging tllCm 10 m",,tion anylhing thnt might be re1""llnt, irrl"'JX'Ctilc of how tri"i"l or Ulumportanl il m"y S<'<'ln 1'~lienlS who aN' 'tunoo in' to their bodv will Ix! more awareofth~~ubtklies.Thi.;'; a proc~of L'CIUclliing patientS to nolkeAnd report trivia, Forcxaml'il-'. in response to the question, 'What efflXl did Ihe 1ll.1 trealmenl hA"e?'. a patient may Oily,·1 don'l "now-I can'l e"plam tl - il just feel!; dif!\,nmt'. Such 111 StArem 1 demands an 'immediate--repon'!e question' j pp. 35-36) - 'Is it a fa,·oura~ difference or an unfa,ourill~d,rr..." ,-""",?' Thus \\"1' re..ch.An under.;t:anding of ... ""r the:-' disordct" .. and whill it ;,;do;ng 10 the patk>nl (ow F~rt J.i').
<::»1.'11ha1
'" "ted Ily~ H. I>o
FICJ IIIld 1Il¥nUOll'lS
~Ls ------.. .
h
figure 1.7 flo....... l\aof1 ~tliting re'~lJorcSt"p •• "d """te_1< f.. tbfO~llc;>l ~nd ci,olOl t"~~e ..... i\h
ClIttCAl. -:
H.SyS
~f'Ilrsdlgy;
thaI male up rhlS concept of
Im~tlnl"" atl' founded 00 an und.." "tandmg ni tho.' fal· Io"in~ 10 txJint... f\i1ruraU)', molny of lho.'m are mclud<.-'d ut the ml'Ihod~ that oIh"", "5<', b<Jth dunng
treatment ilnd when leaching manipulalion, but tho' ...... phase; ,,,ill "al'}· 'rom pen;<:>n to pttSOn. The fundam""tal ide"" IhJ' ha,e particular importan~ in this fO.......' ll a", "knti{ied by bold prinl. \. DiIlglI/J:5i,: The ",alization th.~t, allhouKh the", i, ",u,h i" mooicine Ihal is ~lill unknown. nt1d "lth(lUgh p....'Cisc diagnosis is not always possible. these need be 110 bill' to preciS<', effl'l"live ~l1d i"fur",ati"e manipulalive trealment pro\'id<.~llh" t.... o
2. Th. mnlion>hips: bI'Iu""n Itr/flIloJIlC' and ~"mt'nt: K""-'Pmg the ~hc..lllI\',l and theelini..... l .....a in Iheir corn.'Ct into.·I·"rd~hnnshiI'S b) \'ISUilli"inE; rhe 'symbolic 5<'mi-perm"ablc brick WAil'
3. TIlrory: Not allowing th.,.,rdical knowledge (which in fact Ill,ly Ix! fi\l~l, or Ih" L1Ck of il. to ob.lrucl Sot..,ing or fi,w.!illg dmlc.,1 facts
4. A'''',;lIIlltt ,m,1 """Jyllml ass,','sl'I""" Validathm, proving each Slep in Ihe chni,al situlllion. FJawle.;s ~n~lyli,al ~ssu~menl is the k,'y.ton" 10 this con· cept of manipulative physiotl>t; thaI prodUCt" appropriate ~ymplom alie nesp<>nses. d Kno"mg tho:-' pnnopkotl 01 di!fflet'lti.tion 1'"S1s. and the methods of performing them. d} Ha'·ing a full appft-'I:....hon th.:>t pallen... Can "",... diHerenl KI'lOS of "",in "ilh,n one disonkt" App....'Cialm8 the implications of ·pain-lhmlly.-,.-ange' ·ft\d-of-nng.... ~n', 'Ialent pains', 'pain inhibition', and und",,standing the 'irrilabilily' of a d,,,,,rd,.,. Wllh lIs Impli,ations fur guiding trcat"","t e) Milking 115<' of tl!StinJ: mOL"l.'lllents while comp<e5Oliog lhe joint OoUrfa~. 10 romp"'"" thalpain rl'SpoIlSe With Ih,lt fmmd when compression is not applioo during the.arne test mo~"ments f) The depth oflhe detail of palpation <'Jmminallo1l of softli.,,"1.'S and ""c"",-~ry movements g) The u5<' of 'movemenl diagr.ms· in an"lysing physic.,1 "Xill",n"t",n fi",lmf:.~.
""y
6. A"I"'01"ialr ,,,,rilil/S, fll'C"uSo" there are milny unknown
ilSpecl~
of tlmory, answer,; 10 'luestions
l~lroduction
",Mod by pfOfe!oSi.ooal peopl.,> ""barding II\(> effl.'Cl> maNpulativc IT.... tmenl must .. I",~yli be flexible, n....•.. r d08m~li( and n<'<.'d. 10 Ix> pfOll'(l~od loy Ih.· u* and .. xpla.... tion 0{ lhe ~"T1lbolk semiptnneabl
0{
7. u,!.... i"~ UMtning attentively 10 the roal......t>.- ....'CfV word In oWl optn-minded and n<>n-judStmtnt,t1 m.ll\ll... Utlin .. p,tlitnt.., y'" questim them.. Th" i!; a '"efJ' dcr:l.:mding 51<111. n-quiring a hIgh Ie> d 01 self-c.llidsm. 8. 1<'(h",,/,,,,,,,
..} An op..-..,.mu'lded .. ttitud<' to rre"lrnem I«ItniqlH." L~ .......... li.:Il, Ihus bemg able to inno,,,I.. f..... ly, unhinde...d by theory, bul ...laling IIw I('(hmque< 10 fundional disturban," nnd pR'sent;ns 51gn5. bl R..cording Ih.. l",hniqu~'S by usmg Srad(.'5 of "'''' ernenl. rhrthms of mm".. nK'll! and Ihe .y"'pU>m,'h( r~."pon~dunng lhe k'(hnique. SO ~s 10 qu~lify lhe mooe of Ihe lechniqu.. for a(ur,lle rommunkati"" c) AdeM underslanding of how 10 treal pam by u,in" r.>M:ill,lImy k",hniqu~'S. which are lol~l1y p.inlU5 and do no! include lin)' ",.,..lr!Pms ",hHSOi.,,·~'r Such I",almenl is not u>ed rn olher cnroC'l'l'ls. d) A Similar und..rstaooing of lhe appliClltiun ot .. comp.e55ion fOKe of tho:' joint surfaee.; ... hil.. perf<.»'mlng osdllalOf)· mo,l'm..... I,"hniqu..... Such I...· almenl is also """,har 10 In,. c-once-pt. e) A >lmil,1IT under-landing of h"" 10 ~dapltoxlt Nq""""Of t ... ahng stiffness• .md r:hc: modir.inS
f)
of th"", lechnr'lucs "hen muscle 5pa>'" Irmits rnmcment. ReLaling the 'srad<'5' and 'myth.m' 0{ ~ niques 10 !he elini.clll findings and an) coornrl'L",lpa~_
g) t:51ng a;,l{'f1,ls 10 highll~ht the rKOrdin~ of m.l.;
9. ~lj"J! Irml""",1 1,,'111' 1risI"'Y_ fY"lpt"_,,,,; _!,:I"-:
.\Ithough the hellclin$:state the b.uiliol the ~al ment roncrpt. the tI\"J.tmcm b ,,100 mll .....n<:....1 b). "hal is knm,-n .... the diagnof INalrnenl.
10. T1U" bOO¥', jnl"'-Tl"" Qlwbjlir..." a) Beli..,-ing that th.. p;!tknfs body Ius an ~no' mous Capacil} 10 adapl and accommooale 10 diwrders with""t causing symptoms. 11) IJd;evinglhal Ihe pati""n I>ody can lellihe pati",,! - and therc{ore. th"'"gh lhe palienl, Ihe manipulati,-e phy,iotJ,,:r;,pbl - subtl". but ,·,1,,1 informal;"", abuut Il... tilsnr,k"f. wh,ch '" ,,,rv imporlanl 10 a5S<'§sm.,nl, I,....,l.mL~ll ~nt.l rrognosis
IT IS OPEN-MI'
15
"
Chapter 2
The doctor's role in diagnosis and referral for manipulative physiotherapy Adapted from the original text by Professor D. A. Brewerton, MD, FRCP CHAPTER CONTENTS •
r
Org~"ic
disordr:rs not
tnt: vr:rtebrae ~C9nancy
invol~ing
17
16
Qistasl': Qf the spinal cord or cauda ~l,Iinil
18
The ~rtr:bral i1nt~ries 18 Vertcbr.ll di~i1$e 1B Spondylolim.~js 18 Osteoporosis 18
En',} pat,ent who b
'0 unJ.:rgo
~p,".. J
mobilization
or manipulation hy a ph}";othl'rapist .hould have cOI'.ulkd ur howf'
,'CCl'S.~
to .. doctor, who
h.,. Ih" dual
l'L'Sprlllsibility uf determining thc diagnosi5 and dedd· ing tho,< tl
tn...
Ankylosing spondy otis and mtulutoid arthr,tis 19 Ner.oe root pain 19 N~r.o~ root pain and manipulation 19 Ntr.oe rool patn and traction 19 Impending n~1Vt 1001 compressIon 20 TII~ remaindtr 20 Posture and won: 20 Psydlological factors 20
musculoskeletal syslem. C0rlSC''mcnl. S\lCCl.'5S de(X'nds IMgdy lJ[l roll.,borat",,, m,tw""n doctor ,md phySIOtherapist and \'ice versa. The doctl)1'~ mle is to "",ke a bn,),ld d,agnosi.. orda"",rKalion of the di""rder, and to diSCUSS chanJ:cs;n ll'll' clinical ",twtlon that may de-\elop during the course of
t.......trnent
~
c.vonot Hoi be Nso....J entift'lvOf'l an u"ah"", of pn" en r.>CTh. How~·er. there h.i!,".. b.."-.... deta,l«! 'oIudle> ,,( th<- """,lis of ~atmoent or cootroUe.i tnals. At p.........~lt 1t is still essl'I1tl
ORGANIC OISOROERS NOT INVOLVING THE VERTEBRAE The cl,mcal hi,;tory and I'\amination by llle doctor are """..~'tl,ll in e\dudlllJ:" wid.. '",Hiety 01 disorders that nlav s,mulale splll~l p~ln (TaNr 1.1). Spt.'Cin\ anention i. a\wa\"s f';i,·~." to the patient who CaIl move tho;:, releI'ant po,rt of the spine fll.'t'lv without discomfort \ l05t of the m(lre >oeriow disc1llle5 thaI an' commonly 'luot,'
18
MAITtAl'OO'S VERTE8RAL MANIPULATION
Di50fd~~ that
Table 2.1
~rv/coIP(M
Malig'llnt ty... ptIldmopllthv
may \imulate spinal pain L~_,po,'"
f'l,ptie .Itt<
"""COast's tumour
R~~
~1fIetV ...............
P:ar.. ~al" tlOC "0'" Obst....rno.. of IM.I Dr mxartl:1a Cam1lOt"a 0' colof' Of
SubI"Idr.oid hamlDr~ Co~.., ~ ~isnst
rtlwmn.a
f'l>.ymyJ911
""""",,",' 8rono:llooJ(~'" DrnrotU
OtJ>oe''''''g~_ Co'ON..,art~~
""'II t an...rysm
M:mo'<'(l3flI
I
Gill bladcl(r ~;selse
and is N;;ily mistaken (or inlcnnittcrll c1audicalion du.. 10 penphcnl artli"rial di.wU".
Otlln prMc n'OflCl"\aS Et-:liot-(l~
Prt<Jnancy com..mi'lllltd seoe_ Sjlonol cord tum"", Hjp~_
S>~ ~
Herpn IOSI('
p",hl<'l1ls M~ (,1lI"'-'<.I by ball di,,,ase. hi,lluS h"fni" (If ;"'!;"''' ]'''-~t1tinb wilh dOl"S.1r \.>.~el:"dl<', <Xcl",i"" of till." aorta <>r II"", arteries ma" p"-",,,-.,.,t with lum\.>." ,"1;11 l"l walktng. ,-,,, pati"nt \\ ith dOn;.,JI pain ~holild be tn.',ll,xl with""t h."''''g had a eh....t ",diogt..ph. 1he.... is no Ind",.. llon for lJl.ilrupulalion ,f thl' <,a""" 01 pal" I~ not "ithin the sp",e
PREGNANCY
Pn-gn.1ncy. '" In,. l.1-<.t monlI1~. it; ...".,nkd b\ !K>ml" • conlr.llI1,hcabon to mom.puLIl...... It " moe that the p"·gn.""'r prescnls ....·o::h.lf\ical and tl.'du1.ic..I prot>Io.'Ilb. but il markal pain b dl.... rty orismalinj; within the spire thl"f\." i~noA""'-""ute oor ~ manipuLaIJOll pn:>Vid...:!
DISEASE OF THE SPINAL CORD OR CAUDA EQUINA Oi.5t'ase of 1l1l.' spinal cord or <:auda l'<jUin.~, 0' an} l'\'ld"nc""f p",~~ureon them. is an absolure<'(lllrrai",dication to any f"rm 01 mobilization or ",,,mr,,I,,t,,,,,. n,,~ appHl'S .'H~l tv the slightesl sY"'I'toms, M'eh a, I1Illd bilatcr,,1 paral."lh,'sia~ in thl." fen Thc krill '~pinai sh:nosis' dc
THE VERTEBRAL CAROTID ARTERIES The n~1L-IJral GUObd ar"',",," m.ly be occluded b-,- atherosderosis, or by d ~ or dl'fom"l) of till' spine. Some 1~1l':S fnllow,ns man puLation M\-'l' been d ...... to ocdllS'Oll 01. N UlJury 10 the \...,n.,obr.tl c.a...,)Iid Mh.'Ties, part>cuL,.I) on rotation or ""t.nsom 04 the ned. Befofl' po..'Trc>nniroS; all\ motnllZOltion or m.uupolation 01 the neck. it ~ '-''flllallo ao.k specific.llly for ;m~ ~,..mproms SUggeo;lins \-erld>ral cilroIJd artery dis· ...,5e, particularly iIJlY~I..-ordl5l"rbaJlIeh position for a N:W ~S to be certilin th:ll Ih", dOl'S not prl)du~ symplolll!l bLfore .Ittempting l...·Cfl gent!.. mot>iliz.llion, £x.~mirulli()(\ fo, "ertebrobasiIM ill5ufficieocy is dis<,,~ on P.lgCS 242-246
of the \~ rare
VERTEBRAL DISEASE dAS$ifiCiltion 01 the 'l"rtcbr~1 <'>1""--,,, of spinill p.1in Il1dudes m"nr well·kno.... n pathological disorde,." A
(T"Nr 1.1). In pradlce mtlISt paticnl!> ha\'.. changes lnat Are diffICUlt 10 da~i(y. and it is usually impossible 10 nuke a pn.'Cise al\illOI1lical di.1gr>06is. There is oft"" a b.ls15 of und"'"'rin!; 6Cf\ti.a1 ""fore ad""";1ll: m.mipulalion or tho> Sf'lnc at any ....-cl
SPONDYlOLISTHESIS Spondylolisthesb is .I eunlralll,hC
OSTEOPOROSIS OskOporOSIS iS~1l i1bsolul" c",,'lraindicatIOll 10 manipu-
IMion. and this ,",strictu)l1 "pplil'S "i,;o 10 conditions likl."ly to caus<' oskoporo'i,. including t"-~'t!lle,,t with sleroids. Age in i!!>elf is not" COl1lr.indieatiUll tn manipul.tion, and somel1!lh" mosl worthwhile 'esults "rl." obl"ined in older patients.
Th~
Table 2.2
Vertebral
ca~ses
DevelO{Jmemol
Sponrr.,.lohsthe.i, Scoliosis Hw,molJility V.ti"", uncommon di'orders De<;enerotive D"c I"ion' ""thout root <:ompre",on Dis< I..ion, ""th root compresSion Di'" 1"'00' ",iO, rompre"ioI1 of ",in.1 cord or ,""d. eQuin" O,te03rth"";IOf apoph"...aljoint, HWro'to'i' tn'tability froumo Fmcture Sue" fracture Subluxatbn Lig3mentou, inju,,!
doctor', mit in diagno'i' and
of spinal pain fumo"r Soe<.-ondarycarciooma M,..lomal"''' !nftoet'on Staphylo
B,uceJio mel;t~nsi,
rd~rral
for
man~p~laliv~
physiotherapy
of rain molY hdp; if it is beyond theeloow or kn .... root in\'olwment ;s pf()b.~b1e. 11 is abo more ~"elr If tht: p~;t1 incillde~ paraesthL'Sia" or othcr q~"litil'S SUggl'St· ing ru'fye irritation, \\'ith root i",·ot-ement, a gentle spinol mo"cmenl "'"y ,,-';,dily prOOuCt· radiation 01 pain to " great~r dist~nce th~n woutd otherwise be eXpllCkd; ond maintenance of ~ ~pin~1 posture, Sotc!> as rotation of the neck towards thi' pain, may r"produce the root symptoms il tile p'lSition is held for W-20 Sl'Conds.
JnnommClary
arthropathy
IInl<:ylo'
ANKYlOSING SPONDYLITIS AND RHEUMATOID ARTHRITIS Ank) losmg ~pondl'lit;,; and rll~um.'toid "rthrills both c"mmonly affect thc "piJlalliJ:~n><;nts.which <>co"sion.,lIv mav I"ad to sublu~alion within the (ervic"1 Spine arid ra~lv to ,uddl'l1 death_ E"idenc" of am' inn,lmmatory a~thropmhv 01 Ihe ~pitlc is an ~~...; Iutc mn1,,,in
NERVE ROOT PAIN ANO MANIPULATION Experts do not ~ll ~l7"e wh<:lhe' ",~lierlls with root symptoms should be subjl'<:!l'd tn foru.ful ""nipulation_ Some claim that It i~ justific>si'e ",obiliuhon and nhlnipulation ,omdilll~'S prooucedramiltic rclid of symptoms from am, pain or sci.>tic". e,-cn when there ar" neurological ~Igns_ Also, il i, probabl:' right to milkean e~Cl'Pti(m when a pati"nt h,1S root >ymptoms of ,'cry long standing 'md then app<.~lTh to gl'i" stiff r\l!ck or b.1Ck dUl' to.' mechanical de,angem"nt of the spine unrel~led to the chronic n~l\'e mot pain.
NERVE ROOT PAIN NERVE ROOT PAIN AND TRACTION Root rain due 10 a disc protrusion Or ,my loc~1 degctwratin' dioor
Trilcti,m Can be ~pplied constantly to a p.,tient confined to bed "ith ",,"ere foot pain "ri'ing H\ II", «'"I';oll or til;> Itlmbar spitle. or intL'rmittently on "n outpatt~l\t ba"",. Traction in bl-d is lJS<..-t m05tl) for paticnts "'ith particul"rly p~inf"l ;;ci~tica tlMt has not settkod altt'r tfe"tm~nt by b
19
20
MAI1lANO'S VERTEBRAL MANIPULATION
InUrmittent traction Inn,rmittent traction on an outpatient basis is p",!er.1bly given daily. a"d can be applied 10 the cerv,cal or lumbar spine. Cervicaltraclioo' for patients with arm pain thuught t" be due tu rool comp...."SSion has Decfl lhe subjecto! a thorough study (Brilisl, Medienl !o"r,wl, 1966), This .,how~-a that drtually ",,"ery patient had marked relief of pain during tf>c application of the traction, which was usually applied with the head in a flexed position. Oflen Ihe pain rel;et lasted lor a matter of hours, bul the treatment did not influence the natural history of the mndilion or the long-term results. TIlTce-quarters of Ihe palients lmpro,'ed sul>stantially within a monlh whelher traction was used or nut. This means thai inlermittent Imchcm for Oulpatientssh.)"ld pmbably be ~,,'~od for p<'ti"nl>. with SC\""" pain, who will be graleful for the t"mporary ",lief of p.1in e.'en if Ihe m-emll r"te of "-,,,overy is not improved Lumb"r trachon is commonly applied to patients with sciatic pain, although the~ has nOI yd Ix",n adequ~te statistical eyalualion of the resulls.
IMPENDING NERVE ROOT COMPRESSION Patients bctw~"n ttll' ages of 15 and 35 y"M, who develop acute lumbar Or a-r"ic..11 pain are mo", lil«:Jy to haw lrne disc protrusions Ihan olde' IMti""t,. L"mb'" pain in the younger ail" /Sroup frC<JuCl1tly I'r~'Sel1ts in a way that suggests the likelihood of 5Ciatica in the ncar fUlure, and this is a conlr~;ndication to manipul~tion
THE REMAINDER Although the &",at majority of patient~ who cnmplain of spinal pain cannot be dassificd or diagnosed, this mixed and complic"atl.-od groupcontalns thepatk'nt:; who Me mC6t suitable for lre.l!ment by sp"".l mOOiliLMiu" or manipulation, The <-'SSen"" of selection is 10 choose patienis whost' pain originates i" the spilw, and then exclude all thos(" i[l whom the'Fe is any evidence of invoh'ement of lhe spinal cord, cauda equina, n("n'e rootsoryertebr,,1 arteri~'S, and tho,., with any evidence of disease affecting their .'ert("braeor spinalligamenls. In the management of Ihis large remainder lhe", are virtually no absolule conlraindications to Ire"lmenl, pmvided the correct technique'S, as o"lIine-a by Mr M"itland, a", chosen. The main obje'Cts "f trmtmenl are to usc Ihe g.'ntle;llc<;hniques that will produce the desired "-'Suit, and to m,,,t,fy Ihe t.-.calment on Ihe b,'sl> uf the p.ltienrs progress and rcpeated rc,lSSt.'SSments by the physiotheTJpi5t. Trealmenl starling ",ith gentle
mobili7.ation and a sm,,11 amplitude of movement should be perfl>,:tlv Sc pain may be located at the COrTl'Ct le"el ",jlhi.. the splOr, in the absen"" of rOOI symptl1rns it i5 often only possible to mak(' intelligent gu~'S.<;cs as 10 whcther the cause is a degenerative or protruded disc, \'~r!<'bral in~tabihly, dcgenerati"e changes in an "pophyscal joint,., ton, inll'''''p;nO''s lig.'",,"'nt Or SOme oth"r preciS<' djagnosis, FurttJermore, it i5 impossibl .. to bri\'~ definite indications ed gm ...p of ['<,lien Is. Nor i5 il wi.w to say calegorkally which technique'S are mostlikdy to b,' dk-c!il'('; diff~'1" enl man;pulat<:>rs gel their best results wilh different lechniq"e<, At pf('S('nt all that can be said is that whm thc-sc pat;"nts are t",ato.>d by "xf'I.'rieTlCcd physiotherapiSts man)'o! them do well. and they ~ppo.>arto 1\.'CO\'er more rapidly Ihan wilh other mdhods. Regrettably, we must await more detailed investigations a"d assessments before anything i~ ",ore ddinite,
POSTURE ANO WORK Any physiolher.lplSl ['-eating a p,'tienl wjlh spin"l pain shuuld ~"to",aticdlly r(:v,ew with the patie'lt th" uS<: of Ihe 5pine for aU l'"eryd"y flCIivitie5, emphasizing any posture or """vement th,lt ag,gra\"ales the p.,in. II is wrong to C()nC~'Tltrate 011 ,;pin;,1 ",,*,ili'~.bo" whill' the patie"t i~ rq;ularly making the pain worse by >Urn" unwise jXlSIU'" or by a rep<'.,tcd activity al work.
PSYCHOLOGICAL FACTORS Pu", psychogenic pain in Ihe ncck or b,lCk is not Common, but \irtuaUy all chronic spinal pains are influe",cd by social and p~ychol%rical circumstances, and the doctor's assessment is ne\'er romplete if based on physical ground, alone. Gi,·t't' a e1Mnre to taik, many pat;~~,ts w,th lhese symploms pom out their probl<'OlS and make it OO"io'" that they arc suffering fromdeprcssion, anxiety, marital or social problems or som("thing else that demands help in;11; own righi, Sometimes the patient has be'
Th~
doctor's JOI~ in diagn",i, and
lheSplfl(", and ...isht>s lobe 1"fOWC:t<'d from the ra""ges of a ...',despread, cripplmg d....-ase While il is true thai p.11...... ts. "ho:>e ~'mptoms ~ prl'donllnanUy ps~chological in orig", benefit oonsilkrably from marupuL1hon.lJl p!w»ioIMrL uu.. "pproKh 10 Ir~lment can rlt"\'er be an adequ~tesuklitubl>for psvchologlClll help, and briler k>ng·IL-rm results. are U!Uall) OOlau,...j by doclor ;,t ;s loud,fficuH 1011'<'<11. Thisd~rirllon applies 10 many p.~li,'nl, who go f,om Ihe';II'i.~t 10 IherJpist r&:civil1g ""~'ilr. of u"successful trealment. Among p.lticnts wilh chronic spinaJ p.lin th~re are many with moderate or "",,_ depression. They N.'jecl ,mmed,al.,]y any suggestion tholl Ihcir problems are pt»chokJgical, and usuoI talk about thdr probk-ms until lheY h.I, e recei,-!'d a course of
mar
,~f~,,~1
fOf manupoulative
pIlylioth~,..PV
anti-depress.:, e drugs Of" ather trl"atTnl"ol. Th.,. IS a much belteT" approa.ch for mosI of them lhan t" l'l.'tn.... 1 ",to physKallreatm=1 A chronic an",e'') stale m.ly be a form of dq'res6ior'l, to be !reared acrordid (m a per5OO.)!il~· di5onier. (lb, iou:sI' lhe person.alit\' (".. nnot radJ} bechanged but dlCSl'patl('fllsof'tenh.1'elOSlg!l1 and recognize thai they ha,·c h.1d other s) mptom~ du.., to fl'nSion.llwy m~\ besurpnsmgly wilhng IOdl>CUS6 Iilc>ir pain in psychologl{dIIC,m~An expLmahon U"II 'somelcnse P"Ople get p'-'phc ul,;.,ts, whi\eolht.,.., I"we Il'I\5C nl"Ck muscll"':l alld a p;,inful ",-"Ck' mar be und..,.... !toxxl and accepled, w,lh obvious ",lief that the C~ll,;o;, Is nothing more st·ri"". Sometimes ol double ;'prro~ch is r~'y moly lole"'te the sugg~tion Ihat ps..chnlogical factu~ pl'Cdom,,'abl> provided tlll.·y .l'" abo lold l/lallh", ha'ea nUnOf organic condition Ihat ,,1.11 probably re,;pund to ph,-,icallroalmenl.
21
23
3
Chapter
Communication (with a contribution by J. Graham, MS, SS, FRACP)
CHAPTER CONTENTS Non-~rbill communi~tion
Vl:rbal wmmuniCliltion
26
29
IntcrYkwing 5lr.iII'i 28 Wording 'lulls 29 P:ilr.lllclrng
29
Bias 29 Brr-.lly
30
Spontaneous information 30 Kt'fo"'Grds
Errors in
30
v~rbal
communication 30 31 The reason behind the question JJ Misint~rprcting
~umin9
34
Verbatim eumpks
34
Immediale-r~on~ qu~tion$
35 I. At initial consultation 36 2. Oarifying wbjmivt" assessments 36 J. Subj~ di~renm 36 4 At su~u~1 lrtatllM'nts 31 5. Non·~rbal ~ 38 lCqwonh JB Sp«ifkity 39
an.., of the mOl;I important 'bpecb of thb cone"!', of "",,,ipulat;.-!' pfll siotherapy. as SIMt.'o(.'SOoIHl'nt, and this has ~n further t.-mphasilC'd b, extending the s\\bjO'd into ,'n"li'tlcal ,lso;essmmt ("',rp. 12-1)), It is. as hM bern ""id,th,' k.-ystoneuf th"",m""pt, and ,f the keystoncnC<.'d..> luMher n.>fining. this ji~ in the ,kill of n.otrosp<"Ctiw a_'!Otlll~ll [n ,,->ffO"p<'<:I"c
At initial ron~ultatiofl5 40 History (wibal con~ulta";onl 40 Ikhaviour of 5yMj)tOMS (initial conwlta,-,) 4J Pai~ r ~ d.rnng Itst ~T~nt5lln:tlill consultlit 01'1) 45 At subsequent treatment scssiom 47 Cha"¥S in symptoms (substquert Stssionsl 47 During iI t,eatment session 48 Changes in pain r~ponSC dUfirg rea~sment of test movements (subsequent stSsionsl 48 Pain response while one is ~rfolmin9 a technique (subsequ~nttreiltment !oession) 4& Pain response after a technique is performed (during a "eatment sessiGn) 49 At review se~~ions 50 Questions during a ,et,os[lCCtive a~5e~sment (ilfter each tt-ree to five treatrrerts) 50 When Pf09r= has sIo... ed or stowd 50 Changt$ in syrrpto'Y'S at rrview loesSions following iI breat from treiltment 50 Condu~
51
a.~.ment.
il j,; the as.ses.Itl~'I11 of the pali""ts' ,'war\.'nl'55 of ch.1ng<'5 10 thei, .ymplorl\5 t1~1t is the mos.t important demellt. The only nK1hod uf getting 11u_ i"fomMtinn is ,'j" ,kill in c"ltlmunic.,timl, If il "-"I"lres
n.""t
.,r
..tdting. the irnporlant pMt this sixth editi"n IS "'tthuu' duubt "nde,.t.1nding tho, ~klll~ of communjca_ non with Ih.. P.ltl<'f\t In mro>.pe<:li'·e d~ll1enb
24 MAITlAND'S VERTEBRAl MANIPULATION
throubhout In'.ltmcnt. It is for this reason chapter h~s oc'Cn written in such deta,l.
th~t
this
Skills of communication wit~ retrospeet"'e ilssewnent are ley,lOIles of the ron~pl, as this eotlllibllt~ 10 pill;ents' awa,en= ot the cMng~ in Iheir symptoms
Dr John Gr,lham has put fo..:e into projecting the importance oi this chapter by writing an introduction. Dr Graham is the Visiting Specialist Physician at the Flinders Medicat Centre, wilh important roles in the Pain Clinic and the Coronari' Hypertension Unit and his knowledgeoi wmmunicanon, with all its ramifications, goes far b<>yo"d the s<:opeof this t"x!. &'Cause of his skill and ktl{lwledg,,_ I am plcaSl'e exposed 1o the thinking of an ,,,,usually cleM and pc":"pti,·c nund As one who has had the opportunity o( watching Mr Maitland a,~s p.ltienb both directly ~nd "n vidc<1-t"pe, I was on the one hand excit~'nd spe.lks~lxJl1t 'how I think', Hbout 'a,,,,Irheal HSse$,mcrlt' nlld "bout 'nexibility'. He understands th.ltl1exibihty in thinkin b ill\-oJv~'S 'inv"ntivel1l'Ss', 'creatil'ity' and 'trying a new w~y', but always evaluating the new way against old "'Hj'S I-Ie is evcr p"'pared to try a new SC<:!ueme, Thus flexibility is 'not being rigid'. He understands thM 'the map is not the territor)"'. A map is a representMion of territory. Names are represent~tjonsof things H" ha. developed his ",lid metaphor of 'the semipermeable brick \\'~11'. Brick \\"~jJs are opaque, and hard 10 bct through. On this side of the brick w~lI are the history, symptoms and signs (HSS). This sid<' is op<'n to the clarification 0/ more degant and precise hi,tory t~king, correct checking of wh"t the symploms are and ",reflll eliciting of physical signs, The other side is 'tho.> pathology', and thot is mostly infcrred. The chapter on commllnication is about this side of the brick wall, Clarifymg I-ISS is ch~'Ckillg to 5<'.. that the message se"t is thc message r~'Cei\-ed
New in/ormation to Hny person m~kes sense to that person by theircomp,,,ing it to whal is Hlre~dy in their minds (me",,,ry, mil!'.,) .\-lr Maitland is prepared to \'isit carefully and thoughtfully Ihat subjective world of his patients to ensure that he reall}' does approJ-l>'Spond smile, SCnse of humour, touching Ihe l'''ti<~1t in ~prropriate W~r!; and at appropri~te limes, allow hIS verbal me5.etwecn ses.s;ons. Th"y know, therdore, where to look for SUCC<'SS By m~king his own hypoth<=s explicit to himself he i5 fn~' to confirm or ceit'Ct what he disco,·ered. 150me people l"<.,<,lIy newr do k,>ow whHt they are trying to achieve with a jt'Chnique, so Ihey dOll't know they ha,"e already disproved a hypothesis which ",,,sn't explicit to themselves.) So Mr Maitland says \'Sing a technique ',b>owint; what you want it to do, while performillg it. Consider this m~5terly piece of reframing: 'the patient has l:>een a problem to get belt"r . the'" is a ",,,alth of information in that.' R"th<'r t!Wl falling into a pessimistic or negative way of thinkil1~, he decides to find out why" patient could Ix> H prob· lem, knowing thHt this very matt~"r '''Ucsts U\,lt wme spt.'Cial extra information is '"mb<>-dd~'<1' in the problem. H" is prep_aced to s<-'Ck 'illll'\·jdeoce', think of ',my o",tho<1' and pion......r the extension of concepts (oonsider the 'Slll111p' tt."t). The que,Iion for the teMher b<.'elJmes 'how would yo" P.lSS on to the student the information th~[ she needs about that kchmque ,lnn what il can do? Or for tlwstudent, 'What exactly is Mr Maitl~nd doing here?' 'How can I do it as well?
COl'l\mumc~tion
Thb book goesalonJ; ""y towards oKhM'\'ing these l,."Oals. You Cdn bUlId your .,~~ from \'OUr own lmowlcdge, and from Ihe wealth 0( Mt Maitland's ~rr,,~ ~Ild e"J".'ricn.:e ",pressed in these p;!~ \105t people COll5idcr th;It rommunk.lhon bet.......... P<-Wle who spe.,k the same langu.lg" is ~Imple. n.utine. automatic ,Uld unromplk.,tt.'d, 11"""".,r, C""" In norm,,1 household C(Hwcrs.ltions there arc man)' "lStann'S every day wh,.., misunderstand inKs occur Each of us has been ilwoh'ed, at one time or "'lOll",r, in ;l con""n;ahon wh,." he orshl.' fails to irnp.:lrl a pomt of vil....·, finding it difficult to put thought; inlO words. This lack of Slt<.'Ce§S can bo.o H''Y frnstratinJ:, f'i'rl101l.lrly if the otm.- J't""'i'lI' ha~ a di~t potnt of dew and ... 1Sh<5 to put it 10 \flU. Within a group 01 people,the tl1o....... ot a corwet".1Uon oftm cha.~ rarid~ a5 each pl.'fSOn leads the conH"I'S.Otion off at ~ partICular Ian-
""0
Kent
nus can orrur ju>t ;os easily
in c«Tlmunication
between only ,,",0 pooplc l\.ormal wn\t'fS.)tlon. thereis not as Mmpk and straightforward as mi~rht De thought Tht...... arc two inter\'iewing skills of whICh therapists ",ust he .. wan'; th,.,;,:, arc hl'aring/l"tening, and !l«tng/looking. Ther.'pists may well hedr whal the} f'''peet to heM rather than hs!<'ning to the words the palient uses TI,e foli"wing quotation is worthy of ,,-'«,.'(hng 10f>',
.•" "rl; 11••1;, r, lit... il
~(tJm'{ i5 il..:~',l'1{aJllr",
d;fknjrn'" """""Iy Mm.,~.
Hmri",<~'
JMI>
,,'t'o
li,lmm!< iklf' and br)(h Idng,mgc Looking (olJscn ingl b It....l1 a ,kill, tl",t i< where it dIffers frum merely ~ill!(, &'eing is pas.ivc, looking i. ,leli",', s.c... ing .. n.."It.,L looking is an ncqUifl..:l dl"ciplme
listo:r.mg a'ld obSCflI nlll'~
~rtlill
sLits in
corr,.,u~,,::,,~or
Do<:tcD, COUIl5elJor,o, phY~loth<....ap'st!i and fX"Ople 01 nutty other pron.~~l(lC1S "'110 an' I'l'qu,n..-..:I to und....• st.md t~ prnbk~ofth..~rp.ltienbr-.::I to appu""iate lhe ,ornplcnlies surrounding communkallon Clear, sucCl~ful comml.lni(ahon mav be difficult to achie..., It IS not so difficol:. howcn'r. 'when we d"""lop way, oflhinking aboot ",,,!Xt. ""d Ix-hadour, th,'tlwlpeach werd. word group M.d 1>el1a\ iuur to be d,,,,,,,,:kd ,'ttcntion tu one le\'" "f communication (tor c>;i\ITlplc "'I1Il'1lt, mNning"f "..,rdsjc.an be practIsed until. stl'P
b\' Stl.'P, "e Co1n denio" a hIgh Ie\-..-! c{ ,kdl in unCOV-
ering mearungs. l\'hom wt' Ic~ language ori!;inallr, we did in fact build It W{,n,l by word, grAdually incn..'.l used Any other k'"c! of comrnul1ic~tion can be studll.,j in tho: SAme ~tep-by-.;tcr m,,.,,,,,r. Whl'1l we have~kllls"tlwo I",ds, we can nlll(h mo", comfortably use the,~kilJs ~t lhe So'm" time or in sequences t" S('rve our goals of skilf,,1 and comfortable oonununication &.fl\'rts in comrnuni(ation, such as VIl)l;inia Satir and \-lilmn Ericl5on.. hJ,-o: spent th"',ISlI1'1;, (If hOUl" Ieamin~ ~ oML'n alion and by prachn', ct'OO6l1l8 ",O<'d< tl\oughliull.,. a.nd makmg mdll~ n",'tak~ (leis. llltlO) Theu'sua:..... dq:>enI'd II on ,-,.leo-tape or aU.-tlpe lind pl"y it b.\Ck tn ""r;o.'l."" ,md to c"""truetive pt'Cr5 or SUpt:'rI isms. SUlh ~ pritCtke can gh'e a 1>"'''1 oppm' h.mit,· for us tu notic,' the possibilitiL'" for understa"di,,/\ nnd for misunder::t.lnding our OW" ",,,rds and intonalion_ l1\c skill mll,1 be denlopl'd tn a high i",,'el if a r,1I'ent's rroblo'rn is to be understood ,,'ithout any d,'iall being mi£sed. SKIll In communk'allon is nect5,-;an' If . J to begi\..... to" paricnt•.., that an' I"Q!6ibility (>f being mISUnderstood "" il'0I-ded The ],eJ,rT\tng or tIus art or.J;,ii1 r'l"qu~ p.>t~ humiJdy. cllri'}- and .self--n1, Words, phrases and IIlI bon need to be cho«cn carciully wbton asking questIons to avoid bdnll mb.ufllkr~tood, ,lI'Id pdhents mllStbE' listened tQ can'tUlIy.., that the "...·,'nlng:;of the words the, use a", not ,,,,,,,ndet'5tood, WI",,, (ommu· I,icahon ;nistah-s do <xcu, dunng this I<wminl'; pn>cC'_, the phy"otherapist should 10<\k at h<~lf for the rnis!<,keand not blame the patient (fur tho:' purpo;;cs of (["nt'- throughout this book. the p{1y",OIho.._pist will be rclc.-...d 1rJ ,IS 'she' and thr.' patient as 'he1(her the yea , "",n'- c~rlooo~ baH' alJ1X"OrN INI dcplCl the probk of mffimunicalion. r,X~1\' 3,1 i> an
,,,,,lructions .......
e-,.n>llmt "nd ralMf c~ er example. II .. u...last t!uw'lines lh.Jt bear gte'lh51
:rio...! _""ulwrd ;~1k'l
l[>'tflI/ml'QII/!
",rvillg. tt~lnll Sl!ul"ws so lkldly ll',ml"lllwl tilt' IIrOllglir Olil/ "OjS hi III." mma'. '" il i, """"\'r lImed ill, '" 1i'/rll",1 til""'/!!. mil!! to II~ f"',1> of IIU' >II, ....
TillS ([mid 1/ dldll'l
~
rXI,r"",
1"~~ibJr tlml II,,·
25
26
MAITlAND'S VERTE8RAl MANIPUlATION
I know that you believe you understand what you think I said, but, I am not sure you realize that what you heard is not what I meant! !lfIS>i!lJr 11m! till' IlmlY'r's aU"Jlliilll 'l'IlS art",1'd by I,i. ,.,./1l:T ""'/~'flnt~", ur fro"'" of milld. 11 is <-"1UJlly "nport~nl IQ 'read. mark. Iellrn and inw~rdJy dig.est' the fi~llill'.~ ~Iso'
I tno3' lhal youhdll't\"yot.
Ihr ,n"Js:
undo-rsund WNI you lhink I saId
mOlJ-ds.rr"..' loop/mi.
~
fi.....' is IIta, ill f«1 ""'00
,1<>111I='1' undersl.,nd
wl",r is S
i~
liral wlral tl'e li5lmr'
II/inks is sma may. i" f"cl, lor si'g!ll!y dilfrrl'lll from whll/hos IIlYn :i
80tk verbal and non-verbal rnmponenl~ ~ltmUlts of communicalion ptocesscs
a,~
f'5sonli.1
n.e nO'1-,·<-"Ib.l1 component con.~~lS of the nuMIC~ of beh;o,iour tlwt must be ooscrwd and interpn!tl...t by the pn)'~'pistand.-d b\ her .... hen ~~ ~;ol.s to lIlO'patiFenL llIe ,erbal (QT1\ponenl =Jui= ~~,11 ,n lh<."choo!;ong o/bolh word. and phra-e; l(l formulal!:'"qucsoo.ns..
In
wmm~ry:
the chvice "",I "",mS"mc"t ofllH",I. III >I/cll 01111.'1 115 10 K'" arllJt'llllS ".\lIf;IIYIl5 p''''-';Ib/r wll
''''ltd ~"d "''''lllt(J/''rI'.
if vIII'
(So' En,CS/ euw<>rs, 1m)
Lst...UF~ is rtfrij, c1 roursum .". IhIll is m'trrr it II Jtr- mn'rlf/lwring, Htrtrmg IS / ; I~n""s dnnIlnih 1It1f'11lm. H,."ril1~ is rwUltnrJ, (;"fc""'K l$/ln .,.""in'd rf,snplmf' (11or ,,~, 21 "UI:""
1982)
L
uio;cipllllc
lG M~,'lanoJ" 11"10)
NON-VERBAL COMMUNICATION
",lJn'$l.llld lrlldl
"'" 11u,,! I ..Jd These words put bo:-fono: uS lWQ olm facl$. n.e first is tlwtt the person listening to ",hal is being said frequently dOCi NOT ~<:wratcly 1"''<1r whal is ho:;nll >aid, e\'en lhOtlgh he thinks he dot"'. Seoondl)', it 'S oft.,n NOT u,>Jcr>l"od nor hl!,'.p~l<-.J wrr.xIJy (WT Figure 3.2, lSi process). RrgrtrJm~
CommuniGllion mnslslS of both .-,-,·ertNl ;In
1lw fi",t aSJ"'C1 (If rommuoi""ion that muSI be Sl~ is lI'w l'IOn-"erb,1 or 'bod) Llnguage' aspect II ,s th., "'"" qrlll .11)11 of communicalion. llIe im""ct of "on",.,rbal ,ign"ls Is usu~lly stronger, quicker and mon: dil"t.'Ct Iha" Ill" impact of word~. The siJo;nals are fn.'(juently more inform~ti,"e than words, and howe the "d,·,\"I.lgeuf t.~nsm'lflllg m",~~ U a .u~S(i(>Us ref1e,( action before suffio...,enl lime ...........a!""-'O.l to (~the MI .....Qnk. llecal.lSt' non-\"erbal communi. (;otlon is reflex in !)'P" and tlwR"for-f, less easaly roolrotled. " an be toere arl' of course m.l1lY non_, erl>al S1gnal$ltlall\te consciously used by the ""lient and ",hid, uo not ah",ys ~g"-'" wIth tt'c;r 'Nbal ml'SMges. It is \'~"'y import~nll[l "olio' the "L'l'baland 1I\.lIl-,erbaJ mt.'SSage; logether and 10 be aware of ",hen IhL')' match (ClllIgrurory) and whm lhey don'l m~kh (in<:orl);.ucncy).
Communication
In any ""CI11 il is Imf'O"Jnl to respond 10 (and I\-"!>('Cll 1lOTI-1 commullIC,llJ0n5. To m.1 uS« of tJw p;olienl'S nnn-,"efb.11 mmmuni<:dliion, the rhr~iotherap~1 n«ds ll) tx· "CI1 ob5en'aTll, aIen and 1\.'(;"PIi,'e. Sheshould CDrl!tI:Iou~I, look allhe palM,nl from lhe bcgJmung.. so thai • bas", of In'~1 can be e, 10 be ~U'>pLCiolu of the new u.e.-"pi
t-ldlmS IhlS mighl ~ as ioIk'M-s.. 'It _~ tn.11 PI\-" "''''' tw"lml"'t>. ha\"(_"n'l be;..... ~I.K ces.sful Knowtnf: lhal, I would like rOll 10 I.ncm- lhal I ",-'«I rourhdp, fo,,'ol,l 10 JookdoslInw, e\"l~' Ihml9" Ihal }()U Ill"y fed M-e Im'lal or unimportant. Alsodon'l e>:~l a cure, or you "ill be dl>c 01 fa,luR'OS' \\!l1ot yN' an:: tl1en a.kin!' is the reasonabk ll.' patient'sroofidcr\(\! quickly and help him to n'C('I;",7.e her Cona'm for hi",. n... Inn" of ,'oice, lho. inlonallon and .."",oc:i.'I.-d fanal =rresSlon are abo COlr,por>ntlS of non-' erbaJ COD\DlWUCation that can be u5<'
Peop'" ha,e d,lf".....1 ~1Jt>es, ,j,if.. ~1 charadlTl$lJ(S, d,f~1 k"e'" of intdl e;~, and <0 on. During an inten jew wilh ~-......-pariffit, t!le' .....Olpllia· tin~ ph)'siodlO!1"p~t can
!us.. She should follow
ilda.rt her m:annensn." 10 ht paltems; she,J,ouW 001 tr\'
h~
c""n~ him 50 HUI Iw re5pOOds 10 her p.ltren\5. ~wa\'olnprt'S6:tlfthi:sa;;peetis IOsa~ thai the
10
patH:nt'~p«uliaritiessOOu.ldfonn t!le"romm! the ph~"SI<JIhe"'pl5t's p'-'CUhanne;;. It ~ inle"'Sl;nJ; 10 d'-0" w" came IV oue 0>' n Il'Tfl of p'-'t"ubJdtie< in a unique w,,~~ wilh many leaming~ trom mottK'f and falher as wdl as frum other people wllh ",hOnl we ha'e H, l..:L played aoo "'Or~l.,j. So 100. th" p.\li"nl, by .. differeol Hfe \oo.rtlC); ",'mc to his or her own p<'Culi,lntil'S_ Wh"n "e now ml'Ct, II tx'C()m,-'~ II task of SOme 1tnport,mcc to mo,,, into an "daptablc Pf"'itiOfl lhat fils comfortably wtlh Ihe patl""I',\ p<",ill<'n, IMlldl.r and Grindc, (19'5.1) call lhi. pnxl't<. '",,,tching "nd pacing' It could incl",t" ouch thing5as sitting with ,,,,,hC.ld at Ihe ~nll' ~"gle ", Ihe pallent's h""d (though not to
""t-
mimic them if lhel' ha'e an dCUI" 'wry "lock'), 10 ha"e ous MOOS io the SA"'" -uIll(' ...... ~ inttrprcting the palil>nt'~ nu.1rKe5 correct"', brcau"C' hL. rrame of n ~ ;" prol;>;lbl, qUite differenl from Ilt'~ 1'1150 <.he kl be ""-dre of het- o"n ,!.lb.' oi 1TIl'nt.l1 ..od php;ocal "'dl being.. becau",", il alfl'C1$ how she interprelS the p~tienrsrnm-,erbJlsign;lJ:, Whl'" "'-'Cl'$Silr),""Y po5Sible dS6ompliollSshe m..'y m..1k, 1'l'lJled Itl h~ nuance;, should be cLarified so lMI mi~interpt\'l.1liol1is avoided. Like" i5>e, if Ih...... is" disparity b.:lw ......... the '<'rnal and non·, mal m~s.1ges. th" CQfI'CC1 interpr<,lalioo nl.....:t, t"besoughl The p"lienl's faCial expn..",~ion an.! ey" m"v~ ",cnL, ", "el1.s l"g. foot, MOl ""d h •• nd movements "'" e~I",melv inform"ti,·" in pr,widlng SI'0ntano.'OlI, informalion. and the physiothl'f~pist ~h"uld tle alo.'fl ,md "'l'"rfX"'!o ",Ie'I''''. thC>oC me,;s.'g;,s. It was iol"r..-.Imf': 10 redd " nowlist \Isin!, tile words, 'His moulh Wb IVtl'at!l<'d wilh un,po!u.'ll langu,llS'" (Macdon.lld, l'li'tl)
l1>ere is much to be "'amed and arrre<'
.n the
"Il:''' of non-'·ero..l coounwue<>llOIl, and the A;' YO\I do "-"" an~lhjnK> srol~ and immedi"tel\' stand up ~I""W>. "II.m'. lk>pil" the P"-'C~lon of lhe inslruc\ton, il is common for a patient to bend huther and furthcr, fedm" mof'\' and moee discomfoet. During the bending fo""ard the i",henl tThly, 'lulle "n(()nsdou~lr. dl~play a ""f""erbal mess.lge such as bi.);inning to purse his lips. If this is5CL'Il br!ll<' physioth~rllpisLil will ~nllblc hee to $101' him bending iuelh"e, ",tum him t<> the npeight !X"'ili,>t' and ask him jf he fell an\' discomfml. She is then able 10 n~instruct him on th" neco.'SSity to 'STor', Ihus maJing the lest precise ~nd SAfe.
ta'"
".-hen
27
28
MAITLAND'S VERTEBRAL MANIPULATION
VERBAL COMMUNICATION n,.;:, prt:>Ce;S of obtaining a c1ea, pkturn of a ",'tb,!'" symptoms, "iU,." at an initi.1l cof\SullatiOfl or during Ih" course of t.....\11'r\('n1. dlt>ends vcry much upon suc,essful vcrb.,l m"",,unication. For some l"'Oplc ,')(pr~'SSing Iheir thought,com~~ oasily. while otl",-,rs ha"c dilficulty Howc"cr, commurUmtion skill"can be 1,,"!TI(!(i. Later in this chaph'r, examples of COrl\'c,sations betw""n a paliont and a phy,iothe,apiSI are gi"cn fo, thc pur!""" of lwlping thc physiothcrapislto learn the special communication skills n:.·qnir",:l fo, accuralo a.<;se:iSmeol In summary, i! is in'portanl to ,c"li,.o that the patient's responS<'S 10 qu<:stions will be modified bv h, lifel<~'g b.1ckgroond of e,pcrienccs _ thai is, hrs 'frame of ",fe",nce' will be diffe,,'nt from tlw physiother,'pisl'S, 01 .....l MI import.,nce is the f,xt Ihat th<.' physiotherapist's interp....IMion of the patient's sl.!em<.'nts will be influe'-w:ed bv her O\\,n 'f",me of refer" ence'. These comp""eols ;hould be borne in min<;\ throughoul e\'<.',y treatment ,.""S'O".
INTERVIEWING SKILLS Prol:>.1bly Ihe firsl requirement during inle',-;e"', with p"Iienl~ is lho,t the physiothe,.'pist should ".yin ron· Irol of Ih" inte'Yie-ov 8l "lItim~'S. nus is difficult will, Ill<> garrulous patient. However, Ihe gar,-"lo,,5 pllti,,,,! readily ",ve,,]s all of his problems, wher\,as il Can be extremely difficult to draw out from Ihe " ..I ire"t pal"ml all the information Ihatlllily be f<'
The stop could be called a 'dis,uption', alld this can be achieHxl by saying 'I'm serry, but whalln~'Cd 10 k""w is ',naming th~ la5\ sllbj<.'C1 you w<'re foUo",ing. or 'I was int<'n'SINJ 10 h,,1' ~bout X, rould you Iell me more abOn! thai point?', 0' 'I'd I;ke you to remembe, this mallerY, but may 1 come back 10 il after I ma!ct th.1t the patienl nUlY like 10 relum loindu"couTS<'. Another app",",ch is lo"llow the patient to say >om" of wh.11 he wish£.'!; 10 say ",h.l" lhe physiotherapist
continu"" 10 shuw an int~rcst. but when it is ob"ious that helpful sponl.:mcous infonu.lllon is "ot fort!""'111ing. sh~ may interpose a question at a \'olum" slightly grNter Ih"n his, whil<.' al"" invoking non-verbal 1<'Chniqucs such as rai''''g a h"nd, or t(l(lchillg his ann just befnre starting 10 ask lwr qUl'Stirm. TIlis lends to int<.·rrupt his t,,,in of thought. .,nd mmns the qlJ(.~liOll can be a,k~xl without the n.,•.xi lor a calculated incrca,., in \oh,m<'. nl<' ",ar,ipulati,,~ ph}'siotl,.,rapisl. in pa,tiClII,,,, JVpeatedly use; the stro(lgl'St form of 110'l-\'l't"b.11 communicatiOfl, "'hich is 'Iouch'. n,., .....·ticent ""tient n~..-..ds 10 be kindly told Ihat it SC('ms II<' finds it hard 10 talk about hi, romplaints but it ;","'C<'S.",;ry for him todoSQ. Heshould ber<.'as""red IhM heisnotromplaining but rather Ihatheis informing. and that what he docs no/lcll her, ,he will nC\-er know. To bain the most (lut of an interview with a pati~'fIt, Ihe physiolherapist should Iry to 'fffl' lhe kind of problem the p,lI;enl h~s; she should put h"""U 'in his shoes', so 10 speak. and lel;t be secn thai she underst.,nds his plight. She should show thai sl1e takes him his word, "ven if she has doubts. Her facial expression and the quality of her voi"" should eng,~,dcr confidence and show empalhy. There.", many ways in ,,'hich Ihe phy.iothcrapisl c.n modify the qUl'"5Iiom; she needs 10 ask 10 make Ih~m "",i'-T for til<> ",'ti<>nt 10 unde.-stand, Ihu, makiSp""d more accuratdy. As dn ex,,'uplc, durin b an ,nle,,'iew it" i,np<.>rtanllo"~ti,e I'"/ifill', Illllgllng< whcne-o'", possible, even pronouncing words as he doc'S wheth", it is corr<.'Ct PfOl1UJlC~'\ion Or nut as this makes lhings that arc said Or a"l<ed much cJ"arcr, ",,,ie' and quid"",,, for him to ull..t"r:;tand, No question th.;",fo,e should con lain I<'cl1l1icaJ terms, and w" n~~ to walch for a puzzled look, slightly dilating pupils, ro,'ing ~)"cs 0' "Ilel'l.'ll fad.11 cxprcssion, a" indiCaliof\Sof th~ Pi,lient's 5eorching fo, a m~Jning_ It is import.",t to rcmembt
0'
l. ¥'.,kslowly.
2 Speak deJiber~tdy. 3, 4.
Keep
'lu~>Stions
,hort.
",I< only one quesh(}I1
~I
a lime.
Each of Ihese aspects m.,kes it easier for the palle"l to ans"'e, questions a<curntely, II is important always to !x-a, in mind that Ihe patienl is in unfamiliar sur· roundings, lIfld that his =mplailll is his all-pervading thought.lf quc'Stioosarc long and "wkwatd, Ihewotds mav jusl encroach on his mind rather than mal<e an imP~ct. Thi, may lead 10 Ihe imp()rl of the qUl'slion being lost. At .m initial inlen'i""" il is natural for a pati~nt to ha\'e a strong d~'Si", to expl"in all aspt.'ClS of hi;; problem
Communicat'on
thaI liE belil.··..l'5 om.' iInporttnt. Tht.""*""', ~5lw:>uld "" S"en a R'.:l5ONbly fn.>o> hand 10 l!XJIre;5 IheoIe ~ Ho....... ,.... ill no slap> should IJw, in~ bot- .illowed 10 S;.'1 oul ci Mnd. By aIJo".·in)j the patiml il dcgn.., of rontrol...>d Ial'tudf.>, IN ph,...JOlher-olpblcan Jooam mud> aboullhe pat>enl iba p"-"'fS(II\ ~ ......1as I'lis problem For CXilUIflk-. the mantW!l" in which the I"'hcont milk... his iruliaI5pO!11<ml'olls Olfflmenls aboul hI» problem leIb thc l>xamllll... lilt' n-lah\"f IITlpot"tilrlre he plil(l"S on eddt of lilt- Face., of his problem For .,,~mpk, illwO P.~timb
arc
tllklllfl aboul lheir shoulder prubk>ms, one patient may thot hi,; ~lTIl i. too .lillto tuck the b~ck 01 hi> shilt into his trousers, while the other may Sen15 alone, it i,; likely lNt each of th""", IWO p;.tient:; wili ""'lui'" difl,,~t t"',lt:rnent Such milial sponlalll'OUs comments wilt &how the pall,",,!'s athtude oowards Jill. prob~. and 1l1oI" abo indicat., h;" 'I'""n thN'Shold'
""r
acceplan(e
Who:on a pallent is respondmg. toa quesl1on, he mil, include in his reply a comment O\Itside the 5COpl"nlthe q~bOn-Fort=mple,""ma} hil.\e~asLro·\\"hen
did the s}mptOllb bt'ginr', and ,n his noply he nu~ ha\l'lOCludo.-d lhc comment !hil! he had chang<"! job<. H" must ",,\·.. Iud """'" """"'" lor !>a~mg thlS_ Pt.'1haJ" the 'ch,1ngmgnljul:": IS A"l~Io.>d ,nsome 'yay loa chang..
One ,en- important element of the inil1al inh.'1'\'leW is inslsht it pron.J..... mlo the lind nl p'. ....... lho.' pabenl is, for this gUld<:s the ph.-siotherapi,1 as to how I" conduct !he f'eIIWnd"" of IIx: Inten lew. Bv lhe O!fld of tM inlen-;"w, thO' ph~"lioIm3pi.>t should be abk-Io milU. a ..,.",....."ble judgemt't>I.os to !hep.... en... ~<,
w
blht~
"oct creclibltit}.
WORDING SKillS PARALLEllNG TIllS h~s 1x'cn !ouchi'd upon on page 28. and it is (Mlly It:,'mt b,· e>.per"mce. \\'h~l ... lIW~nt is this. W~ a
p.>llcnt is talking "ben,. ~n asp<.'Ct oi his probk'fll, his mind is running along a spL..-i(M: line of thought. II ... hkel\ that, along th,~ spoe.;ifk iiflO.' of thought, he could hal'e mo~ th.m one he' wi5h"llIO ""P"""" _ in f,,", there could be thfI.c or fou' p('lnts. To Ink>nupt hun m,l\' rna\"<' him ..,.,., h~ pbo.- in hl5 .tOO\ ~, unb \"l.'U. the therapist. Are in dAngt-r nl \oslng)""" p\.lre, 00 no! stop him (unb he to']U'>l rambling on), N'C
roml
m hiss}'mploms. n... physi"'ho!rapilt e...-fOI'\'
interpose the queslion,'Oo yo<, ,etale tlut to the onset of yo"r symplom.?' and tll"n follow with 'Whe" "',," tll.I?'. At Ihat momenl in the .;;"Iog"e, the p~ti~."t's thou!!lu P'<X~'$C5 cenl", un the chang" III jobs. Jf the
appmpri~te,
~bo"l'
alq ....
question i' interposed at Ihll stage, the ,,"-,wer will bt: more accurate and "'ill be mad" m(11'\' quidl:than if the patient is ~lIow,od to ronhnue taiking. ch""glllg h" tram of thought Con\e,..,.,l}", if the question is lefl until a later staS" the p:u:iel11 "lit h.l\e to start afl'Kh to re-onentall' hi:< thinking before he can ~p1y This takes extra hmt'. an.J thoughls thai might h;a,e been 'OIl !hi' tip of h.>; lOnl3tW' to mention ma~ ....tonu~.... ~ bot Io5t Th.- skill of malung use of the P.11io:'nt·S I "" of thought i>. 'mmerbl'ly ulual>k. lbe only dan#!" w,:h ~ teduuque 1M'S in losing one', OO<.'n tram of thoughL This p1r1lliel''',-,:of 'l"""lions with ~ p;th~"rs rnomtat p"""""'-'S to' an important skill 10
den,lop. When II quO"Soon i, appanmUv m,sunderstood, ,I", p/'!I"'.n!lrmp,Jr.mfd blank I,"",'if, not tho- patient, for the Comnlurucalion error; she should nOle the mi5unde~taoding ~nd lI~c1< it "'.g_ by rl!phraslng Ihe quest;Ol1, if n,'CO!SSrapisl could !!./Or, 'I'm SOtr~', wh.~t I rNlly meant wos, did so "rId 50 "tc.?', II is Ihl, 1'1"(1((>51, of self..:ritici>.m lhat '" ou, be,t t"ach<-r,
BIAS While the method dcscrib<:d II"", In,') som"tln"'" be it is importanl for the thl'rapist to he
thal·
1. Som" peopte ~re '·ery 0iX'n to .uggC'S(ion 2, So",,, p.,opte Are "e~' opposed to sugge:;tion.
Thl.-", '" a ~ItiU irlleam1ng WhL'Tlto use any particula' .1\ Ie of question - 'A hme to use it and 3 time n;)l to
usei" Tl\ion> ..... skiJs in ~ wonhng nl q..-tiQn" th.al the pb.'JO!herapbt shouki Jearn il ' ~ ' is to bt ~ 10 'Is maximum dlcel The first of thoe:\le is that. unJ.:0s6 (are is tal.en to pI'e\"ef11 ,t.the pf1~henrPlSt'S qut."1I01\S 'nll probabh hI".,.l blas_ II is mo:o;t impor_ tant that question. .hould nor bo:' b"lSt'd in any .. ay tuwards the MIS"'" koped for_ I" fact,!Ius .tatement (an be carri fl.rtht>r- if lhe physioth<'Tapist is hoping for a 'yes' aflSwer to a p.:1r1lcula' que..hon, aS5l5Sm.. nt i. bett"r ""Tn"l if the 'lu,><;tion is \\onJC\J "" that it is biased toward, a '1'1)' ~nswer, for example, when a palient ,wends for lilt.> third In:atmenl and Ih" ph~~i{llh",apisl is hop"'~ tt",t 11<.' wilt hal'e ,h"wn some ,ulJj<'cti, ~ ;.mpro.·cml'llt, ,hecould ask him, 'Did m.· la~t t"'.llmenl m"k you WOT!lt' in any ,,~y?'. This
29
30
MAITLAND'S VERTEBRAL MANIPULATION
... iU mfh...>,,« the pallo.'Ill l<' ""'> >OlJlething Jilc, 1\0, ..."",1 not much "n\'wa)" To ilSl:, 'Are you feeling ilny Ire~tmmP' ""ll innuenre hIm (esp«ioJlly if !he C""'~ .ut' mlllllT... l) to" anh !>il\ Ulg.. '¥L", ltwnk ~·ou.l Uun!. t am', ra~ than giving ho-. the n>QS1 in'port.:mt mfo;>f11'Uhon rontained in !he fil'Sf n.~, 'No, w"ll not" much ;m~-w.. )~
bt.'ttl.'l" frofP the Last
or he USl'Sa ",ord, such as ~turdav', "'h,ch mU$tha... e bl'O.'Il stdled for a rc.uon. The rN5OI\ ;;hould be sought wrule ,tlSshU fresh m tl'M'p"lient·smind. To follow lhe p.olio:nt's Ii"" ofthoooght b iI b. policy than following one'~ 0\,,, l,"",of thought-
""It.. .
S~mrn;lrv of ~w'Y~w,ng >lills;
lklain conlto! of 1M int.rv_ ~;m.u.~ lilt p;lI,mll~allh. il'lfol"1lallon g,....n is
BREVITY WhL'fl ~sking qut."hOl1> and ~'ponding 10" p.~tOenl" ,mswc'S, the nlimber of ind"'idual words used b)" the manip"lati\"e physiothcr,1piSI ShOllld be kept hJ ,m absolllle minimll"'. 11,i5 i1"(lJds ronfus,on in the mind <>f tho.· P.,hl'fll and miSUlldcl"Standmg.. and it also «.'n,;o....... ~ time. Ilo"eo.·~, ...·hen using ron'('1'S<'tioo 10 establish rapport" ,Ih a 1'-1tl('nl any numb." of "ords can be ..,;cd, ,md the, should be arromJ'dnlCd bv p"'-'O'ly of plc.... ng ~I SJgm'. Oflm .. ";nglc .... l>Td Can a51: II question ad"'twrely, lind th.ol """,,,,"ord1\"'11 nnt (Irll\' 53'·e hlTM'in a,,1J~ the question, bu! will .. I~ ha!otm the answ~ becaUSl.' the p.'tit.~I's thinkIng ~ are thrust imo Ill.> quick answct"~iIUdtion.For~mple, if a p.:tlieIl.! has >aid Ih.1t the polin 1IJ"'l'00s ~~ both ~ica""," .. (!'"'UbC)?' 'Be<:au.., the pain in my bacl: w<>5 killin"m,,: Thi' isstillnvt a mmpan...1t1, ...,asl<. 'Is that the sam... ~ u",,,,1 [If won;e Ihan "6,~,1?".
im~r!anl!O Ih~ ph~sioth~rapSl
Us. tht pat,~nrs languag. and words ",h~n~r po<sibl. Sjxa' slowly ~k d.'ib.ral.'y [(r"p qJ"lions loon Asi only or~ ql>61 on al a I,,,," Allow spontant:OOts ;~furrn;lhon, ~ I~;S may rtYtal ,.,..m aboo.t Ih ~lress upcri!:r.c. of til. pa~rl Usc para dir>g sk,' IS Be: a"""~ II a I ti-s of po55ibI~ ~ ,n tilt
non-,
SPONTANEOUS INFORMATION Another important - III ~uch ......). as 10 pro\'ldL' OJ'i"O'"I"ni!ies foe spo comment is far more \'a1uable Ih.1n a dlroct ilR§...."t'1" to a dill'ct quo.~tion. Th,s IS becaUSO' It pl'O\idcs quahl\- 10 theans.....,.,. gi\L'f\. The qu.lIit)" is of the I:ind Ityl prov,des an ln~ighllnlo lhe patient'~ pcNOt'Ia.!t1J1. hIS "bili" to aco-pl (or not accept) his symptoms, ... hile also pUllinS his symplOO"l~ in a mnl"d thai I~ COrrL",1 for him 15ft' pp. 28 "nd 36),
KEYWORDS J~n.lll}·.
a patient's an~"'er lu a que.,hOll 011~'Il includes a pI..""" U\31 l"'luin.'l; "n i",,,,~dlill"fuJl{I~>-,'I' qur:.:itm,
romrrlOll1C3llO/l ~
Usc 'mlbad. loops fur dlmlOhon and ck..... mdmt;ondillg
ERRORS IN VERBAL COMMUNICATION Thai JX'Opl" run into d.Fr"""'IJlties of misund"l"OliInding is indisputable, but thl' whole SUbjL'("t is 1'\',,11)" much easier to undersl.lI>d whl'll we examine Ihe 1,.,1Iow;rtS id~a:
11", wap i'!101 tit( U"ilQry till,! Ih<- '1a~""" mlt 11K' 11111110:,111",01. (ll.'k"'''',I':18:1) \"''hat this ....ally means is th.tl a thought is a reprtSel\tdlion of <.om(" e~",-'rnaJ tlung (,"1:5ua.I, lIudilory or ku..-.tlll-otic). A mIIp of Adelaid<' is .. rep...-sc.-nUII(ln of Adelaide - it is not actwlly Add.lId..... but mo.-my .. coding of some dat,-, .. bout AdeL1id<'. TIv Illform.1lion in a hum.'" ,"11'1(1 It; such .. map (or II\CIfl1~ a pem:v"nn. I\.,lmms is always dassii);ng, lind mapplflg 's L"OiClltialJy the ~me as ""1mlllg llte ne>.1 ,;t..1poinl is that people opemleoul of llxoor internal maps (modL'is) 11<11 nut "I ditl.'Ct SCllSOt}"expt'rience. The)" G\Il ol1ly make ",n;., of new in/ormalion by compMing it wilh whilt Ih,,}" ~lready COdl'li. Since people code their informati..,n at dill"1'\'111 t,m.,,; and in different ways, Ih,,)" lend to ha,., Id~ link",) Iot;.-thc. ill Ihcir O\\'n indiHdual ,,"ay~.
1\.",,,
Communication
People (uneOf1>eiously) rdrie"e information from Iheir minds whL'Il they he", words, and communicalors rwed to check what the "'-Xl''''er acc""ses (",tril'Ves), The retrieving is calkxl 'a transdl'ri""tio"al ""arch' by lk",Jler ""d Grinder (1975b), i.e. thc person mak"" a derivation thrm'gh a sear look al lhis in I~ context of a physiothempist carrying aul an inte"'iew. The words thai she U5<-'S an! a way of repreoentin,; what she is thinking. By understanding the possibility of using 'unspccifil>d S<'arch la"guage' or 'increasingly spL'<:ified ""arch langu~g"', the physiotheupist gains great power i" choosing ,,"olds "'dl dnd devdaping modifier 'luestions as "~ enq",rl's further in the ",,~rch for mL~111ing r'OlIowing gencral introdudory remarks would corne the pre><:nting complaint, "hich allows the physiotherapist to he'" an 'unL>(hted' expression of the probl"m,1t is here that the physiotherapist can greatly increase he.r own skill to obl~i11 an accurate tr~nsfer of inform"tion from the pMienlt" herself. lhe pnxe" could be calif;(! inlerp"'tation.. but it alw~ys depL'Ilds upon accurate checking with the patient to confirm that "he h.1s th" right mcaning, This is ,1 f,,,,,xlb.:lck loop, W,II'OIII f;ed/>rlck Imps, (omwHrlim-
liO'I h(liI'l.'rPl peoplr :IWIJd "" al II""" rist of bemg ,,'ry i"oCCllrnl,'. This also mmllS tlhlt the hNrnr is really a",,,,,, of the danger of making assumptions. There"'" mam' identifiable"'\!Js wh"n' mistak~'S in ""rbal «,mmunk"ation can and do occur They <xcur io thc physioHlCrapisl's thinking SUTTOlUldiI'8 the ",king of the question, io the word. lOSed when asking the 'lueslion, and then In the way in which the palient heMS ami interprets what i, said. The "rror, ill!: further multIplied by the patient', thmking proceost.'S in preparing his respon..." and'" the words he Ihl'n uses, Fir1aUy, mistak,~(}(cur in the ph"siotherapist's thoughl processes in inlerpreting the patient's answer to her questioo. Fig"'" 3.2 sl10ws lhe,"" are;1S for mislake., in an L'Xample where one qUL'Stion is asked bv the physiotherapist, answe"xl b,· the pot;enl and then int"rprett'd by Ihe physioth=pist Th"'" arc th"", m~;n "rea" "lwre ph~siotherapists make mi,tah'S during an ink,,·iew. The first is not expre,;,;ing Iheir thoughts clearly, as in the ditty '",hat you he patient and the intonation used may be quit(' ml,leading, The5<' factor,;, Iherdo"', a", ~"'~s ,,·ith which tn.. ex~mincr 1l.1S to t~k(' th.. gl""atL'St ca,e, It is wiser to confirm the meanmg with" patient than to IN it pass, This 'C011firmin!\' is a f"-'quenl rl'quin.'men!. nut ~ rarity.
'fhere are very many influences tllat lie behind the way n patient expJ'l'''ses him""lf and, although it is impossiblc t" identif)' all of th"", he"" some common on~ nl~'CltCl be mcnlio"'-xl.
MISI NTERF'R ETI NG !'irsl, if " patient hilS a hil;h pilin tolerance h,' will,,,e weak words \\ hen expressing the level or grade "f hi" di,ord.,,-, ",,"miner will make an error of judg~~ meotif ,he has no! pkl pain HIIi" I",i', lol..,.u",-e In\ oh'~ multlple factors, e,!/;, culture, pt.",r !¥Oup eXp«:lations, ~nd the reason for playing a symptom or point of th" problem up ordCl,,"o Lo'" I""" 101e11l1lc<' is agnin mulhl~ct'-"I"l, aod ttl\< p'ltienl may uS(' exrr,\\,a/iant language ,"ch ~s '<'x~r,, cialin!l' and 'agonizing', Th,> word, m,1y COI"'C\-, tile p"vchological impact of injury upon the palient, or his nC<.'d to impress othlTS "ilh the '""riousn~'Ss' and <;hange in his lifestyle con· s<-'quent upon tI,,,, injury. Alternati' ely. the p"lient m"y be wantinl': to tx' Sure Ihat Ihe phrsiotherapist will be gentle in Ihe examinnno11, as""-ss":',,nl and Irl'i1lmL~,t Some olltsidc is''Ul'Ssuch a" an lI\surJl1cecla,m may alter the dL'gree to which th,' s)"mpt"m is prcscnt~'<1 either psychologically 'If somalically, CtlllSt.'io""ly or IJt>CO'lsciously. The physiotherapJs! ",-",d, to rccog"ize and underslaod thai people always hit"e rea,ons. COnscious or un",n";;o",,, ph;sicdl or psychological, lor th"ir eX;let mode 01 pn'SCnlalion, ,,,.d Ihal it expr~'SSeS a certain need. The physiotheropisl should therefon' never be critical of the \Vd\''' patient pR'S<'lllo, The, cry 1'n.~nl.1ti()" il""/f is;l me"sage, n~-'eding to be d~'Co,kd just a. much o' the ot~r findings that thr history and ex<1rninntino' rewal Secondly, a p.lticl1t may be reticent in t"lk,n,; ~boul hi" symptom", e'·en though they are ""lficiCl'tly restricting for him to be "-,,,king tr"atment. It is extTemely "asy 10 misi"terpn~ thew, erily of the disorder if this aspect of the patieni'. character is nol p<.'l'ce;wd, When il i~ perceived the physiotherapist should guide him to talk ~bout his ,;ymptoms, eXplallllll); Ih,lt wilhout his c'Hlperatian ""ors of illterpret~tion wi[[ occur and important infomwtion may be mis""d Thirdly, when a p"ti""t is not fluent io th,> language of the phy"iotherapist, hi, only means of exp"",-,ing
11,,,
31
32
MAITLAND'S VERTEBRAL MANIPULATION
Thor.pi.l 10111'''." Ttl' REI&l~ SHIN) Tl-E OV:STION WHfCN IS
.-
TOBEASKED
Tnol.JrlJa""""'e"",'holie''''_rT>J
E~,
~ng.~"'''il'''"ft<;iorn_c.II>rJIld_ \~"'!Pdo "'-pro<" nlorrnoberlre<11l'.oe
2ndproo.,..
),011'_" HEARl>G I
\\,ORDINOffiE QUESTUI T"'eror<x:ccn""'"'tM~""~"'"'"""CIOOSrot ,;,,:,.tyBl<~r""I1lI~_."need>lok_
T'o,,"""''''"'''''''ottl;s .......
1~_or"""'rr~l>o"l4>d""'''''
....
_000<
rot
1. \\I1,,, ... , ... oI!1en moy tie _odl'OlI)'h
............"ID
c E~,
""p,",*,. CON3:DERNGffloREPlY
ll+:>-Mthol"""""' .. _"'hOlJ(j'I..,.tnIt~~ =pto;nt",,,...,._dillrlOlYJlreao«1llfoJr,,,, _~"" r_ ,,_ at !he P'1"i<Jt'1e-rOpOl AWl "" rfIemOI'/oI(iI
_'ioo ","l'be~or olOCW'~ 6ti1prt1
f£MUNG Io.~D UIIJERSTANIllNG THE WORDS USEOtlTllE PATE'ff3A.'1S\',\;R F'o:.rr.'ml)'
".dfl".,c,,"""Os""'
to_'ldparllctAoo1y""""OOocrb
'llicul'
.",.,...
Ttl<""""lIn ........,.", ,no mt¥<T:>.
-,
''''''J
Tt~pr.-.
.
INTERffiETING TIH, AN,I'iER
""IO_"'"
~_oIft~~<1oo'''''
polienl'••~ _ I
.....~tJo
"_oNl(OI'It:ofhf<",,oo;<>.>:Inghor .. ~ ...j~oI!'erJlll'~oI>fT"'~rmj OO'/I"VIglt/JII....-.rotoorhd
Ithpr.-. RHATIW THE A'lS\\{R TO T!'E QI,IESTIOf'/ ~N~""",I''''''palIer(s,., __ .. ~",.oilt..~_"lacll_"",t'"
"""••eopenlO mI.oremn
Error MIlprou..
DHERl.!lt\'I't..,."e41>Cie'llkroo~"".·~mlO_'"
lr>lq,.."'n.....po:iJ'o'eoltht.e
~.tIJo"""""Cl>oro.·ror~'>fs9hp-oco>.
Ellor
5thjll"••" PUTTINGTI1EI\.'IS\\t:RINTO\\'CJR()$ r.tra,stot.t>o<-g>tslt'01.tO"oc......-.gtt-.e,JeS,"" ~.,W<>r>:l." """dI:IoJI1lort>op.
......
'
Error
Communication ho><' b.>d his
"""h nllil~'S ofbo:h.1,'iour olJe ""mph' ~Ihodsofnon' v""",1 oommuniC"ahon, wh'ch "ru eXill:<;"••lleJ when v"rb,ll commonication is difficult. B.·c,,,,.~ il is 5<1''<1,1; 1<1 MlSluJl:t" III<' p;;limrsJ"a~,III1;, JIlt' /JJ'.lfSItienl'. ""hni<: background ,nnU<'fln"i Ih" manJM>ri~"",hl' 3dopl~ on ~"'p ...." "inl; h~ problem. Pmple from som.. counlr;('l; are hardy and tOI,gh, wh,l.;· In oth~.. counlri..,!hl'y "", .. xp<-"CloI<1Iogrnan and 00' \\'h'k>thc"hoI.o family fIodsolroUnd lohclp "',Ih dre;slO,i;. "'ol.l\;ang.l"t(. n.. ph~~r.p~ ",-'O"(h lObe \<'ry a"ilreof lho...... ethlllccha .....t"ristics 1<>""Old misinterpreting Ih .. ,·",bill ,1I1d non·n-rb.,1 m~s,l);~'S. F,fthl~; 'I. IS (l;lI,\' lo nti~judg.. (or inlerpll't wmnsJr) lhe expf"CS6,lOrl of a paliml5 disolt>ilil'l \\ hen filctors such"" Lligatioll, f.o.nuly or 'lOcial situ.,ricJrI>.. or fiMn_ ~l prol:>lems an: in\'oh~'d. II '" ''''l0ally msy 10 01'''' )udlo;" tlw inn"en"e of a p,'lk]1t'~ psych,-, To,wn,d ~llch a.>mmunt<:ation mL'I"les lhe "".,nin". shnuld };,.-e!he pal"'nl the bt. fit of an, doubt. al 1t>asl until II is p."'en llut,. f...mp~. the emotion.l.l elemcnt is a m"ior f"'lor III thc P"""'slenc.. of h... ~pnptoo",. FIl,."lllcntly s,,~h judgement"; ~Oln only be made (and perhaps .'/"'111,1 0111> be mOld,,) in 'l.'tnlSpl'("t. It i" i"t"r. esting th.11 M,I..... (1978) makcs lhe "ta!emenl thai the
"mll-
fta' of find'ng 0IIt loOmtI"ung is stroously wrong, or a 0 ~Ik fo' tb:' ",nloat and as50CQted proftsSoOrls ha~raltft:au"" of difficult V<:'b.-.I communic~tiGn CJltulal difft,tnc"" Known ~I or psychologIcal probItrftl; llolt--siclnl focus on tilt
me ,mp~tI\tflt of symptoms Th. ,ndlV1dual ,llntsS tllp~lltncc
'<:'11)
pa~1
(his ,11"."",,1 'IS moocenl ur\W pW\cd gmhy·.
S,xlhl~'. WIne p.illents will onl,. commenl on lhe symptoms thaI ll,.'II1a'n and do I1"t comml..,t <.HI
phY>;lOthc.-..p,,,t can St.""- lht'po<,I;\'" ",Joe of~SI'm~ lomallc chdn6C5 r.alh.. r than acwptm.-; P,il}. S"ch ~ pali,.,,! h.l.5 rom.. 10 'K~<'Pt a Cl'rMin amount of d'!KomtwI a~ t>c"'8 nom,a) ""d tim" "h"'1 ~liblllg his p.-.."t pmbk'lll. he b [,""1, lo ....p.."", .II 1_·.... deg~ l'f ..,,\-mty-{ordbablhl\·) lhan "oold be ..xpn--...-d b\ " palit..... I" ith Ihc .sam.. pain bul w!'Io is no.m.,II" symptom-free.
t"'"
"I. ,'....
Mis IIwprnaticrl of In irlforl'l31JOn ~ poudIlt' dt.t' 10 • o.ffe~n~ in 'Id'vidLJa) plI'~ II(ttp~~t't ... ~ich may I~ to diff",tnt ~tbal and non-vt'~al p'.",nlalions of tht pain • A ~tict~t pat,t~t, i.l:'. Illt paftnt who is u~w'l '''19 to ......a a ,rt'tvint irformatio-l clut to SIOiciIno
THE REASON BEHIND THE QUESTION Dunng the learning std~ of .'..Lng palifflts questions "nd mt<.'rp!l"bng their "n,<;Wer'lI. It is difficult to know' ",iIe", lo sl.tr1. a.... certa,n questions lh.,t 11.1"" h. l>e Jsked 10 "'"id 'til" fiIl~W of lOCKlig""Cl" b"mj; polnt<'d "I lhe th.'r.lplSl q"'''''.....''' "bOUI dil..... ,~ in pollit,"!'. " ilh cen ical disordO'TS, fQ- e>.ample. or tho< pur.",b,h!} {If ('•• uda "'1uina on, ohcment in lumb;or disol>rd~ II is n.·~ 10 ~sk "bout th" dl<.'d of n.."t:md activities. of sitti of i;<.'lting up from a ch.lir "ft,'T s,ltin~ fo< n.llr Oln hour. Or theetfr>cts of coughing.. sncc:r.ill~ and deep in,.pu-abon,l'tc, BUT du!he tho.'f.1pisb .1"'d)'S "-now Ihe "-'olsOOl> behind rt- q....",.,on...l And do the)' know whal I"do w,th an JIIOj"l'T """'-'Ihn' g<.'1 un<:' En "Ih,,, "orti,. lhey h",e to l.."rn the reasons behinJ 111l' questiom Cl'ttilinl~ ttK:' ("an be I"ught """",oilhe Il,.". 5OIlS. lUlder somecirrum,.tJ~bul r>uI ,,, ,"1"\' {irrum_ "r.lncccant'<'cO\<'m.i. "Jlu,; ....... ...,tof,,'"'m~'UCdhon (S<'\' F'gun> ~.2. lst pmr......) is pmb"blv Ih" k£,\' to mod of pal"-'nls w,th low [umNr problems l~. 'How dOo.':> 'I f..... ,.,hen )OU firsl "dkl'f\ In t...... mornmg b<-ior.. ,"ou gl1 oul of bed?", foJ. l".'wd b)'.· And how doc'S it fccl Whl'll you first l).. t 0,,1 Of ~ m :h" mornmg~·. Th.. for askin!: the first qaesuon IS that me theT"pist l\('('(j,s lo Imo... "'heIhcr prolonged rest ~ t~ s>mptoms "JrnPiln.'d ,,-,lh shorl-tenn and "Iso 10 know "hdho... Ih"I"'b""l IS ",lken<:'
Tho,..".
"v
"'' ,<;(\0
"'"t.
L \,....... hc ch.ln8fl position in bed j,uch t i tumin/; trom l~ "'gon ones,d,'lo lhe ulh..../ .... ft.""Is" "h,'TV Iw'nge uf pam ~J \\'h,,~dOl... n.,ftooelit~ b) Dol-'s he "'-'l"J lo ha,·t been in bed for a subs~. Ii"E period of tune befol'e this oc:a..rs,. or does 'I
l3
34
MAITLANO'S VERTEBRAL MANIPULATION
occur if he chan!,'l.'S ~ition almost as soon ,'5 he lies down? c) Does lhe " . ' . di5.Jppearquickly without gt"l'
ling any "-on;(.' throughout the n.ighl?This wttCT "-"'POn5e ind'C,lt.,,; that the physical ~amina tion should be able t() dctcrmin" the provoking jlOSJllon and mo,'ement. In t~atm""t it will be ttu~ po5lbon oi the p"tK.'n1 and 1hi5 mO\-emeru by the l!lerapt:>t ..·hieh ,,;11 prob..bl\ be US«! as the IfCatment h:!o:hnique 2_ H" ITJ.1Y be wakent'li by 'Ill ulC....i\SI.'ll intens,ty of the aclung. suWlCienlly few him to hd'"" to get out of bed dnd ...;ill:; around un"l tt... ~ aching subsides. If the therap'~! OOES I.. the ~ason bdund lhe qu<'Stion. h:ls !>he g<>t tlx> answ"r' f\'l! So. not ha~",S the answer bas<'d on h<:r r<:"soning, wh"t ~hould she do? The thin,!; she should NOT do i!> ""lie, e thai 'e, 'J:)oe, the ""-me thin" haplX'n if \,ou lieon Ihe "th,,, side·. If the aru;wer is 'NO·. that is; hccan lie on I""other sid.. withoul any problems, th.-n il;" likely tI) be a po5l11onal factor. If it ~ the position that i:; lhe C<'lUSll", fher, til<' ph}5lCal ex.am"",tion will """eal the mO\<'Jnt'nls in ~in ~ilinns thm pl'O\oke and ~ the symptoms. For treat",enl, whether the SyrnptoIlb need I'TO\'lIk,ng or n<--paralE' decision thaI is maations. HmH"\<'I". if the a"'Wel" IS that ,I makes nod,ffl.",""e how he h{";- h"~stiJl "akened by mcn'l!l<."'t:! aching. "h,,:I> fl>l'C\'Olhim 1"1$'-" o"t of bed111m th~ probli!'H m,,~· r,., an inflamuMtory disorder. or ..I least hav" a I~rge mflammatory £omponent. lheret'on-, qws.r"",! \\""t other su"""'tiVl" qocstion $houk:\ be asked? 'What happens ..·hm}..... 9-"1 Ulli of bed'? A.I/S"oLYr. his back Should be notabl} stiff, not ""C. t'SSarily painful, it should tah- in ,,~c('SS of 1 hour ait"r rising refore ,t wea ... off, and it may not atway. mmpletelv 10lJ$<'r\. She J1O:.»' has ttw- an;;wt"f to the onginal q ~ he has either wylosing Sf'Or>dy\os>s. an mtrad'>c"l disorder or perhaps a locked joint.
ASSUMING If a palienl ""~'~ Ius p.1m IS 'constant', il is .. rong 10 ~V~ that he m<.>aR5 cUIlStant thrwghollt lhe day and "'Ilht. He may m~,m that "'hen he has pain ,t is.1 ronst.lnl pain, bul it isn't present all da;: long. Jt b ,mportilnllo check the Il'IOTe e:xact IDi!aning - oonsLo1nl meaning 'slead)" or 'unchanging in dq;ree', roast.ml '" locallOO, Of ClJn:>lant Cr.-er ti.ln<e'
AlthooJgh I.... foilowingcatchphr
'"leW
f\[VERASSL0\1F. ANYTHINC If we add to the possible mistakes ....~plaincd abo,·,' the communication problems cr"al,>d by l,mgl'''h't' diff"ren<:'leS, pE'l'SOn.llil}", distr\:Si;. etc_,ll is ..~sv to underslan
VERBATIM EXAMPLES It "'as ....rv g.-atify-ing to I'l'ad thai )1acnab (1W7), in his bool &d:IIchr,<:on5fderro the dialogueof history t:lking sufAaer>lI} import,lnl to portray it 'n ..-erl>.lbm question
and MlSWt'f fom'. TI,i" {rom a m,"" of Macnab'ssl~lUr<'. g"l!5lhe i'lClusion "r lit"ral quoialJons ina book theel.... rnent of ~!rty Takmg an ao:ruralt· history is 00 kooo. unporldnt than making iln a«Urate ~ t ot the SubJo-'dl'''.lnd ob]ect" echanges lhallal.e p1a~ duro 'RR: Ircatmoml. For tillS reason '-erb,llim le~t 's used here to pro\"id.: ~uidcli,K.'S which will, it is hnpt>d, help the physiutherapi>t to adl;.,,,,-, the d,l'U, of '-l<:("uracv and m;nemenl rcquiI'l'd for good ~1. The pnxt'5l!i oflea~ 00... to ,,-on:I que.tions, and "'hat aUtI)matic follow-up (!ueshons should be ashd when c<:rt~in answers al>! g;,'en, [,In be ha.sI~Jl('(t by unden;umdin& the &U;dl'li",~ thHt n", p....'SL~ltro ", Ill<' following dialogu..,. The guidelines should nol be mterpmed .os preacning to the ignomnl. or IlWtmg read.,..., as !odtooIchildren; pn'Tt to show the e~k'T\l to \\ hich lhe rule 'never assumt' anything' should be MI<en. Similarly, Ih,,}' nlS<.> show th~ prllCess of cnnfirming messages SO as to avoid m"tak"" int"rpret;>lior>s II is IT"OOt'l" ....al~lk to undenJlAnd thai we cannot avOId malmgassumptions or h}~-but if "·e mak" any ilSIIumpho,..; ""phcit to ou~k'~, we are on a good position to know lhat I""y ,,'re assumptions. and to know when Ihey Me wl"(lf1g IIr confin"cd or in need of chanJ>ing. Thl>y w,lI alsoshow how accuracy can bl" aduc\"l.'d wJlhoul the p.>timJ be1ng made to feel be Os being t..... loo .os an ,m"""ile, and ,,·ithout imtating him by ""cessi,·" n'p._"I.ihon of quc:;tinllS. In fact people hav" enornlOUS amn"nts of informatL(II1 ston.>rl in the compuler thm we call the mind, and illS ... gmuiroc "",p<'Ct for Ihis mallet" and a care for lhe quality of oor rommunicahon lhal pns us I!'><' poI~ lial toenate .. good relationst\ipt'IW1IOnrnt'T\l. Before ,'~k"'g B qlloi!Slion, il is vital for Ihe phy.,other,lp'sl to be clear aboul four Ihins:;s
they"'"
1, IVhal Jl is she "'islles to Jcno,.. and why. 2. Whal IS the be>t possible way to word it J.. IVhal d,fferenl "..,..·cn might she &"t.
Communitation
4_ I low the ~ble "."Iy to h..... quesbort'i might mflucn.... her planning: ahead for dle roed question., II IS probably the bst of ~ thott f"kki Ol.It the good ph)'Siotheraptsh from the Ie$~ gaod A mi;t;ake that ocru...... t.a,nee nwnipulati,·..
,m
ph)'SlOl.her "ns""er is us,.., lly tn
A.... amle!iS of the body"s (,"
Kt....' P,ng qllestiOl\5 brief. Maling features fit Assuming nothing. COlllroll"'g thp intervie,," l'~ralldi"g qUL'Stions, A~king le~ding qu~"Stions.
Using spontaneous IIns"l'rs Knowing tht' question·s purpO>(' Emphasizing/using h.'y "on.b Immedta te-re5porLSl." queo;riOl\5o. Whm
tN>
p.otM"ot's problll'1l'l i5 poll1\,. "ith or ,,,ithout
guidefuoes for polrticular qut"Srion> be dJ5CUSiSed in tt... followlllg groups:
lom't~>d ITIO\ "men!. Co\f\
1.
tmm«lii\t...~~
questitln.. in
que>llOllS - immediate crrtam of' the p.otin\t" s
~ to
staremenb. 2. K.........ords - words that Indicate a p
3. Specificity - assisting the patil~ltlo m.u:.. me.mingful ~ __,:>,menl. 4. At i"itial consultations, questions .,bout 11) Tht· history b) Th" b•.'hll\'iour of the symptum, Q.J~stioru; about pain ~sPC'nst'. during t...-st mO\"Mnetl15.
5. At Sllbsequentt~lme"'t sessllms, questions about ch.1nges m the s) mptom,;. 6. During a trmtml'l\t SCSC>IOO, questionsmout .. ) Changesinpain~dunng~ment of tesl IDO'''t''I'"IlC\1ts b) I'c:hnique is perfurlTll.od c) Chan~inp"-in~.. flo""l",atmt'r'lt techmque IS J*riom...od_ i. At "-..,.. j ...... sessions, qUl.':>litJns: ..) During a retra>pectl\ll' asso..'5SlJlC.'I1t b) After "a.;:h three to fi,c I"-,,,tments c) When prog~s hilS slowed or stopped d) Following d break frQlll treatment. The g"-~ltl",1 pcr<:enlal;" of a physiotherapi5l"s patients ":,',,k treatment ju,t bernu<;e of th"ir pain, while all other aSp<'Cts of their pmblcJll,. as f. ~ \l'ea.tmmt cuncepl "'hich tlus b"ok outl.ne. is cle.rl~' tIOlll<"le th.at takes into llC'OOW\t p.oin to tn..- "",elusion of all l~, but It dcoes l'l.'OJgIlizc thaI "lOST patients are pdlients bl-atUSOl' of pain; without p~," would not be pat IS. The J'UTJ'O"t' in .
"'''1
t"'"
IMMEDIATE-RESPONSE QUESTIONS Many questions hot,(' to be askeod of a patient during .. firsl «InSUllation, and the polt......!'s "ns"""'l! to ~ que-lion> are norm;oll} sllltemmts ol flld Howe- ..., durirlssu~llfC;1tmrnl -.oRs..M"""" it is. the ('fted of m;,atment that is '0 be ~ , "nsw,'!S to Ih......, questions ha'-" to be changed from slslmrnrls of fllCr to ro10"''' what would nil'·" rulppt.·ncd with ·hemming a .lirt' before treatm ..nl.l-rom a communication ['
35
.C,_---'J~6~~M~.~"~"~'~D~.~'~'~ER~T!:'~BR~.~L~M~.~'~'~PU~l~.~n~O~'===================== _l"\'. d.,.n.~nd if yo" h.,d he!nllwd ~ ,lnl llefo~ we bo:gan
t",,,.menl?'. \luch nnw is w.src
CONVERT SlA1EMENTS OF FAClIN'll) COMPARISONS
n........ are II'Iiln\' ~ to lho.""'p',t', tMl an! sl.. "'m,"'~ l.f f.ld and "hoch. if aocepllod dl fae,," ,,,h"', 8"'" r..be Impn!SSions. Foro.ampk', 'oUIm'-
'Wh"t is it "bout the pain th,'t n",k,,,,; yo<, 1,,,,1 it is Iikf, a pillCh.....1 n''ncr, ,1Ild
Q
"Where do you tl't'llh,' l>e"" i"
1'",,1...'\11'
"Th" p"li''''1 "ho mad" this unock HI~ hislory ofepi» wmploul>I rel""-...:I by trl'.:Iring hs hip.
""ere
"In
ins
lilt- qll~tion. '1-10" hal(" \'l)lJ ~~ the patient 1IIiI)''''''; 'Bt.'1!<."l'. tholnl< ,'u,,' Roll""'!" thao J~uming that this rrll~ll1l' hoe Ius,mp".... «l.u. n.."lt of I~dlm~t. the st.>t..........,t 'bo>tter' must bl> loIkw-ed hI' '!kotWr than """"'''', '8l'nt,.. than rrlllfl?". ~Ilct\l.'" mdllll; .,.~,.. [n .:JctuiIllo>ct. 'Ill,",.., ltun" v",!' m.lV be nwdmng bo-Itff 2~·hour ~11"" he had foIlowiOj:; the treatment (of "Itich he had bero ..... mt'dl. n... folloo ~ .."loman(.aJl). Th<.oy ;I."'r~"'ll.od in g p".tuillu,tr..'" I""difler""t l..ind~oI.IIl5"'('f'ith.ll ' N:' b\- p~tlCnt,...
lhan \ho,
1;"'"'
"The gTOOI''' ~re: I.
Q
-\I iniri"I ..........ltatlOll5.
2. CLmh,,~'>U~Ii'''~Inc:nb, 3, Sub,o.'CtIIC d,ffcr'cn,ns.
2. ClARIFYING SUBJECTIVE ASSESSMENTS \........." d"'l"rll'I"ing till' "ft~'Ct 01 t~ ~t tn.'.11ment. t.... p~r1r<:uLar il>p«t51,... rr>ed altt-.- firsl ;trw;! ...ecoruJ <:orL.wI.:>I>OR$ ,...hich shoIlld be foJk'''ed up, such as til<' p.1tiol,,'t h"wing paIn rul"~ 1m ~hoel;.:uw;! 9'CL< on firstlhm& U\ the morning. 00" pam pronlled t>vwatling there m.ov
Q
'How"""\-ourlq;,,,t!lW.l1llnj;"- monu "'S'"
A
"Oh. VERY GOOD '
8<'<:aU5C ,I '" import.mllo lnoow how ttw leg ~~-mrt'-""~ are changing In respon"" 10 !Il.. .lment. the 51.11.......~11 ""er:-- good """,t be fun" danfi,..:I. Four 'mm<.'d.i;ltc""'fI'O'lS" q.......IMb a~ IV' ......
4. At subso.-qu~,,' lrNlnl('nl>. 5, '\,on-,crll.ll r'l.'5J'l'f'~'
Q
'How doc... tI",t con'JI"lN' WIth )C">Ierday otho... mominj;''''
1. AT INITIAL CONSULTATION
Q Q
·Do"ouITM'.:InIOO~C>-"I'"
At lhe fir.>! rone;ult.1h..n ,I p~t ..... t rna, tid\(, "ymrtolTl5 that could be ~n,inl> fn:om a «nical dbord..... (Jl' a glmo-humeral lii;;ortk,r. Oun"8 the 'il1bf;.'CllH' "",mmabOrl" the 1h11i,~.1 m;l\ rn.'ke tho: oommmt, 't k,,-~ it ",,,5th '~Ilh ,!UK-I.. m",-,,,ncnl!.·. 'The immedi~te-fC5pon>eq",-'S li"n... hi,h the p~iothcr~p;'l nm""ll'I..,,;";
Q
·QUld. mo"ementsof whal?'
""d lh,'n, (o110W1l1g th<" r~ht~1t', "n."',,', ~>k Q
'In what dir''Chonr. "r
Q
•A...,
~Otl ~hle
10 ,hnw me thnt '1"lck mm·{'·
me'" 11"'''?' A palit."l may h.wea dl'fl1111c I)pinioJl ab"ut wl",ll",tlils
Of"
'Is there .. n" d,ff1m>nn, b..'lwem tho;- reeling in ~O<Jr right.md ld't \togs now7'
Q
'&'me as the 0Ihr... k'J: lOO~rent,
""'hu'" ~t all -
3. SU8JECTIVE DIFFERENCES tn "-'Sp'-""'" to the quest"", ·11< .... ha,o! you
bce<,t,
~
patJellt will often re
I,
dcarlr As a compomson '" b<.-.:nf,sllught.th"lrnmediatc< rt'<port>C q",-",linn can "Iways be asll-et in Ih" 1t. . 1l1< of thecxample "i""".lt ;.;\ ,,,I,,able way<>f CU""",t"l!: th,' "nirtform<1li,esr"lcmml i"t" " IIsdut a'ml'''ri......''.
wr"n~ wllh hin', /\ny ~'~I't'('S6ion "r Ihi, kind "-"luin::s
Q
'Ilowh,w"roub~",n?'
i",,,,('(li,,I,, r"II"w-lIp S(l th.lt the poinlne makes is neilher Tl11>ul1derslood nor ignored. I'or ..>.X.unple, h" may say" 'When J g(.'! the P'J1Il. ,I 1"",ls like a pi'lCht'
A
'I r,,,,lthat wmethinl\ in my b~cl<. h"s ~hitled:
The
;nl)l1cdiah~-r<'Sp<1nsc,!u,,,,!i,,n
Q
is:
'Is it a fa"ourable "shifl". or u"fm'Ollr"I,I,-?'
Communication
l'atll'l1!:S a", able to fe.>lthmgs WI Ihl.' ph)'siother.lpist ........bk' I" a$5e5S by '""y phfsK:al ex.uninatioo. SIw:' 'S then 1l"I',lnl upon the panent'~ Slillement II is 'eI)" importanl thai a ph~-siolhenpbt 3houId iOCCt'pl wrul!hc ""hent $/I}"" and put it to gtlllement
Q
'Iow han~}·ou been?"
A
·It f,oelsdiff<>rcnt:
nus depth of qtICSli"rung'" n,'Cl5Sary al tht> first aSSl.'SSment SO tItiIl the panenl Itslms !he pnrision in a,.....('rthai is being soup.L AU four 'Illation> are ne<:nWI)'
'ns
,mmedia~que;hOn>.
(3) Q
IT
T1n:;~i$~,I.m-
Q (4) Q
TREAlMENTS
All lhe following =p~ an! n"5pon.oes to the- fi""t q~hun askct'. ThiS subJl.'Ct Is discu~>ed ""mo' fully in eIUpl"r·to N,,\ ..rlh.. I~. if the following
Q
'Notloobad·,oo·(;oodlh.l.nKrou" n...'mmcdLltt. po~'qu""tionis "An,' diffo:orenl from us lr Of '\\'hatd~ tII.a, O\Nn'
(21 When a pali<.'nl "1iL'nd~ lho.' "","ond session and SOl}"!> ho.'., 1"-" lho,> "'III('., ,t ~ .. neo::~'1 patl of lhe- NUGJ!>Oll proc,..... 10 confinn his s13temmt
DoJoum<.""JOU''''rIell'''''"bctI,.,.nor ...~l' 'That's ri!;ht. 'With all J d,d la~IIi~, did I stu il up at alP'
'llow does In.,1 ,omr"~ with YOll. usu,,1 !,;'II<.'moipain"
'How has il been?" ·s.,tun:lav"'a'ilmuchN.'lIerdlly·
n... kind of i~ial.... ne<J'Of'S" que;'rion req", ....'Cl hen! is:
Q
Is lhal unusual?', or 1lEfore beginninlt tneal\"OtI h.1\"e had da\'S "htd> ".-.e m""," bctll:T, as you"'y Satun:l.:ly .. a;;?'
mmt. oou d (~I
Q
Ho",h.1sltbrenl'
A
A 1ot,Ior bt'iter.lrs incMlible'
""".J.'
£T II scrm 1....>OO\I*lr I<J lISSU..... 1tI' lIltS Il1NJt sulJ5l3nt",! '''lpl'l!~Jrnl_ ~"J 0"" ,I r_ 1>ro/lnNy ",/~tl'll /c:llrml"'fllt. /ionnw./ oronoa if/~ (C1Is,d,.... ~ '" rurrd aud aOfS n
Ir""'rue,,l?
Ti~rrf"n'
II",
i",m",lint<'-"'''I~'''~
'l"rslilJll ,hOI/hi l~' ,Ihmg tilefiJl1m,'irrs Iii''''.
Q
(6) Q
A
'Ooy-ou mean )"01' arc lOOperc""1 and we "'" ,lop I",alll",nt'·. or 'Do ~'ou nol h,we "n~ thing lei! in til<' Will·oi ~\ mptom~?·. 'How has it !>t'{'n?'
'Abitstilf·
fT n",,» i".......,.flJt'r '" lbul his n",m frr/liITj/11IJl if ~ ~"ld r.:tllfrlim.iIll"IJ. <11'liIl'SS.1hri",."t'Jia!t-F('S1!'J'bI'
Slrongl~
Q A Q
.1IlLS/mts:
Q Ii) Q
'00
,'OU me,on
'Ho" has it be<en;" 'I "as not wakened last night br the pins .:Ind m.·..'dl..... ·
A
ThaI's right:
ill
Q
'lI"" dId }'Oll fl-.:l "l,<:n you walkood oul o[ here compared with Whl'n you ,,,me in'·
Th" imml-'diat<:-IL'SpCt"Sl' qUl'Stioll is
II Q
'Just tll""\1""" 'And you had no
II
'No:
Q ~acti'llls I"tcr"
ifiJ is
",Inll'll hJ alII '"",,"....,11 Mil im1llt,I.rINr,,~"b/' ljIIJ!Sliml m",II,' "",rId/,inK Iron la 1/11' frJl""-'I!~.
II SUBSE~UENT
of ,rocA'diblepain W<15 al3am'
'The fi,..l bun;t
dauJrt'JPlnsDIl.li,wurr ifllris isUlluswJ~,od
TIme c;ln be Solwd by asking s,mplr, 'Is it a good d,f· fercnro or;' boJd dilf"""nce", insre.~d of spending I,me offering sllllg,'StiOIb as 10 tI>c w"Y~ on ,,-hich ,I might be (tiffel\.'l11. Tn fact. the patient's anSwer to the '!\ood Or b~d d,ffcrcoce· q,,,.,,!ion mar "iv" more answers thilll{'Xpt.'Cloo
4. AT
'Hm,!tasitbo:o.'n?'
A
(8) Q
"Is th,ll unusual?'
·How h", it box,,?' 'Worse .
37
38
MAITlAND'S VERTEBRAL MANIPULATION
'vmnit" is.J. ~t:ltrnl('f\llhat must ALWAYS bl' c1arifocd in dL'Pth """ny 11Illol"S" p"tient ",,11 m.,ke lhis n....pon>t. whffo. on mo", dct.lilat ,m'<;'SIigahon. the wl.>r.><.'f\,ng "'"'y be lrealment ~ f.tlho:r th.J.n Ihcdisonk'f .l:So'lrh.l\mg been nlMk' .... Dr'§('
Q (9) Q
In wh.at wa} h.h it OC"l'll
w~".
and !IO on
'1Iowhiuitbeen~' '~......,~:
Q
·Anddo}"oulhinklhatis&omIhl'I...... tm.·nlr
II
'h ,:
'\'o"
"-"""'}..,.,firslawa... olitbt>ingmon:o
!'Of'C~'
IT
oompltA
All of ~ abm., eumpJes 04 immediale-responsl" ques-tl,,.~ .-()Illmunicalion, lout tt..... ..... "",n,' ("O(.J.mples when the t:!
lions ha,-e bem mated
ao e>-amin.llioon
II
Q
S. NON-VERBAL RESPONSES
Q
II IS 1J U'mf
tI.-'Sl D>O\L..-nml
n..
ph}~pro.t
1N1tSl '1uaJil)' such ""'p"-"'6OOfb. for l!>.omple. in ~ to the que;tiorI.H~ h;os ,t been'"', It.. !"'timl "'"'y "-"'-POnJ ~1Jl\p1y by ... rinLH~ hi<> OO5e "The inm-.'\iiate-response que;,tIon '"
/I)
'Thdl doesn't tool- 100 ha~ beo>n w~"', de.
~_
Do you mean il
r1iUlft"'=~f'V'lIIl'JnJ"'''''Il('!~''Tlll(rlilol!l aOn' u1k'TI IWfillJ>llnl Il'l'
Examplt B
II
'I'.lirl.. "('00 afk.,. llefl """,'
Q
'Do you n..."n 2 minutt;>!;. or an hour or sot
1\
't would ,,'y II ~to1rtt."d to lx'Conll'.>Ore within "q"arkr of an hour.'
ET
WlwI "fcd, I" br ,tdrrmiucd ;~, i~ 1111' Wn'!!I'" " ',,,',11,,,,,,1 ,,,n',,(,,,,,: '" 'di""rdrr S(j"",,,,,,,'
Duri,,~ tho.> phy.;",,1 e",,,,il\o'lioo, whL'" Ihe p.'rient·, mowmenls are bdnlo: k'SIt."d, the pulient n",y screw up ius "yes o. m"ke ,n ,'ppmpri.>!e cringing mm'CmL'fl1. '¥he" such ",,;meL'S 01 ~I,"";our OL'Ctlr. the phy,iothe"'pist must relurn the p.lli'~l1t's joint 10 a pain·fn.X' po5itiol1 nnd im",ed,,,tcly ~,k'
!lUll,>, Ira, /1,.. 1=1",..,,1 /1'(I",i,/II,· "rilal~
"""1'
Ihr
Q
fT
""",-<"". ,,(
Ilm"J'" (for allmplrJ ust>l "" tilt' /ll'Illm",,' II'(I""'J"" 'Are you able to teU ........ lh.:r II ,~ ju.t o,()n.~ ness from m~ thum"". or i~ ,t Iht· protoltcm ....1' an" lrealmg wluch ... "'iln.' ,;on.'r P,,'~'I, """ of ./1IId~ able UJ d,f:'rrt,,:>.ll" Iht Sl!rt'N'« illlnl< """II t-~J III /('II$l t:ro-lhrrJ:;.
Q
'WI",I
,~actly did
f~~l,t?"
you feel and wn.:,r<= did you ..... a;, tlx-re any,hine ..1""r
It is also nL'Cessarv 10 (0110\\' up then with queslions to determine whether Ihe pain was an increase ,n i"t('flsil\", or an increMl' in thedi>nibution of lh""ymptorm.. Other common nu."Ula.'S thaI n.~IU"l' an imm.,,,hdteresponse question are: th<:' first mOH'I1l""ts of sq ......z· ing ~ eyelids or "'onlllng the 1l
",,1""'~il".StlrI ,1"""lJ"JlrnIIS~""'~1
A
'I'd say 'I
Q
'Good -
(10) Q
"'00:5
)"Our thum"":
~)"QU.
'Ik>.- Mn'}""OU beenr
1lw,'I;o,rruk_ P<'"~.,,t willlakc a long Ii",.. to "1IS""''f, ,'nd m.l' not 8"" mLKh information th.J.t i5 comp"ra1".:_ It.: nl.1J1 8"-1' "" 'tem-b~-ilo.>m d<..".,riptic:ln 04 tho> sJlmplu"",he felt from thellme immedi;>lcJ.. following the l.'~tlr~..,lmenl unlilthc mo""""t the qUC'Stlon '110.... haH~)'OU~?' is.lSh>d. Tho.'P.lh('llt musl be pem,illed 10 My Wh,11 h., feels is flL'CeS"lry, pnl';dt'd lhe physlotht'rapist d.,.,,; ,wI I"", [MImi <{IIN'IJI/(·I1'ie'l'. The
inlllwdi"t"'n:>spo""<' qUl',IiO'll, which shot,ld t><" J
KEYWORDS
Th.1t's mosr ht-lpful.·
'o.,.,r"II, what cfk'Ct du \'U1I think th.: 1a,t treatm.'llI 1>.1d?' or '00 yo;, ft~1 IhL,lasl tn."lm..nt h." nhld., y01l any WON'!'
rrequenrly dunng qut'Stionmg .. patleOl wm use a word or phr.ose lh..l1 Ius a .-.pt.'Cwl slgnifKanoe. FailtIn' to m::ogni"" the. ml.".:lftS 11>..1 ,m opportunity 10 impr<:t>e th<:' ~t:mdard of the assessment i5 lost, and the assessment made m.'y thL'l\ be Incurred, Th., following dialogue is a true n.'COrd of the quesll<mmgof a p.>rticular ro,tic"t .. howas not a good witness.. Her m,lln symptom WlIS aching shoulder
,In
Q
'How
h.~\·c youlx'(;,n'"
A
'QuilL' wdl1l101nk )'0".'
Q
'How
A
'J",t th.. S.1m,' - "",.., ~i'1ce Monday'
1uI~
your
~hO\lld"r Ix",,,?'
IT There nr!' IltV' lI'iI1S~ 10 Inldl "1! 10 and "'" I,m·, Ol,e ~ ',IJ,r' anJ Ilk' all,.... lS 'Mmwuy'
Cornmunial'
Q
'Do you mean
I"" soreness has bN>n ru~1 tile
Sd.~,.
A
'Yes.'
Q
'So Ihe I~SII"'illm~",t d,dn·tdQanything ...;thC7'
A Q
'It ... as SO«' ".two- rOll were trNting it'
A
'Yes.' 'Is it stH[ sme?' 'Yes.'
Q
A
'No, it', just the s.ln\t".'
,\
Q
·You h"w rt"fem'd to the should.,. as ocllluS pm·ious!v. and toda)' you are tallcing ..bout sorenesr;, are ~ dlffenmt or a... they thl" same ftoeling"OO you are just using difft"rrnt wonb1'
Q A Q
A
"Ott, I don'l know.lr·sjust thatil hasbo.....",son-·
Q
'Was II
A
'lsupp
5Ot'! ~fo,...,?·
Th~
diso:ussiol\ resarding >01\'110"'" may "-,,,rn Ill\' I,i,;"l to justify p~llril1b the 1",1I'~1t for clarification. Howe..,,-, it is ,..:ory Important for the manipulilti'·e ph)'sloth.,,-.lpb! 10 ",. olCCUtate. beo:: II is the 511b,..rtn~ I thai fn:
CVf/lplrl~; II pal~1 ,f~ 001 cllli1tl.'lI" /r,-r dt'SlTiptioll fro'" 'IlCImrg' 10 ';;oml~' u·illlOlI' ",15011. from SI)"'" 'hm~ Ilk' palit'fll hJS SOIh1 i/ "omdd SI...," 1I~1I III"", I"., ,",,-~r ~ chal1g~ r;f ...,ml.' km.1 ill Ii,'r symplllm~, rI~prl( Ih( firrl IIwl ,hi" iPls;Sf5 Illat ,hI' ;j ',Jrr ,.,,,",'. Tlrr lITo!>"'!? mq1lirV "111<' OlCrejor['(Il>II!Plllf The pa"~.... t us..od the word sore~' riltl\cr tho').n ·.dung', which shouJd a\crt the phY"'oIherapI~1 to the facl thaI tl>en" /Ililj b<:cn a chan(:l" in lhe !'\'1nplOlJb This Olli' .,cord. tlW' keyword m tlus e'Qmploe,. dem.:mds that the physOotherarisl rt'COgrlim; tile impllColbOl' of the wOld ~l1d the..."fore kno....s tlut she must question the pat.....t until the significilI'l«" anJ meaning of the word al'l" cbrifioo. The patient tn her "n~.u statement said thdt her sboulder had t>ee11 sore 'since Mo"day·_ jrr~"'fX'<::tl"e of how poor a witness the pallent is, Iht!", must be a ",,,son why she dlOS<': spont.mrou~ly to rnl.... tion Manda\'_ "The rom'ersation s.hould !here([)l'l" oontmue, al'ld jo1lm~ing is theacluJJ n-rNl;m record
u.;
Q
'Back al lhe beginning 1'0\.1 made the (001ment rh:tt .'our should~'T had beo.., !\CllV Sl~ Monda), What is II that mahs ~ou rl'lall" the son.'T1CSS to Monday"
A
'Well. !>e<:llUSt' Ihal'. when It Milme SOft':
Q
'W,lS it ..ore on Sunday?"
A
'No, ,t was Monday.'
Q
'.....'hl... on Ih" Mond~y were rou aware of the sorme..r
A
'Is tins the fll'sllirnc lhot it has been ing treatml.'f\t?'
~dllr-
'Is il JlIst as so'" as it Wdson Monda)'?" 'Yes.' 'If it b IIOlt' 5On'. wh}· do you k-cl il is ~ju5t the same- as It "'ilS befon> Mo'ld.ly" 'Well, bl,ocause it is achIng just the same a!> it w ........ henl fi~t began lreil~L'
The
1L5f rould
goon, but"lltMI is I\{'G'S>"lry b to know,
1. I low to spolthe bnl'uafle limitations
2. How to get Ih ... p,ltil'l1t to ,<"m:h for helpful arulw~-n; by 'f'<.'('ific questio~.
It is ll<.'C~ 10 ha,,, only a lillIe und"rstnndll1g to realil.l" ho"'somd>tlCh who has pain (Ml insist mat II ~ the ~, bKao« the original pain has not e- en lhough there iii ~ supenmposed. The lalUC' of h.J~ mg Cilrril'd Ihis ..nalytic-ill assessment of tht' subjecthe changes thrllugh toa cunclu~oll Ii..... >n the fact that, now. the phvsiot/wr"pist knows
c""ngoo..
two Ihings: II"r techn;,!u" dId not improve th" patient's symptoms 2. Her teeltnique did produce SOI'Cl1C."5IS, ",hich holS no! 5ubslckd, I.
rer
Ther<."fe-, she musl ch.>nse hef Irl'alm<'flt technique to "'-Old ttwt ~ W,thout the information b<'>ng clanfled, a wrong tl'Chruque m,ght ... ell be used. There .on" mlIny l/u!anlXS of ke}·WOrdS. such as '110, l10t much·, or 'no, I10t {'Wllv', which indi<:lIl(' there is something. alld so should be follow~'s that y~'S terday it "'~Sl'·t- follow it up, ·Nothing .....ally· 11I"a115 there is something. Th" list could go On for l"I...,; II>,., imp:>rtant thil1gs al1" don't miss the key woms; and don't fail in following them through ro obta,n I"" con\p"""" ""'SWeI",
SPECIFICITY The use of exlrli"me altcmahl'escan a~ist the paticnlto mak" ,In ~llsw"r "'lsier and mor" itCcurate, NWl1"riCi,1 scales lllay also be helpful For t'Mmple. tht~ pi1til'lll mal "-'flO.1 being 'somewhat be"CT', The physiolh"fapist can make this specifIC by I'''''' iding Ih" p"'li~nt ,,·ith a o-1O;;calc on ...-hich the pabent must pl..n~ his
39
"~_~40~~"~A~I~TLA~N~D~'S~V~'~R~TE~B~R~A~l~"~A~N~IP~U~l~AT~I~D~N===================== own assessment of rl"Ol'res5. Pen:entagcs Iib.....'is<' rna} l'l! llS<'rul. \~J extremeo; may' the pallent into bcin" more ~pccirLC_ For e>-ampll.'. dunng a relroole,,, sl.1lcmcnl, no! a com~l.and thel'h\"Siotherapht ""tll m.>kc the p.lbrnt be more specific by n-plymj;. l)l) mu ITINn cu!t'd"',lo which lhe pa~fs ~ IIU.y be. '01> no. IllX th.J!
much bo.'llcr'
Sinularl\. when lakinS" pabenrs h~ thl.-ph~~ lhtnpisl mil,' mqUln''''' ro ,-, long 3S" some mcidcnl ocn>m,d The ,"ague p-1bmt ""'y <;;ly. "Oh. ~ ago', while the &1rrulou5 pabenl mily "'Ply, '\\dl. I ttunk ,t was wtll'lll,,~ in India, or m.nbc;1 WiIS 8urma', To rn.:Ikc l'lthl..-r "-'Ply I1'IOn' spoofic. the rtl,~,nt"'-'Mp;st (flUid rollow up or mien'""" wlth'2 yl·,' .... ')f 2Or. AT INITIAL CONSULTATIONS II i. impo,;,;,blc 10
(0"'"
""cry JX'$Slblt! 'q\lestion-
th"l Illi~ht <)C("\lr dllrirll!: lt1LI1,,1 ~""SlJlt,\lio115. Howe"er, once the ;ntwd"cliol1s and h-,Im;"" In pronOllnCe the pMi;ml'5 rlnme (as he prorlOlu1cl", it ,1nd p"rt1aps rl'Cording it rhonelkall)') 11.11',· 1x."-~1 completlod. the 0p"'njn~ qu~tion can 1.", made 5u«inct if Ihe followin~ guidelines ,Ire otlliotro
communication guidt~"'l's f',.t...·t.,.,h<.....'SS, II 1S ...~lJ)' todi-i h.-ll dunng l,ftlllg thIS se:ond I}-pc:' is l'l"I')' common, and II ~ , l"}' ,mportant III det l;'IIlIR'I of It\(> pam 10 enable the state of tho;> a.boomI.11lt.. to be ~ and In-alt.'d..:t,ech,el_ Comml1JUU'lDoo probk....... ~ ... g..,,,t""l in ttw hislory taking of the!o<"C'OOd group of patients beca.,;;e, 11;I lhen> is no obl"ious InJIll)' tJuI h.l»cau<ed thedi5Ol'dcr, ",uch prubmg IS needed 10 dct,-rmme the predisposing factors im·oh·oo in lhe 0I\Sl!1. In this sirnahon, lhe pahellt does not appn.'CI"Il' tho! fine qu"lity of d('1aiJ th.,t the phY""'lh,....Ip"IIl."lolr'",. Thl' following Io:t is but one example 01 the probinI: 1ll'fi'SS;l'(:,md group M pal;"nlS. ET
~1l"W"r-qLJ~li,,"' Mll,latinn
I. If the p}'mptoms 1>0\'\ l'
Q
Till' may !<'It"(' m~ 11I1l'1lI.\: toa'" when it I.-"a"
A
'I don't know II lust stm1t.od achmg aboul 1
IT
/lIS """"SSlIr~ lobJOll'
w""~
,kw..r
ple area', theopo:ning question might beWnat are sLo~!",
or, 'What is ,'our
The n.'SP'J"".' I" !he exam",er's firsl qUl."§.llon ,,-ill guide the nl'Xl question intoo",.' of tWO din.'CI'OIW
"*,1 I,rrcif'!t.t...d II~' pill11_ aM1m' iI ,,~ ItIt'Clwmal1 or 1101. If Ihr'>T m» mr inrikl1ll/!;l' I'rrcll':lal<'ll ~lJ"t;;aM, It ilU!ln/lttT 50 lri...alllt' diJt.
hy ItJ mo"Xn,.:",~ ,'-'lwtonall ptltfm of. pIIr~ dL-.J"" -.,1 t~ ""'II t'IYn 1',,,,,,,,-tr tJr hy ItJ IIIIS b,1d of pmo/pi/iItllll{ o!lSt'!;ur I!~ prrsml
\
order, or has .1. disorder wluch
your probkom< al Ihis ~IAL' prOOlem no"- >"_
ago and it isn'l gL'Ihng any ""U.,,-.'
"~1. it ":ilY ..... ;or linwJer IW t" koow ifJr hiIs;w f"ft'iorlS fJJl$IXfr<. J/Jr lID, IMy"., prm'Iih ''''
unabk-IOOO?' "01.1
'How did it bo.'!;in?'
ET
2. 1f)'QU know that the paDent has had some form of treatmenl wluch h.35 bet'n ot t-o........·t;t and tNt he may be .1.111 till
3_ \\'herl
if / nSK n (17)iIN'Iy
sl'mrl,1JlfOtrS Iy 10 JII~I.'r. s,mld rI"",,' 1\1'15 of iii, 11i>lory Ij'lw!l he f''£'1., orr mOSl i
~11'trJ"'_
Q
'H,a,-" you ('\',"1" h.ld
Ih,s, or anything !il" it.
Wore>"
uch will be discussed S<..'jXU"
f:T 11rm."'o""~I<'ftM,,.IIn·.. ~lwmllll""", '""',,.. IJ.. '-is Ilral I'rttoftJlIS tpi~n; '''''''' ban mllM 'ji/Jr•.,.i/i;' all(II,,"rt:r.-fi,rr does 'wi 4;social( II,,,,,, wllh IllS 1"'"5<",1 pru/J!OIl, U",;.-I, !1M boY!! mllt,1 'arthrilis' 0' 'dis< Ir
HISTORY (INITIAL CONSULTATION]
CT I rail /1('1<' Jm'rIIlJY
I. T1I<.' hi~tury of Ihemmpldint 2. Thclxoh.wlouroflhes}mplom...
A
't\'o ,
q",.. .li,JI/,; in sel'<"r.!I''''.VS. brll
pro""Nyll,,' 1/",,1 mjr"'lmlil", bff""SI." I,,', pn"rlll Hislory lakin!; will be di".;-ussed in much more det
thouglll< art' dm'ftl~f QI
10 ;11('I1d a link 1111".
t",'ifyill.~
11/5 '110' ""s".,.r_
Commyn;cuion
Q
"",he
A
in ~'our
''10, ",)1
lOT A".
~fe'"
/~",g llult 'IIJ;i.hl "llJrru.w~
",~lJr:
m<'ll"~
'l'!o1 m.lly
,,,n.-I!liJlg: SO I m",,1 Q
IT T" I"IT'>UI' I~ ... 1,,11' oJ! l~mh'I,~ r lril/ $IIW his ~, n~"m II.V hrlp """ t" rrnmnbrr_
'Oorou IDl.'~n you',·., 1>('\.... had ~ d.1\'~ 00<:1;·
I" mr I!lall.. lrm da"fv j/.
'Whell "<1u ""W. "Not rcallv it "<1und~ though )"<'u ",,;y fla, ~ h~d s.:.methini;: n
,
IOb1
'I\ .... AI; 00 tl'Io! Thur:.day:
Q
'\\",,~ it achinl; wl",n yo" ", m, wif" during b~kfMt that mv rock was achIng,
~s
A
'WCU, mv back gcl!;" bli stIff if I doa lot (t/ Fardening.bul then","'Yonl' has that,doro'l tIv.1T f:T ;\'u.. ,h 'CO'lmg ""~. \\',,'" , lW'J In h.,;r j,. I.. ~ r{ 'I;fp~ trl;!n11" tllt'drxm'''!pnlnri"" Q 'How ~JIlg does il tikI! to reeon"l" from /I certain amount of garde.ungr A
A
'It mighl ~ke 2 or 1 d"l's to gel back to nor"',ll aft"r a whole we<.'hnd in th" /:dr.:len:
£T T!",r'.' 1~"'.V " ...flll ;,'fi"wali~'l, II I1dl" mr I" kill'''' U~'QI IJI'
,,",,*om lokra/r.' rr"Ii~ I dm,'r wl.ll""j'
u-hl'tlll'r 1"5 hid: i5. drl<'Tll'rl11l11S '" ';'""""",g ,/Slie. bIll 1"",..... 1;".. I'll ~ 11m drl'TIIrrlltllwr,
,,"li/ W(r- provided I don't forgrllO find OIJl l;rill ntttl /ilbrc
10f'mftl"'m",,,'1'1
n....,." al'\' manv wal'~ the qUL"'lkllb can m't,>ckkod,
')'1.'5.
fa"lv
Q
'What w"l'(' I'OU
'ldun'I~:
'00 \'OU ..,member-If It (ame on, on ont' da\'? In oihcr worth. did I~ not t.a, .. an\ ",(h~", on<' d,'~ Mld h,.,·",,.'; ache lilt' next day" .
Mkr a dday. \, hile he ponders tl1l' nn,wer comL'>.
que~lio",
II
'y,.". I think so:
Q
'WhJld"y \\"sth;lt,c.-.n l'
the
du Jnythinl>,.1 all On the WEDNIS-
.
",0, I\'ebcentn'inglo~mberlf[dld ~")
thing.. bUI I CJn't ren",mber- ,on.. time I coold h.we hurl II
FIKSTa""U'<~of"
A
~ou
LT So "an·lli,tl\·I~ r,';;tlrl/~ /II,' 'I'ml"I"-,,,"'g!lU:l<Jrs' rdcrud 1<1 "/.on",, Wlli!, hi, "',lid i, om'Prj,a,,1 lonmu, I'!n",ral aeli,·,I,.,:, if 1 rollli",,,. willr q"",lidtls ,,~iatnl "'ilk <1('1;1',1,,:;;, Ill' n'r!I p,,>br/ Ny bl'aNr 10 IrIlSllw n«:wl''1'''ctlv/lruJ Ih,,"rsrwr ,,~II fV' _ ,../illbk. T" ~ I"", /lb.....1 ,hr ,,.,,,. "n!""'tI<'-... I.:'1tV ·I'mti>;p.'sl".t r.td_ (j:1t",...I'.
·It ,,,~I 'I.lTled "chins" 'Dunng tht' momi~ ,>r the afternoon?'
Q
Did
DA' th.~1 hurt ..our b.t<::l.. "'I!rl in " minor ".,n-. or nutk \ou AWARE: of "our b<>ck in
an; 'u, 7' A
quicl
ET Fa..l" qwdlv m,'l.m' ·""t,k"h'" to !litl/. ~1I1 it', "o1 pn.-cN· ~,","XI, filr '111'. SO 1"11 Ilml 10 prill'" 11"'7,,'r,
Q II
'Yes. that's nglll"
Q
and lhe answer for e,1Ch ,,'til tale .. boul the -aml' Irngth of limt' lodctenn'Il
II
A
[T Tlwl slhat /M'rl''ft11t''1''''''''''''wlvnl. .".Qllm JillJ ""l ,,'iull 1'",,\1k.1 il TIl<' fir-I tlrm,t i, 10 II~lkr I:mr /I,m! ~"'''d U~~'/lll'r 1I1<'1'l' 11'/1$ m,y Iril'j,,1 i"..idml tdlld, IK'r:lIrrM
I''''''''''
'You said il (ami! on 3 "L'.'ks.l"';'~. Did ,I com'" ""SUOOEI\LY'"
And \\ IlL"" ~ OU wenl 10 ~ the nighl befOfl' \"Oll did not llan:~' I, thal .......1 ~ou
mIght ,,,..11 h",,, SolId, '1\0, I don'l think it )1"'t,'1 ,n,:"k up on vOIlllfadually without your ",ah/.'ng II iniri.lt1y~. Ho.- ma~ I\'PI~. 'Yes, now 1h.o111ool b;,o,,;:k ~I il. I Illmk il " ...._ like lllat'
sis mp'"",,"'rIts. n... nlJV 0'''11" d"ri";.: vtl..... pIIr/s illjrilll ,"s'"'",,, ",dimr,,, I um S"h.S 10 I"!i~' 1<1 .,-.k
Q
Q
H~
till! ",.,'tIl,,<]ftrnJtmml .....,lIIttolllll
;;l'ardlll1.~IIII,."ri",':'
/c
A
~,rid 1O!l jiJra II,,,, 1o<,11<m~'I' his Illlm
0(
III,,.,gM. Th~
1"Ol'\1 question probo:s for Ihi5 To do th", fir:.l and l'I:lum to Ii>(' pr«lispos;~ phy,ic~l actiYlILlS IJlI!r m~nl,,1 ",-orie"l"ti"". It may ,llso n.""ult in ;"i,.ing out m, ~ rele"d"t pk<:<, of inform~tion, which mlsht hd'" bi~'n on the 'tip of his longue'. >0 10 'i""'"' th~n
will ffisull in dd.'I" in his
41
42
MAITLAND'S VERTEBRAL MANIPULATION
This ted",;,!"e "f pamlleli"s q'II'SI;OIlS with a pali""t's Ii"e of IlwlIShJ is al1 i"'porJm,1 c.l"m'lllliWliOlt I"d",iq,,~ ro follmv at all 1;"'''5, 'mless ti'm is a !'t!r1j ,lrotlS rt'O!1 for dCpilrliligfrom il
Another communication guideline - which i1pplies particularly when a P.lti.,,,!,S respo""" to the op~"ing question, 'When did lhi, begin?', is 'Oh, ag~s ago' - is as follows;
Q
'H,," yl.>ll Ix",n duing any U/\,USUAL work on
ET HIS r'''I'''''';'' i'ifcrs 11101 il did,,'l slarlla'/ ",,'t'k, b"l awl's 011. 17", melllOti /ila/ will m,W 'l"ickly
A
that Wednesday or about that time?' 'No'
Q
'Had you been doing any HEAVIER work than USU,lJ?'
A
'No,'
Q
'Had 1><.",n doing any particular work for L01\'GER than usual?'
A
y""
'No,'
IT So II,er1' i"d a".!1 OBVIOUS phys,wl arlmly
Q A
"'hid' /las I'rollvkedlills aelle. Tlte ,rexl step" to i"''''''lisatf lI'f vtlwr .,,,erlispo,,msfmclors' - th"re MUST /Ie a rr.'II:i<JII for tl'e ""S~I of ",!rh,S 011 IIle TI",,,,llly IIwmi"s, 'At Ihat time, were you unwelL or <)\'ertired, or under ~n}' smess?' '\\leU yes, J waS pK>lty tired, I'm O\wdue forhoUdays and we tuwe had tWOII\l..'Il oifwork sKk - and now you mention it, ",e had be",n worting long.,r hours tf\.~n usual to 1lX'ct a dead1i",,'- I'd f"'b0lh" Ihal;a,," I "'as il"'ol""d in a lot oj lifting and carrying that day:
£T 110ft"" Wkes quite a Im'g rinte (",!lid, ii> qj,ilr /l'll",,,,able) fo, a pcrsml 10 n:lrievc pier:fS of ill/orlllatiO/" 50, miller tlUlII IhillkillX 'WI'y did'j'l .!I"" say IIml whm I asked you ('{Ir/ie,', I should lliillk, 'Wpl!, at 11'i/>J ( did'I'1 ",is..< nul "" II,al bil of illjumwliu,,' Q
'And that is unusual joryou, is it?'
A
'Well, yes, il is. I do have to do quite a bit "f lifting, but tht pnossure was r~ally on al that porticulor time:
bri"g 0,,1 II,c a"""" i' 10 prmJidc IIi'" with 1,,,,, rejermn'I'Oi"J5 a",i JlIII,jvrcp 'Ii'" 10 I",,,mrp
dmr
51"'0/1(. Q
'Do rou m".on I> months ago, or I> ytWS ago?'
A
'Oh nO - no, only about 2 or 3 months d':;O'
As "'ready m"ntion~>d, when inte"",,,,""ing garrulous patients, trying to k""p control of the interview is c>.tremdy ",fficult. Dur",); hi:;to,y t~kjnlo;, Iht:>e palienls tend to go off at tMgents ~T1d gi"e a lot of ir",I('\'ant d('Ia,L For ('x~mple. tl", "pl'ning '1u('stion ,11ld answer mighl be ,lS follows: Q
'Whm did it start!'
A
'Wdl, J was on my way to "isit an old aunt oj mint', and as I was getting onto,
Wl>ether thephysiother~pist allow,; him to continue as he chuo,""s, or eilher brings him ,..., ck to an;;wcr her question or gently coaxes him lo answer some of her other questions, will d~pend on Iwo thin,\;s. The Il10t is, how much of his talk is likely to be talk for talking's sak('? The Sl'Cond rdMt'S to th~ aJ110lU1tO! sponta'><''Oos infonn"tion of !load qu,dily she might le~rn il she allows him to ~onhnue. Ii it is the former, she inter· ".,n<'S. Some "x,lmpl,,,, of inter\'~~ling qu,,,,tions th"t ",ill e"abl~ th~ physiolher~pisl to keep control oj th~ inte""'i~w a", as follows QI 'What happened?' Q2 'Did yoo fall?'
Q3 'How long ago ",as this?'
o
ET Tlumk)lOlI "Very ",\1<;1" !hllt's just ,dla! I t!'lIsloo~ mx for, NiJW il makes ,msc, Ille hislDry ""d II,,,
symptom, are compatible. The ~bo\'e is I\ot the md of the 'history' qUl'StiOning, but sufficient diillogue hilS 1><.",n p",sented to show a communication p.l11ern which can be adoptoo. As well as the unanswerL>d 'So Imlg as J do"'1 f"tX~r 'luestion mentioned earlier, the physiotherapist ne«ts 10 know if the", has been aoy spontaneous ",con'ry Or wo,-,;ening of the symptoms OIW the 3-wcek period, Also, Ih.,re an> muny jaccts of the p.lticnt's past history whlch need to be sought. and any question you think of later ffi.
Such question;; sfwuld be skilfully interposed by gen· tly increasing the v"lume oj the words llS<.>d in Ihe qut'Stion SO Ih,lt the p.lticnt'~ d",ughts are pulled awa}' from his current line and subtly directwto that of the interf'O"Cd question, The important thing is that Ih~ examiner can rrlain col1lrol of th.. int..r"iew without in;;ulting Of upsetting the patknt. Nevertheless, it is important that e"ery eflort shollkl lX' mode 10 make patients fed that they are not complaining; rather, they should be told that Ih~y are i"j<m"i"K - 'Whut you don't tdl me, I don'l know'. On~ of th~ best waY5 oj ~nhancing the inter"..ntion is to louch Ihe p~tienl (their knee, arm, h~nd etc.) and to s.~y simultaneously 'D'd you fJIP'. The 'Iouch' has the efkd of immcdialeJy ch,,,,ging the d'rLocllOn of their thinking, Some people dislike being touched, so
CommuniCJtiQn
lor them still use 'touch' bUI do it through t...." sI,.." ... (thcrttly k"SSl'nirls t.... skin-on-skin siltJation); rnau- it both brief and light.
BEHAVIOUR OF SYMPTOMS (INITIAL CONSULTATION) \\ithout e ~ in the dlDlce of ....00::15 or tfl,e phnsmg of qUl'!;l1oOS, Ml enor.......... llmOUnl of lime c"n be 1.1ktl In lkt,·...mnirq; the beh.I>iour of a patient ~ s' mptoms.l.nfortunatel}', tune has to be!iJ""nl if the ~kiU is to be Jearnold, for I'lOIItin~ li1i1oCf'1e5 as " ...11 as ('>:pem.'oce "The Information ~uirnf, ",lati..., to the beha_ jour at a p.ltienf.ss...mptOD'b, is,
Q A
'5<> roo do "'wc SOME stages w",," it isn't achingr
A
'O"I)'aIRightlt.-cha!;I'tI..Lda)"
TiwrrordCm;5TASr rrlJm IUt'J bylli/lmls is ooufUv "'\:'rJ;: tim at:"'V> Mi,mr,wify"'l1 IT '1J;als new eINT. H.. IJimbtrX pnxn.«ilt/rrJ ""Iotd.' 0( fir a..,t",,,, ," lririclllllM:llo kJllltl' Ilrrlllll II labo 10
",Id
At""
,llh;.idt7J Qtl,~ 11I~I/IrI, .'ifftrr<.s and/or J"'ill all grllin;; (\l,I of Ix
2. Doxs Itt I......
2. TIl{' constancy, f,,-'quenc)' and duration 01 tho.' ;nl~rm'LI"'ll pain iUld ",missions, and an}' f1uch",!io", ol illLen~itr 3. Th~ Sll'gc of SLability of the disordl'T.
Tv ",aU w,,' oflli, ~wrTt,,'lr,ll" lJ/!hQlIgllt, II", fvI1'><1-'ill); i, Ill<' qllC>IIOH asJ.l'tl, ll'ld il ,!lorlili quickly follow hi5 a"SII'cr', • , il ncll(s ALL do~'
The following is 011" "l(~mplc th"t pmvirk-,; a gllldt' J.~ to the cho,ce 01 words ,md phrases thaI will ~~vc lime and n..lp tlw' II",r")'lsl III """id making mislaken interpl'l!I' atio.... alld inc<'r,,-'Ct assumptions, Thecon""rs,lllon Ih,lt follo"-'. is bcl'H"-"Il llw p""m;n"r and the !lo'Ul1e ""1" inten iewed ab(,,·c, who hilS had 3 weeks uf b;>cr...clle t..""t ..... Ialel; only to the beN, iourof th" bacr.:..clw
n....
IT ""rl," ill II" illl"",jro,lr 5IIid 11i$ /taet.ldlr :1'<1'; 'a'Ol !J1Ilt', 'CMs/a,,!' (i:lIl
"'<'If"
·rrm.!,,,./Il>r!~
ll>
ro"'~\Jrrd :Nil. 1M mOlt~"':UY 51rD71"'''' fbi.;" 00n~ "", !lv,ht filel lloot. jurpri;,;n.~ mm:1\'T plZl~'$ S
If
Il:5t II...." PPUl,rd,..!d!l prmr to> 1f'S("'.1f rht fiN ~1. 'l» ~t•.f«! BIf!, "f"IPI~ ,.. ~" lI«talllll'_""""".~;pj[h'>5Ol-Tf.r..lJ', Thr 'U"'./t1", .. Jw.' m,d '"" Iilf"Iplllrm /ITt i'Kcml.\"l/iMr, To 1I;'t!<J" ",I;l>t ·,j"'}'RIIl'S hI> "SIr rl',<'I,ma,,! It IS /'SM',lMIf IIMt il be clarijW.I, mdI( "" 1'lJ>colllll' 10 j.'
Q
'''l<'lVr
b!f
q... "i....t fro'" !Irr opposi/t dlm:tiOll '·\C th,. stdge, you don', haH'
Q
'Does thl' ,1Cl>e ,'ary at all dming Ih" day"
A
'Y<'5'-
ET 1\'<11,11",1 I""'! I,dI' me ","c1I, but il dO<"> I'roPlae a po"'! fro." ,,'lwlP 1<) Wt>rk, Tht"rr orr ""'"V u..vs I ,olliacklc II" Ilrrl {n"/jurslifflI5, &sk,/lIy, Id,~ll :/\1'11 I"iuou' I>. '*"'s 1/ "",..,,...115 tlttday I'rq.:~ ,,,. dtv< II drl'rlIJ 011 PARTKlUAR QClll'i~OT POSTTfO"Sht ~lIly ...fopl! H<J:l>ellll I grt !I.. a,,~-:a'T "'Q~t quidJ,,' I II lTV IhlS fiTS!' Q
'\\""t mal...., II worr.er
A
11 just grts "''OI''''f' A! the dol\" goes on:
Q
'00 JlJU IDe.ln tI1en',~ nothing you l..now of wltich ma\.i", I "'<'lroe - 11 IU$l get" ....,..,;e £01" nooM'ious ... 1'
A
-Yes, chal"S right.'
IT 8«.."-.... a,
IJr/d",S tllf'
Q lin} period
when )'00
A
b"kachc?' A
'No, ii'S lho:!re all the time'
1;'1"
rite lIl't' 'fHt'S!;"'. is loa:J: him if!1t lUI' m,,,acltr If 11'- U'IIke'I' 1lllri'lg l/It "iSIiI. ! the Ilight?' 'IIlIrighl'
Q A
thel1~'
Q
1. The n..ldhonship symptoms ",-... r to re«t, dcli>'itl..." and pt:>s,t,oru,.
1_,...of/"'Wl"·l)r·Q.Wl51<JJ1/i<:"I(I'T.tbP'"'~"
~oo mean '115 not aching 'That's nghl '
'Do
'Is the",
anJth;n~ rou COIn do, ho."t"e and now, which you kno" "ill yoor b.lckr '\\'1'11 I know that "'h,...... "1' bet.'Tl Sllllng here my bael. has .td>t... l more.'
"u"
"
£T llr<:au,.. he "mv hm... /tn-JI pufi'rllli",~ Mlrvlry /vforr he arrm'd ll'hicll 11,15 COU""! 11k' ;"0>"'--"''11 ache. ro!!I"r. '" 11> :/\'/1 as. lit,· ,itrmg /wili.l;; for mt, 1J'''folloll'lIli< q".. ,t"m 11I115111<' n,ird' Q
A
'Do you ",.. an ad..." 'Ye5, if J sil and
~itllng
normally mak,-,; you
"'~h:h lelc'
b,on It ach",,:
43
44
MAITLAND'S VERTEaRAL MANIPULATION
IT I ~hJll"",drr if lll.'n';" I~" ,m lICIil~Iy ~~I;cjl "'ill {rI""" <1(1",,-,<. I "',,, "-,,.I, !Q b,w' hrJ{ Ihr Ildlf,,';th ""tiol,~ /fl illcrt"t"f, mul u~",rr_'r lit /Hljll'lyd,lfj{'ully ,,-:,"lti'Ii: ""I oj"dul1r Th..",,,,,~ 10 Iwqlll'
'After .... ~tdting tele\i:;1011. do you ha\'e ~ny pmblcofl> get""g OUI of lhe cOOi. Of c.n you lmmethately ~tilnd up ~'tTalghl iI1ld walk a'~a'
dOfl'1
my tvluatok. Imn.~ it l> In' • 1lT<1)i1ll:abr fUllr'm rf l ..... lwrle doo.-drt """ it j" ..... tllli 1'r'Sf""Id.' I" ...nIOI...... fur iIII' pot:rrn 10 IJt'ftnni, m,.lmSL<""" tr> dlofr quNlOtb <1uJJ "1oUdl f'.M..,..rJ;hurlocffwllm tfrlil. TI.,<;tJf-lrIilVbrmild "'ld .fIN fur <~y /1)...15 """"I..... r' Jus
jat:I
ill~;"'1 IS
I"""
/hJj fib
.nt..n"
'i"''''
_IJ
_"'r:..
Hrlu...w.
...1..,1• ., 1I\'R' 1f'$l,.mJ N /usillllif I~ Ioo:s~"
".Intl'd IllrJl tllI'1I~""
nOt"
II~ ",,,,",,,,, IItJr41 Ill'
:{r.... h'r ~tIJ lI"",fJ w,,1 fer Iorll>'"- / m",,' IN: tbr il'It"',iotI In 5HCh ~ 1l'l1lf1b I" mr, .... '1'''11a!rnJMs ..,.......... he't-~~ill"ll(.Jn, ..... ll{"/Id~"ld;,.-..'iQ>r oflll"qlllfliIVllJuI~rn'oflli
.,i/f!lt...., TIltri,.,..
/ 5Iwuld m/l awll, II mom I', tho"K'rt Ifl a\'n" ION IIIi<, I.. ,rmf o/lIV "' '1'" 'Il""', rUlldr '{in'S IfO i,ldialrn", 0{ ilS rrl.ttn... m"ltorltrrl,l' 10 I"", I'l "lI"a~"rl.I ,(IIi$ proI+n,. n",r.*,rt /
"'''''''''10:''
1uI,,'
Q
IT
"OO} III """rn 10 tl '1Uf':.I"''' .",...,
sf,(f,_ "', '{rtl",_~ ilul
Q
'00 rou oo\"c
=
,"w /IIIf,Jt'xl """"WI,'{
In>Uble ~...'1tm~ OUI Ol bt>d
in the monung follo....;,,1: a \"rl"i lleth" day' For """mpl.,. if )"QU sank.., III wl"ekend. d.o yO'Ll. !u,.., more troubl(" IO'llh aching or sliff ness than during the ",eelr
I""
A
'Yeo.,IJo 1t"'~m"'"Iol\on~to&fltosleq> I'm qu'!>" J b" <"lJffcr In., 1"Il,·:-1 m"nun~.'
;md
£T Gt.uJ -Ihb fil' 1M /VUml rrf.rrrrJ 10 Nr/1iT" rnuI SlrmgtlJnr> I:~ lud.\-mtmI .."""'II!ft'JItI.~11O>iI. Some ~ m.l\' COIbId..'I' lhe abo\e .. 0>"·"15 ...., 100 good to be true How........., as lhoe ph',">lMr"rrsl Ie...... how to ask kl'Y q",-""MJnS 10 elll,)t sront.~1\O'OU:S ...,Wet'S. so IN! "ns"er; "'--'COm<. mort." Inlorm.lh....·.Ioo.1 hoelplul in u~nding both lhe penon and h"" probk...... Al u., same IIlilt'. the p.tl"-"'I qUldl)" g,l,ns COlIfidence in the ph~'>iothL'raJ"S1. Also. bo::auw lhe 'sponl.:m,.... us" a~w"", ..""ble ~ accur"le Judg~ rnL"Ilb 10 be rl'I.:ldl.-, the i'SR>Mom.....b .ll'C'of gre.~lef ""ILK' for ..".,..,ing progns>. lolhe ,demng doctor, The bd,.lIiour of lhe ralll..,r~ symplom of .I,ff~ may .. bo be :.ign;fi<;anl ",1><-", lhl"" IS son.e patholojl;Y i,,'·ol~o.illg spond}'lili~, lhe «)J'l'~~lion .",d Ihoughts may be so",.'lt"ng Iil..co lhis;
ir,,·
iT 11I\I,,11,,1e1l<:r~'iflli5 bIlo.k f"~s slifJon srllm.o( "'II
01 /1m in /I"!' mo.."i":i' Ifht 110l":' /lQ<... ,m~"!IliJ"om.~ "I"'"J,vlili~,lli~ tucle sholiid I'<"qllll(,lIff;mJ ~ ~b1!1I'{/illfill. [I'.... ifil i, 'WI1'Ny pam/rd, 1I11"'iff Jl~ ,llllul.! t'IU ""'To' IIrll112 /l""rs 10 IN'}""''''· 1<1 hi, Ilomllli drgru of li",ir""IIlI
t...,." ~lme
Th" l'"-,,'l,,r v"lu., of thi~ i1n_wer is lhJt ii' has used lhe word 'shff' without bcin~ guid<-'ct qu/>lity ~nd degre
thesliffJloC'SSla~I?'
·llowlongd.........
'When )'ou finn gel 001 of bed in the mommg. 'I ~uppo.l
spe-
'Onlya few minules. I'm ~llil ."·are of it when II"an 0'·.... t:ht.- handb.~sin I(> .... ~sh my i.lc"',bul by breakfa.llime il has I:onc.'
1m", dOE"! it fool" A
C>pt.~,-.mded. less
A
'No, ill~Lcs mt' .... h,\;' 10 StJ'.,g!lI,,-"I1 up.'
IT This
mon:
Q
normally'" A
kno"'1 i1nsw".,. or iI
dfkq"..··,lion
m,trirnlWI mil"'!"'''' IIi, ~llsll'..r /11I11'/ 11,'1
",Ie"
I''rlolmgq""s/",,,.
Q
'How d""" your bock f..",1 ,,'hen )"Oll fi"'t !'leI
out of bed in tl,., morn"'K" A
'Not SO good'
iT if III' 01",,, I/{/<~'
"ay 1.,_, mrk b ,Iif!,
'In whilt
1'<1,
,1111 a/\l"'iaS
w~yisn't it ~ood?'
~
il-mli,,;.;
Comm~nication
A
'Il's stiFf'
ET This "" ;1"lcmmt, "",) nil st"le",,,,,I, n |
Q
'How ,tiff?'
r\
'Very stiff'
Q
'How lonf, d()('S it take for this stiffness to wear off?'
A
'Oh, it's fairly good by ~bout
midd~y'
ET Hi" joi) nUlY ;,m,!,.,· shift ,,,,rk,S
Q
'WhM time do yo" Jl:ct up in
A
'AboutS('verto'dock'
th~
",,"iiI<'
morning?'
ET Tlmt "'1'111" I",'s ,r'fffIJF "I !e'",t 4lwrtrs. H,nt's /00 l(lPlgfin /H'y ardi",Ii'V mrcl",,,imll,,,ck I'",I,I,'PII.
PAIN RESPONSES DURING TEST MOVEMENTS (INITIAL CONSULTATION)
Q A
1:.7 R'SI,I, tirol's cleaF. Nml' 10 te,1 fi"""",1 fI,'x','" Det"ikxl de'iCription of how movements shooJd bc ex.",,,nro is pro\'id<'<J in Chapter 6. The following text, whife it e~eTTlplif;es the depth of questioning "-"luired of the physiother.'pi:;tto know clearly the beh,1\' iour of the 5ymptom,;, al50 ~how,; the words lhat Carl be chos.cn to speed up the process. The patient is ~sked to bend forward and thm return to the upright p<1sit;on.
Q A
ng the phrsical examination, some '1uestions re'l",re mlKh "'petition. &""au,," of this, ("", mnst be taken to '"-'"Did irritoting ~ pali~nt by repeakdly a,kin); tile ",ml" question with the Sdmc' woros_ If a patient has both loc"l spinal pain .md rde,,";! ""in, it i, c·:;:;ential :0 know how e"ch is .,ffe(tcd br mo\,ement. It is danltftOus to assume tlMt the beh~\'iour of thl' referred rain pmallels the behaviour 01 the spi",,) p"itl. The wardmg of the questions ShOldd therdort> I'" well pIarm<x1, b..""auS<' it is <",,,-,,,lidl tc", is no contrdindication to exam....Iion 01 iIll mU"ements throui'>h ~ fuJI r~n!!c. Before >"-ling mO\'emcnlS, it is <.'SSCnti,,1 to know the st.llc of he ~ympton",. Q
'Whd" sl~ndinh there now, what do you feel in your back and leg" \~h"le lot.'
'Did the pain chan)$<"" Y",;'
Q
'lVhM happen<x1"
A
'The bUllock
Q
'Did the calf ~hanlte"
A
'No.' 'And nothing dSt:' ch.,ngeci eiU",,?'
Q A
To ~",<.'S~ the beh~ "lour uf the p"ti~"rs s)'n'pto,n~dur-
'Which isth" w~rst" 'They're Jbout the s.unc '
Q
p~'"
increased'
'No' 'Good, And no\\', hdS th" bUltock pain subba<:k to what ,t was l>t-.fore?'
~jJed
A
'Yes'
Q
'Did th.~t happen jmmedi~tely you started to come up, or did it take a while h-. sub~id,,?'
A
'It "nil' flUt't more ",hil., I \\'as fully \Jent
fo",'ar,js: ET Tltal', idml """"','ri"g. 1 "(}i(,ha,,:a ,'I''Y,'oml'lrlc
I,irt"", ufl,"!' Il'e '!fmp/oms 1"!lIa!',, 11'111, ftmnml No/!' Id'~ "''l' ,.-Imt Iml'I"-'115 wilh aUra
fi<'x~""
IIw,../IIml, .
Q
'Now arch backwJrds', which he does, while J walch his mo"emenl ond his nuances, 'and up ag"in: any pain that time'
A
'Ye5.'
IT TI,c "'''''''Piln,1 willl'n>l",bly !m"" !m,! ill Il'e 1",1I("k ,m,l!<Jr Ill!' talf ACClmu-y ~,ul tim!' MI' II", es>mlial f,wo", IIml i"jI"r"cr )/,c lmrd, usrri ill 'Il<eMiOllino: Imual"",! t/,e 'Where?'
A
'In my bUllock'
Q
'C"rl rou show me the part which i, aff<.""l<xI?' (which he dOC'S).
A
'The
Q
'Equ,lly thro"ghout~' 'No, the thigh isn't too b.ld'
Q
')\'0 CJI!?'
A
')";0.'
Q
YOllr buttock and call are more painful, they?'
lOT Now 1 "i'<~I/1) h,,,,,,
A
'Y<.,;.'
A
1''''''.
Q
till:! llii":!,,, O'J~, aid '''' I",,., morr I~,ij/ l~'m)liIg f,mmFd~ OF "",n' 011 /J,rPirimli [\lck,m"kil",j tm>, !las tire I",i"."bsh'"d foIlo"''''g
45
MAITLAND'S VERTEBRAL MANIPULATION
Q A Q
I/rr:lrmg ",",hN,ds lIS iI did "ft" Jrmwtd flaKJll? 8talUSf' 1M '1IIIgnlng' Ilspt'd Is« pp 63-64, 188-I89J"'JrY"'I u''''mon'OJrrfu11ltottghlJorIM p"1..rIlIOIlflSlll!T,JlrillllSkilfir-;l
On lesting lhe fiflh mml'ml.""I;
'Has lhe bullock pam sub5ldoo agam"
On tf5tingthe slJ
")es: 'In the same ""ar as II did when ~·ou bent (or...anll'" 'l"'o,'I'sonlyjusto;ubsidOOllO"'-'
rr
17lIrIJ~",lOntrIltion_l",u.sIJ'KOrlI"I/nd
""',*llll'll~"'lISlmskbdorrl_fur8rl,1
'OK! rour bullock hurt more when
'Only bultock?'
A
'Ye5:
Q
'Same?'
A
'Yt'S_'
T1usmodeolquestioninf;~noIon1\lhep.1ttenl'5
A
Q
Q
\'w
bt'nt
bad:;.... ros or forwards?'
A
'&l;kward5,llhink:
rr
,",51"""""'''''1:1, ·11~;,.k'.IItm'ltl'dlffrrmlrCIIIl'l Ill'KrtlJ'U"",ylll',h11I,""lkllly 1Ilkm for,l" Slf"'I,loms losubsuk m(lunlallhis ""SU""_ ";$
temperament. butaooltis inlelh~ And "I the ........... ti"",",hl'wil1CQ1n@IOR'Sp«t)"OU,pen."P"~and
cnnsidcrationfor hlSf«"Iings, It is 10 be hoped lhal he IS !"ammg tus role 10 mak~ 109 judgernenluboul hl~ ditoniE'f". Non-,'erl>al CQmmunt.-alion was d~!
pro>lde"ifil is tobe fully uhlized. Perh3F-lhefollowingcx.ampll' helpsshowits <31ul" in rnodifymg the >·.,rbal rommunicahon. Li't us l"mgomgto,,~sm(l5'(/Dst'lydumpg, .."tPlr(lll. a'eml'ftl dl'Sl'rve. area 10 Ihe right mlf,lhebutlock and calfbeinglhc To omil prt'Cision in this area WQuid bo: a grave ,u'NSQfgT"al<",tpam. m,slaj"e,CooHrst'ly,Qn<:ethl'bI'ha>'iourollhepaini> Following Ihe sub)ccti<e e~amu,,'tion and I;>stmi! eslabhshOO,lhl'lrealmenlt<'Chniq"lSun~suitablr forward flexion, the expressloo on lhe patienl's f",e modified and Ihe appropriale care gi>en 10 IrNUn('f\1 may mean, 'How much loni!t'r is Ihls gomg on?', or andassessmcnl. 'lfshesays,~Didlhalhurl'-and~Whercdldilhurtr Tho::mlon.ltlClnoft:hepallent's~canako ()f"ICC mon>,l'U !iorn'iIm' Tlw plwsiOlhcrapist should be e~pA.'S8mU(hlolhephysiothl'rapist,provided..nelis alert 10 these expl\58lOOS and, more importantl\', IftlSwllh her mind as well as her ea.... Dunnglherooshould respect them and ad upon them Sometimes il suJlahOn,@'\'en-possiblead\anl.1geshouldbetakenoi ise'\·en~rylob.lLan«'lhclmportan«'ofthe all a\'enucs of both \ erbal ,,00 non·\ etb.JI oommunlC'" rM't'dlOdeterminetheonfonnahonag<11T1S1tNlofnot 1>Or\. Thl' more palJmlS one ,"""", the quicl.er "nd the u~thep.1t>ent.Ondt'«'mtirungtNlthe"'lteris ~xro...tl"lhe_ml"rltbl"t.............. the ~ Imporunl, she could temporarily ......u...... 'hl!;dr1llYl/~io'l'dwlrlr"""dml(ba.-kul/lrdsl!li1'
Q
-..o...·lctmesee~ouix'f>dIo~ ....rleftSide'
And..., thel"Umif\oltlon ronhn~
!iOI'fM'oftheans... ersand,if,lisqullesafelOdoso. dclerSOll1l"oft","examU\ahonloalalcr~She
could ask lhe patienl 'Can ) ...., "nd y....r Nck. cnN1JOn about the isthela!it. pa,n~lOmO' ..emmt>...,thoutg""'lexpl"lldiIU'" IT lalll_Itl"~grllm.~lm',,'rdSm" qUickly irntalt'd by 1x~ng fT I"msomxIOll'atcIrJt;sp..-tllu"hrroYlllld.",tJH' aWllte ... nlCqUl"ihonsin""'$olIT'ledl.1;l1l1h('rh~~ ~l!gllll"!'l "ry quickly g"llhis mf5S<1g". OnI'way around this. will1Qul losing p=isi0fl,is 10 Lei us a..ume Ihal afler bcndm); b.>ckwards 20" he Slart> 10 wrinkle the mu~k~ Mound his left "Ye, Ihe vary Ih" questinn. On tt'Shng tile fourth ml>vemenl, immlodiateresponso-muslbo.· wh<'1l "skini\aboullh" pam re.ponS<'. ju.1 say l1lIl'~\ilmp~g.\"".,hou1dsho\o.' how I11SJl'O!6ible
10 detl"lT1llnt
'("0
om
Q
A
'UUllockagain?' 'y,-",:
Q
'Up you come' (at Ihe um" lime encouraging tl\l'll'lurnbya,;;;isti"l:il)
Comm~nication
ET I should b'cllrif!dhawl flSkwherr il hurl. AW",,,S" tanm.b:Il~,m'pfJO"sis",,,,,,gtnp,mClI"e,lhisisa
timeui"'I"asllu71lia",:rlabtn'l',a"exNplilmmusl
1'1' ,,!/Uk U,,,ll'r t!1est'circumsla"ccs, ifl
Q
a~,m,e
correcllythalilu""I,is/;ultixkthatl,ur/'iluiillbt' goodpolicyloSilytl,isa"dll"",aUhehasfodoisSily '!f"S'O'o'l...'juslnatlhisIJrod. '1 assume lhat was hurting in your bullock andnolyourcalf?' Affirmali",'nod 'juSI lwomoremOl'eml"flts. then I"d like you 10 lie down. Ik>nd ovcr to your Idt side. now to your righr (using Ihes<~meobscrva tionsandqucstioningasabovc).
Spontaneous answersart'shil,mportant;w I'll keep myqueslionsastlon-din.'Cliveaspossible. 1.
Inwhalw"y? Q 'In wh"l wav is il worse?' A 'My butlock has been more painful , Q 'Sharpcr,ormoreachey?' A '1t'smoredifficultlogelcornfortablcinb«l: ET nUll's 1101 rmllya'rs".",.illS myqu",t;I)II, /;ul ,t '5 tdlmgmesom'il!rillgpositiw,1<'II;chjortl'ellIVllI""t rms<'i"stoarceplQ$b''''gr''''''gl,arlSl<~7.
2
Which pari? ET BeC4wsrlwmayllllL'l'llnc""'ro<Jtl'roblellllsJwuld detrrmm,' if Iris rIllfpai" IIllS changed, and il u",u!d IY I'I'lter tv do> I!/ls IJtfo,efirrdiuso"t 'u'!ren'aurl'whllofhisi"cretlw/;ul/ockpai". &Ca"selllol'el,iscalfIXli" IlIls,,'t u'Orser,1'd too, lam go>i",~ to a,ll/'" quest/all ill a u'lly tlml
"'0'
AT SUBSEQUENT TREATMENT SESSIONS CHANGES IN SYMPTOMS (SUBSEQUENT SESSIONS)
""lIi,ljI"errcehimtoS!1y'~,the'lllf!,asbren
,oo,set",,'
Letusassumclhatlhepatienlisagoodwitnl'SSwilh righi-sided buUockand calf pain, and lhal he has IOSI allanlagonism he may have had to the qucshoning of the inHialinterview. The laslIrcatml'Tltwas2daysago
Q 'Doyoumcanyourca1f?' A 'No,lhal'saboul the same , ET Tl,al makes tire allSwer 10> Mlllt I "'1mted to know !'Crypositw<,.1 know Iherea,e Ilm'l' parl,mlar timrswlu71c/lQnsrsi"symplomsarrlllostlikelyto lun'l' b<>err d"e 10 lrealmerlt vnd tllllS 11I0'" informalive for mels.x pp. 71-72J,b,41ldo,,'tWllnl to q"esfio" hirn ,e<~a,dins tI,ese I!",,,, times u"It'SS! ,a"'lOtgcllllt'an5u'I'rsspotrlarreously
IT / ,ami 10 drlermine 1IU' effec.l of Ihe last lrealmCf,t in II",mo';/irl/o,maliwlluy IlOS.. is usual, butl'l'e lx't-"flterribly tired , ET Afle"slthistrlls",elhathissymplomshaw"oi b«nsij,'I'ifkalltlyll"'rsr.lfll...ylllldln-",hellYmld hat~5/XJ'/5Ctohisa1lSwersh",lidlYasfollows: Q 'Yes, il is quile rommon and it Can bca good indicator Howha\'eyourbackandlcglx-en?' A 'A bil worse , IT Most rCSIXJIISG nlTot quallfymg, /;"t for 'trorse', c!arifymgisma",/alory.I"eedtok",,,v: • [nwhalway? .Whichpar(? • When? • Why?
47
Q
3
When? 'Whendidyounolicelhebullockwo~ning?'
Q A
Q A 4.
'Laslnighl' 'How about lhenight bt'fo!"{'?' 'Nodiffercnlfromusuai' 'Su there was no ch"nge from the lime you lefl here afler lrcillmenl until lasl night?' 'That's righl ,
Why? CT ltisrsse"twlthal/nmstmalel!U'palieutjeelable 10sayl!mlileft:elsllisin'retlSfi"I-"'inwQScauscd byll",I,ealmrnt.
Sum"palientsan·quileprcp.'redlosayangrily,'You made it worse', bul milny more are nOI aggressl\'e and do not like 105
48
MAITLAND'S VERTEBRAL MANIPULATION
'10 one hM'S the feeling ~ssoci~ted wllh h~, ing molde ~ p.lhent worse ~nd being told so, f low('\'er, the<;c ieelings mUSt be overcome; the iniOl'Tl'l<1lion bein~ «lIj~hl j" rna«" import.o.nt th.n lhe ph,-'iotherapbt'i "'mohon", and it is essenlJal to know ",hill h.t;; made the svmptoms worse. llu:: b<:st way to aslo. the question. ,,·hich he ('5 10 on'n:ome one's inhibillOfll! ..00 10 m.lk ,I ea"y for- the !""hent 10 '~W"ft is to"a)
.might 0\11:: Q 00 ,au think it ,,-as ,,'h.ol I did 10 IOU lasl time' which II\dlk it worw?' • "
'\01 ll'alh~ bd.. use the ni!;hl befOll' I.lsi Willi "II right. And, actu.lh; "'h<.'fl Ildl h<.'1"C I rell betttr, and I mink I e.. en had a better night
th.n usual: (1" TIIPI i; ~ i<'JM QJlS;''"-'1S ""'i"",smglro-,,'ll('ll!ul Q
'),'OOJ 1l.11ll'SS" (all ~, I 1I0W A'ue'!l' 'mt'~"''''
.I,,"d ",.. kc I"", ''''r.i<' lib! "'gf,I, bu' ,;omdl",'g
DURING A TREATMENT SESSION CHANGES IN PAIN RESPONSE DURING REASSESSMENT OF TEST MOVEMENTS (SUBSEQUENT SESSIONS)
""m
The t"'-" mon'fTlC015 on re.ls.;t.""""'-'flt foIlol> the' Ii des/:ritx.J lor the ,nlh,,1 inlt."ft·"",·, but with Iwo , The fi.,I,,;. the- onl .. lI\O\'emenlS IN.t han: 10 be t""tr...d aft" llw\s<.' 1lt.1t w,.... .1bnorm.ll. Ho,,''''-cr, ",",'ing s."d Ih", !IOITll.'hm"", it " t'lIJ\:dS.cept,on is that. ,,,11<.... Vltt:' I~ (ht!t;;~mga t""t mmement. it is often helpful to know t~ pdt~I'~ opinion of the h'S1 mo",~, ......t (oml""\..(1 \\ llh "'hen the physiotherapist Id,t lot."j II b~ lI,kJrlK
e>:""-'Vi,
Q
'How d.".., Ihal feel to you comp",,-'Cl. with when you CIImc ill for tre;ltrne11t last time?'
A
'Dill"",n! - "",ICr'
"'I'!'/ h",,,,
Q /\
[r
Q
'Do you know of anj" reason why I~st ni~ht ~hvuld ha"e been wor,;,:,?' 'II nuw be lx'Causc I ~Md to
Tlw1It ""''' - ~105J 1It/lif"l. 'And how did you fcl,lthi$ moming romp.~n..d w,th olher mominlls?'
'l:l.M;k 10 w","l it h••s bet-rt;lll dl~.' (.r TlIIII'; rX«lI,m, TIl;'; i:; ",.'fll i"~lfiotr to I.,-:p "'11 )lulgtrnmt t:Jf t1k' pr-<sn:t ;;:.wiilty ,0( /;" di$
,il" U>r, QIr,1 _"'!I ,,.,.,} 10_. ;11 I ..... """,,!
The I'oIlo\<"inl; is an """mpk of .l. p.Jtimt not ,lI\$w~ng the qUl'5lion. It is import.ant l(l remmlber thor infonnallOn \'Oll ;Ul.'K'{'king; thi3i is theonh "") 10 a'·oidbt."1ng kd ;lwaV from the poinl, quire unmtentionallr,by the !""bent's "r~wer. The qU(':$bon is ilSkcd:
Q
A
'llow o;Ux'5 IT f«>t' (toe ooo-spo.-cific, thc
This ,,, not ~n an;;we. to tile qu~'Stl"n, and the phy.rould \x, led off the t',K~. l'hl' follow-up '1uo,.;!lon should b.'· i"lh"r~pbt
Q
'Yc'S that's how it is now, bUI how dO(:S it COMI'Al~E nK~lt
A
with when you ",mIl' in for tre"ton Friday?'
'If,abo"t,h(>same'
ET J 0",1011101 drro'Cl "".~ r/iffi',.,."cr i" "fIlSO' or q,ml· iI~
'1 """...",,,,,1;
>(>
I,,~ ,,,,,,m,'111 is ofml
PAIN RESPONSE WHILE ONE IS PERFORMING A TECHNIQUE (SUBSEOUENT TREATMENT SESSION) II .. important 10 know "hen f""rftll'ming" t.-'chnique on a patient ",!wI pam "-~ m.11 be \.lklOg pl.>c<> during the p<-'I"fonning 01 !ht' Io.'t:bnique. """'"' md~ ~ no p:un; or no I'",m \(I st.lrt WIth but ~ may occur .... the Itrluuque ,,; conhnlll.'d; or while performmg tho.' IlXhnique tht...., ma\ bl' ~ or ll'prvdUCbon of the p.lhenrs s)'mplor'OS, ... hod> nlaY bcl\il,-e in one l'Il throe ways; 1. "The 5yrnptomsdec",,;.,,~;'lnd dlS"lpp<'ar (II"")· m.o)'
during Ille f,rsl lo-:eo «
11\("-""",
2. The symptoms mil)' OOffit.' .Ind go in mytlun ""th the ml'tlun olth,'IL-d",,,-/uc 1. An "chfo may bulld up, which is not in rhythm
w,th the lL'Chniquo:
TIle communication ;"sU\,,:> :lS8OCiat{-'d with d"term;n-
bl!"",
ing the iour of ,I.... ,ymptoms during the per· formance 01 the tc'Chl1ique Me reblL'Clto trying 10 help the pati"nt understand wllM til<.' difference; might be, SO that he can 1;;""" ust'ful ""~\\',,r.
ET Now 111m J lUI:'" sMrlr,j 1¥r(iJrm;"i: Ihe' ffflmiqll" I "'1II;f kno>w lt'~
wml'lCms.
Communieltion
'~\ou
A
doing thb r '0. I QUI', feel an}thing other than the
Q
~tn'tehing ,
A
feelan\'disromlntT dl all "h,le I ..m
IT fbi! 'J: ~~l/I.
Q A Q
'Stdl nolhlng:
A Q A
'Y~'S
cr
WMII """d 10 b"",' "Ow i•• r"'NOIlI/"!" I"i, i. as""l, .1Il! 1",11./-"p;nlO"" aellt,'or ,,'h,O..., II i'sPinS 10 'romt "lUI go' (II Thy/hm 11.',11. Ow ftdml'1"" To
'No.1 can feel a litl1.. in mr left buttock now' 'And that wasn'l th.. 'C" hen I starled?' 'H~~
il chang~"i sinc,· [~t"'trol'
'Y~'S,
Wsslightl), ",,,,.,,.,'
hi~.,
0.. 'l"r
'" curh • uUJI 11131 Iii'
""" of r.m
"m
,1lI1l'11..... ts:
Q
'Does it rome and go in
rh~thm
WIth the
lnO\ement, or is it a st<'<1dy;odw.-r
A
'II S lust a slight ache:
cr
"~l I rO'"nJ Ii> ohltTmul<' I:; qui<:kl," <1$ 1 rmr i< :riItfht'r il is going /0 " ...NIl., :Al'. jkrfl~ ,I;t <Jf tlrr 1«I",Uj,,(. ,rhtll>rr II ,,~II rtrIf:I/Illlw MIIIt, or
rdwIJrrrltu'i/ldt'rTl",,,,,,",I$" Afk.,. a ful"thl'r 10 ",-"Conds, the 'lu,~tiO"'5 asked'
Q 'Is il jusllhoc ""me or b ,I,ncn'asing?' ET 'fhr IjlleSllOII I, asKed 1111, Imy, btl/lll_e II i, !lOp"d 11,m tlr~ '!lmplilln, ""II ".../", "\l>I",~ lI"d tr,~rrf'rr 1/,. /tr!1,'r III ill( a"
I"fi"""'"
A
'It'~.lboulthesame:
Ten seconds larer: Q
,\
How
iOOlI~ 10
Q
IS 11 1lO""
'It's~lttnnlL'
«
'And no,v?'
A 11'580"'" E.T Tlml" R~ NiMI frspo'!5<' To l;""w whal is happening in such d~'Pth" Iule OI'Ie IS pl'TfOrming a tt'chni'lu" is \-itaIIO proving the ,·...Iue of Ihe '~"Ch"lq"c lNs n."t patient (a man with a tCn:ic,11 problem) was nOI a)loud wi'no;,s~. On performinll the te<:hnique, M 16pooded 10 a 'lu~lion by S
'Yes, I can feel ""methmg ",lule you'A" dvlng ,,"c'
'1s it """ the pain pm can g.."r 'It's hard 10 Iell,'
Q
'Is it a nice f..... mgOf.l n.osty feoehngr
A
Q
'I don't kno'I<'.' 'Does your nos:k
A
'I don'lImow'
Q
'Does it feel a< Ihough what I'm dOing's getting al 'he lhln)llh
A
'Oh yl"', it certainly IS'
il was Ih"re, irs always lho:re'
"/ilki'll rrr;in' frw
In
A
Q
li~e
it Or dislike it?"
Ouy the la5t dnsW,'T pM'lde:. the infOf1I\l\ti..., ncedo.-d, i1nd qu.,.,tio,,"'S has to conl",,~ untillhi5 is ochic\','(j \\'''''n you are pcrlonning iI It."Chmqoe l11>,ng you. hand on a ~jnful art'a ,lnd the polhenl n~ponds w,lh 'undcr ,our hJnd:""",, \'oo.l5k If he is fe.-llnS "n)" thinl;. the "nrr..,
A
"'illhc-f'""i'>UA'ofm,""nd... ;"dtherl\O\o..~ nv....t "-oproducrng ~'()U' pamr 1 drln'l know'
Q \
Is It on the sutfJa! 01" d""P ln5id"r '011. dl"fimlely not surfOl«'.'
Q
Of course, if the answer is not l1S d,'Cis,,'e,}oo Ciln ch,lIl!/;e your contact as "ell 10 !K'C if II... pain ch.,ng'''',
PAIN RESf>ONSE AFTER A TECHNIQUE IS PERfORMED (DURING A TREATMENT SESSION) To d~termine the ~ffect ol a teduuquc, both Ihe ;;ub!i!<" ti'e"nd ph,-siocaJ asp«b muSI be.1SSeS6<'d. The patienl IS a..ked IOsl.lnd so thJt lhe ph,'siotherap;.:;tColIl rea;l;i!'SIS his 1I'IO\~ls. Befort !\Stulg the lI'IO\'ements, tre p.atientlS a5ked whether he fl'\'h ~ny dLff~1 i1S .. A$ull ot the kdvuqlJl'. ~ foolll:m. iog ron,t=1Uon shows how tIu-~ c.m boo done qmckly ",,!hou' sacrificing the d<epth of mfurmatJon rcqUI"-'l1.
Q
'H",,' do )'01.1 fu,elllOw comp""-'l1 ",th when J lasll\ad ~'OU ~landingr
A
'A!xrulth"samc
ET 5os'lojt<:IH,yl" Jr,' i, " ••(I"mgnl~ now lach.d Iii, Q
m""""''''''5
'No,," belld forwnd. - C01lle up af:ain )-luw was you. bUllock Ih31 HIIlC'?'
ET /"", ,lOll'll thaI lilt ml,gt It'llS 5 ",""r,mtl"" fur11t, .., ~!I,j till' q,,,,hly of/liS """l"ItIt"l /i.JoUd brUer,
49
50
MAITLANO'S VERTEBRAL MANIPULATION,
A
·tt dldn't male m,' bullock an .. WOlrM.' lh;!t lln>e.' -'
Q
·Andn<J\\·thatrou·... upnght.isltlln~"l)1"«' asa result ofh""ing bent forwardsr
A
''\k)'
Q
'Before
' OU Nd ,)J'lr trouble with ,-our back.
how far could ~ou MId (o....um.?· A 'I think that'§ as far as t could ....·er bend.' fT l\tll.9I b:;I i, _>forrzwnJftfn"'l$much~ /tr. bMIug pam is 110 w",~ prtJt'CktJ hti 1"..71 III(l{It1!lfIrl. NUMJ kt liS $« upptnl'd kI
_
If, ho.....,..,r, lh"", has bo..'o.:n p~~, the .. sse:;,.mcnt m..)· be made in IlK followinll manner' Q
Beea...... some p;lhents .re unable to think in tIu'5e terms, it ~ ~ . lolldd I(l til(' question- In doin& so. It is better to bOils ttr q..:stJOrt toWards an unf..'ou....vle ans...er:
Q
'Well. a.... ytlU less than halfway to being com-
A
'Oh no. I'm more thAn Nlf better !hank you-'
pletely better"
lItt'otl"",..............,/s
And 50 Ihe routine continue'S tt mOlY be useful, ent has changtod. Tho.'rc Ml' ~Imcli""" situations where ttl(' ",.h~'r'I1 starts to mO"e more fwelr and with more quanntr but th., piun is .IJtl lhe ~me. ><,me, atthough parts 01 his mnvements arcchanll'''!; iltn.·ady. Br a,kmg the p.ltient ~bo"l ()lher a~p.,cts elf lhe moveme"t that is bcin!\ te't~.,J. ho.~ may le.1m about this and COIlC<-'Illrale morcOiltht'SC nsp<.'(t~ of the 1l"S1-llW"emenf as .....ell
QUESTIONS DURING A RETROSPECTIVE ASSESSMENT (ARER EACH THREE TO FIVE TREAIMENTS) II IS (n."'lo.lel'fl)- ~rl .11 the
third, faunh Ol" fiflh lIJ\ lIS~t of lhe m the patient's slmpt0ffi5 ,>lid sil;'"6 compi1n-d" Ith tha:;e at hIS fllSl, i:sit.
treltment session!! to
'Ho--' do ~oo ~ mmpa-t with ~ we
bq;Mt1" Ths qoc-.tkW> is ""tremdy "aluable, bcOlu,;e 1M .MWi!r en.Jbles ti'M:' rl'}"Motherapist 10 see the progfC'!6 lit Ib prop." pl.~pt'di,'e lI;snol uncommon for II patienllo rq>Of1 al ~h ~"cre<si\'e treatment Ihat he is foelmg bctlt'f, 'Yes. I ~m s"'"' I'm a bIt bctl~·. ret al the fourth f~.llment );Cf;Sio", if he is a5~cd how he is compared with lhe finn dar, he will 'UID' and 'an' and ilo..-:.it;lte and finish "p by !;apng: A
'Well
. rill not an;'
wo~"
II is fur reason, such as this Ihnt lhe n.:iI\lSpcclh'c as.~cnt
WHEN PROGRESS HAS SLOWED OR STOPPED Makmg a reilppr'IIS.11 of the eff(.'(:f or treatment at .. sla!;e when r~r~s ,s 1'101 <:ontu'un'/; as il should is .., difficull "5. or '1lO"" difficult 11\.11'1. ,\ first consultation The communicatilm a.pl.'(1 is m"rh the sam.. a, h,1S "lre<1(!y!J<x>" discus./}lelll" from a "'arhi"g pOutf of \"'''''', an~ ""lImS d<>wn what it is you wish to find oul. For this reason, di!lCus.;ion is de~tl with sepa· rately (S
CHANGES IN SYMPTOMS AT REVIEW SESSIONS FOLLOWING A BREAK FROM TREATMENT
AT REVIEW SESSIONS
Q
'What do roo fuel the pcm'T'ttge of Imp«:r.-ement has boIen (crnp;ncd "ith whm ".., beganr
musl be made a routine polfl of ~ntment
Rro,;cw consolt~t'Ions iI~ oooJucted 10 assess the changes thai have taken pia«" during a" i"terYal foI· lowing cessation oflrNtrner'll II is only the communi· caliOfl aspect.1$ il relates to ~.ng changes In the p.1ttenl'S symptoms thal .. ilI be d.5oCUS5l'd here The p.1henl to be rl'\'K·...ed thesame male pat.....t ..,110 was .. good "-Ilne55 and ho had rigt.. bull<xk p.llIl grea= tho.n calf pi1in lie 1MI n!Crived trI"iltment 10 ciaJ'; ago. Folkl\\ ing the introductory p1c.Jsanlt"tei, the questions and "nswCf"S talo.e on the more serious ,~
Q
IT
"-""'II now, how 1\.,..., p'" I>eo.-...." T[)suIl:'
50
I"",
tilms .hould b.- NgU(, If> '0 rnrouTagt '0 dl"SCnb.- 4Sf>Xt$ tIS Jllry ro_ to IllS ,,,,,,d. ,,, 011. ~"'~ Ilw~ !1'l11 a>'~ III JIll! ordrr of impot1QIKf;.. lJ.~lichlU'S<"r$lllrm.
A
'Beller, l"m ple,lSl-,<1 til say.'
ET Well tlllll', II Iml'l'Y sll1rl; 1",1 wlmr I "cl'd 10 drra· ""orc;, wh"t IS /Il'1/~r, in what w"y " ,/ 1it'lIcr, hIT'" "'liCit I.l IIllC Iv /,,,,,1,,,.,,,1 a/owa",1 how """II
Comm~nk~lion
I> "I)(I1I11I1lrIl1tS rtali"''!!. To I'~1.~ !he~JelrmJ1"D'
A
'10", I ,J«J {if"$1 10 k1w", III u~"" """,, ITt' hi/!. 'mproved IIIld Ihe in'pro1Ym1'JlI oakrrrd nit! 00..' much better ~...,,;;,ll"" loll' if
lOT "lid I 1raTffl'l """n hi"l for 10 dR.!f5' So TrI/OOuI rlra/ I"",, /uti /:non rot,I","inS ilf:l7'WO'!t'TT' ~hr()llg/lcllt tilt JD--dtrv intt1T1dl. Jl;; IImJS,/ nat tfuJ...... thIS. 1'11$ a/>olll dJIIInsrs m Il'.lntxJ: symptao./.>
II t\II'l ~ltiotlt'dspottlnl1roush; I tID h.r.y !",TI!C..lor qU61llJrls rrlalrd 10 h.s >ymplt"'rs llral
J alII bk, lrr.-inK rrrordnJ 1Ja.m .lId "",.w ""'III 1'011I/5 IMrh ~l'1t'ib
", hl'> lasl tmll"fl'nl
A
. And ,,-hal h,a" happened 10 the bu!tlXk ;>(hlng M\d ,ilting 0"('1" tt." Lut -I d",,"" 'I thin}:: II'S k5s0.1ting •
Q
'You think?'
"'The aching dOl'Sn'l boI:her me dunng the dn now, .. nd when I gl.'t out of !>I'd in th<> morning
...
'WeiLl don't sir a lot .... eT'\-- d.a\, bull impl'e!ioSlon ii's impr
I don't !\ave an}' dIfficulty putling on n"
ET TI/15 rrin'orcrs
Q
HOU'<'l'<'T,ltbll«'Sfll""'lilrl/'OUS~I"",.lIlr
Q
""'""""
11wt oounds good. Ten me. in what ""y "J'l! you
A
'I ha,-",,'I had .m}' c"lf symptoms for tIM> \a:;I: -I days-'
,rltt'"
ben~"t"?'
inS'
ha." the
ll~ r;,;'rnol!e tl",t he i> WlltiIH,iltS I" impll7
~ksand,;.hocs
!,,'"
~T He
1.ISIl'1 mellrmled s.rui"Ii"' ImlI lmlM /ir<1 dar· 'dotS,,', bul"er mC ,IIlring the d~y', I/r!,.,,; $(lid il 'doc"", bulhtr' !",n. >Q rl sow!>!, U:I tllo"SI, tln'rt art 51ill S
if'J ,dwl !" Ifleu"~ by,
Q
'Do }'OU feel """ !\a\" 111l1'n)n-u tl\"nly OW" Ihe 10 daY', ,,' do you think that most of I"" ""pro,em""t came in tl'll! fltSl f"w J.,ys "rId that vou'"e been static since?'
'I prl'Suml! you me~" you slill have SOil'" during lhe day but th"t U"'y U" k'S. ,1~1Il Ill"} Wl~r". Wl..,t is ;t that you do fL",l?'
n
By p,dlmg /IllS qll,'Sliul! ill Jilt' r'l'rliClllarorllrm,,,,, dW","II, 1 am dd,!>t'mlrf.v i'!fl"r",jllg him all'o.v .from Ilk' arls"",r I am ~xp«lillS'
'\.
'Oh no,
A
'\1y buttock aches after ,.'"'~ ~ sitting for a
I'-r
Q
'Sitting for how long:>'
fr.wi,,'1 chi!i<'lhrs OIly furl!,.'!', It s.rt'>l1S arm'" I,ds slill 'I'rpror,;"g, _IIJ al III ""t "'~I'(J, 1I1'1""'rs Mlf15frx1
J!
Q
symptom~
Ionll tun,,: '2-3 hours: '[)o}OU !iohlllw\edlffk1.1lly gemn)l; O'IIt of the ci'1urr
A
No, not now: 'Andismatall?'
A
IT
ism"'"
l1'.m/ if/It wnptonl5 cw rlttn "" mroy rolW m
511ill1g, lit ~ itl pm.
Without nw h.ning kI ""k, bf.1 I "lIlY IIffli ttl qUll,'rfv .t 1l1..w. wft7. fo.:_ I ""...1 ", wm /~ ~'1SUVT5 ,.. Ill"
MptI"'''' If''t'S~ ""~ rrl4,('S ttl
'1II1[ pm't II«' <>11m- rrl41t"i ttl a'hm
I~ gaiJHvJ I~
,,"PIVI¥7n,.,rl and u.~~111U I", I;; eM/mllmS to ""pM", 1J... In"ff "",1.1 pror>r 10 k InltH,V. .., Q
lip rl", cal/fin;!. 'Ilow,stheulf?'
A
'O~,
U'I"" elmr
that's all gOl'e'
fiT TIIIII mrst' ...,
rm,,'l''Y
~n'
'When did
a5ki"s abollt ;p':mta"eo,,~ C'Sl'rcially if lile j"m""k amI coif IlmYtly linked.
IIWI' make
"T~J/,
A
",.~ior1s 1M! Jr un tdtplrot~Q',dallied ~"I'PO'nt
Yt'§.,' \\~lJ.•/1IIl1< 1II'~
th~t
go?'
imprm'ing:
,i_,
A Q
Q
T'", ~lJ"" il'~ ~lill
CONClUSION Although tIllidi5cussionabout communiulJon "nd ,Is probl....... may sc.= length), II rrot.",,'ly touches lhe ""rfaceof the subject- and II mu,1 ~ ,~nizl prim.K)-of the ,ubje<:1 will show on reading the section on 'relrOSp<'Cti,-e asses,mt'n!)'. II Is hopI.-d that, if the foregoing has been understood and nbsorb<.>d, il will make n..'!rospedive asse,;,;mc"t. a p""'"rful tool for the mnnipulnti\·<, phy,iOlht·r~pl,1. eqllippinlS her to be "n ('Ssenll,,1 consultant in nssesoLllIol tllC pali"nts' musculoskelelal disordcrs.
I,
51
53
Chapter
4
Assessment
CHAPTER CONTENTS Li$Un and !!diNt 55 As~sm~nt ~t As~~nl
initial tlQmil'lJtion
throughout
t~atlTll'nt
57 59
AUtrim. GO Components - 1 6\ Components - 2 62 Communication 62 Beh....iour of pain, rrsislanc( and
mu~clt
spasm
62
Behaviour of il1Iin 62 Behaviour of resistance sa Behaviour of muscle spasm 68 Identifying normal and abnormal findingsWl\u is norm~17 What is abnormal? How can
Ihey I>l' ddined?
69
Ideal spine 69
A.V\"ragc spine 69 Abnormal spi~e 70 Ne'N/oid liss
72
At tht beginlllng cf ud! stSSoOfl
trut~nt
72
arious d'31i;
()I.e. HI<' }""Th, \
C\.'S,f"lIy. M.ln~ of th" sugg,-"t,...i CM'ses of the pat;':,,!', problem. Me not whoU)' ,ICc...'pl,'
AsStSsm~'1 d~rin~ lhe perfOl'mil~ of a treiltment lech"ique 75 After the teeh" qu~ ~ ~n perlormed (to dete,mi~ the immc(l,ate rlfed of a t~nlque iilnc' Wilke iii judgement ,bout ..holt ~ld Ix done MOW) n Asscs'lmrnt atlhe coMplet,on of the tre
81
Analytical aSln5ment 82 COnclusion
mon'm~"'t i~
8J
not
,,"'-'(!
much b.>lh" off ,,..,
~nd
to its f"ll",t adv.m!.1!:". Huw NI, patient> wOl.lld be If pas-
SIH mm"cmcnt tr.:.ltmCIII Wl'rC 1.lS<.'d "nd wlltmllcd hy
prof",r i<s><'Ssrncnt '" thai its nl1" '" the a,-crall m,ln.ll;t~l1<'nt or
Ieamed.
Ileurom"_cul""k,·lctal problems could be
54
MAITLAND'S VERTEBRAl. MANIPULATION
During th.. Ia". f,'" years, pas;;i\e mo,·t"m('nl h& )}'Iin•.'d groo1l"r "-"ClIS"'tllJn as an •..ffe.::11'" mnde of lre"lm ..... l. Furt1ll!rmo its us.' as a SOUro! of informalion n.'garoing Ih" 1:10- , iour of joint d"""ro....... has l;ooeoen
reali7.ro by ~doctorslobeof gn"o'Il' aJUI' ifd1ol' IOinl accuratell- throu~houl IlNI'
lfI()\i'mi'Ots .. re ~
ml'Ol. \\,Ihl",t
~I.
IJn1tm.....t
.0
~lv
an
;tpI>llCiJhOn ()/ ll.'('Iuuqueo ladjI>g guideI~"-"~
h.o5 been rdMn:d lO in Ch.Ip~r 1 (pp 4. 12-131. 11< ....aJ identity lII
The,••• 1wo1lWUlg
proce5S6
on ... ~
E.>,caminalion ;" dcs<:ril:o..'d
,n
Ch.Jpl"r 6. Howe...er.
for the purpose of Ihis cn..l'tcr on .>S6eSSffieIl1 il is......,."...
SillY 10 elaborate on CC'l"lam pomb, becaU5e ,,;!hour U1 ...-amm.:ol",n lhe proper "---~ tnents Cilnnot be made.
accura0: aoo dct.1il
"'edinl dli~nosis onIyd'~v..otflit mobollla:M;lr! or 1"I:I";~:l1ation COJId II( a lIe,I1l'Il'I\1 01 moitt hlf\hn drlililnl ~",,,,",lJOn of _rnents is e..5C:nlil to drtrrmir>e the eun
The h i s seekng the souraIoI!he ckordllr. a'ld ... -=ond IS the
...-oIlhe~ ,"~ONE
A.
I,
The SOURCEIs, of the symptoms Name IS \he poutble $OU""",,, ot *'Y pl'rl 0I1he peIlenl'••ymptOms !hal musr bill exarnned. Joints unde
"'''''r.)
f.'
2
Ara UlBr. any special tests indicaled? Neu'OIogical e'ami""lfO(l OIt'9\" - speclly
a, t>
an_..,.
8. Inrluenee or aymptoms and pathology on ..,mln,tion and lifst treatment 1 Is lt1e pain _ a ? (Ills/No) Of Iatoo'? (""slN~) GloB 111ft (l)(amp/fl 00 wIlfch !/toI baud. I. LOCJII S)'Tllptom$ I. R.peated MOVEMENT causlng pIlln - 01 go lust bIIIyood f'1 ~, S-rtyolpa,nsocau')t'd 101 Dural"," belore paO-lliUbIidIJI; t> RefalTad'\:llhef syIfl7loms i. Repeated UOIIEMENT CiIolISIRl;I PlI'" - 01 go fU6I 00y0nd referral 01 pcun . • S-liy of Pl'In so caused .. Duo""'" betore PMl s:t:>s::tn 2. Does Ihe nature 0I1he d<sorde< 'IdIcalIea:udon? (I'M.'Nol ~ PathoIogyTf,rry - ~dy •. • , Eoasy 10 po-owoli:A ~ or ac:oM aposodII 3. N .....e...,~lions.. ('lb1llotSpagly
C. I.
2.
no. klnd '" .umlnwe.n
Do ...... _ ...... wiI..-::I1O bill gende 01 MOderalely llrm wiIh yow l!ICa!TW1aIionolltl8~? Do """" exped a c:emparnbIs s9> 10 be - , . or 10 tIlIllafd 10 ind? Wtrf?
~rn<>
D. 1.
no.
.tJJ$( oll/'lll SOURCE of Itle . ~ : Auocl8led ".amlnallon neUfQimuscubskeletahnadiclllllldofs teading 10 the cause ol!he & V ~ Issoeiated taerors nus! tM aamlned .. As Nasons "Ily It'll ioont. roo~ Of odl.. Slnll:lure _ becoroo symf*lrMllC anG'O' t>. Why the joint Of muscla disordef may reeur'? (e g. poolIu.... musda ombalance. musel. hypennobility, mtabilily; delorTl'llty;" praumal 01 distal jon, 1I1c.). Tlla ellec1 01 the lisorrler on """' stabolliy ~
~I
2.
po_. Obeslly. slitfness.
E. Treatment 1 2. 3. 4.
Which lhort·term or Ion\l.!elm goals 01 t,aatment are ""rsuad? Do you ",xpeel to be traatlng pain, rOOSlarlCa, I'l'8Bknass or inslat>dity? Ara there B")' pracaullons or conl,aindicat,oos which need to t>e respected? In planning tha TI1t:ATMI::NT (ahar the axamlnatlon). wllaladvlce s/loUd be inc1LJdad 10 prevonl Of I_n fltCUrrooces?
At!fIllleng Guide (11198), ...i1h ~
""""'ide
4.1 Asscumom.: an initill ,ug~ 01 {fUlmen" ,..-0 roml"'nmont l~inllng p<~ses. so-ol.,"g thl: j()jirttof th~ n>Q\Itmonl diSOfde' I'! ..ell I'! ~king (ho, rou-,,"'" tht SOOrtt WIll gu,dr t,eat"'."! proc.dUfO Fi~u",
Assc:ssment
In Chemo:r>l. II is u..... ne<:e>.>df) for hoer to mdl\·,d~' lnO\'oI'f'I'Ioerl~ in dl':alI FIf'St. and I'l'105I importantly, eumi..... tion 01 the pabml should I'f:\'eal which particuLu int""'L'11L-bral lo!\el or whIch neural romponffit is rt'Spon$,bk> for hIS ti)'tT1f1loms. lind ",hilt .-fleet the disord.... hM on his mo'·... ~lS It is by n!SIoring lhese mow,,,,-'IIts 10 normal th.1t his ~ymptoms will Jx> reli...ved. Slxondl,', abnormalitv of loc mo\"cment of the faull)' C~POIl<....t should tx. determmL'1 dh'ulgc:
"""m,ne
I. Til ... p!'l.~nce and behaviour of pain Illrough tl.... a\'"il"bl" r;ttlge 2, The mo\"ements th,'t "", restrictLxl ur hy~r mobil.... :>. The ,,"tent, q~lality bd",\ lOur of stiffnL'S' (including the rele\ant symptulThllic responso!l during nmvL'II1C.'n1 or alth.. limil of rang.... 4. The e"tt'l\' and bL-ha\ iour of mu>doo spa'''' durinS 1110\·,m"''IIt or atlh.. hmit of rang...
,,,,
IMwvKl\.W oflhe 5)111Ptomi is Ihl" I\'IOS! importanl a5J'l"."'I The 'bo:oh.:l\IOUr' of the <15ped$ lisl:ed. abo..... relates to nl()\'ement5 of the raulty inl"", ertebrnl JOint and the roncurrent S}'1'I1pt()fl\i!.tic: resporo;<' al the ti~lI"J ,f/if trealmC.'f\t. In rdation to tJ., pam~tJ\'" structun.'!i in lhe\~a1 cal\illand the in~'ertt'bral foraml"n~,.e the dura, lhe "'-'f\~root slee\es and the llt1'\e 1'I)(Iol$), their ",O\emrols must al>a be ~ for •.Ange and the bo.'N. IOU. ~ ~)" resuftir1ll; p.oin. ~!laInl" n'l(J\ emmI .~rntt11 need. to be..-le of the neural s!n>C" tuft'S. Also, in 1M dailv managl"mel1t of ihl" n'rtcb.al dil\Qr"d«Q. it b ~t ..l to lno,," the Slilte of condu.... bon of 1M ner>'es in dto;;e pahenls "'ho5c symptoms indiul" invnhemcnt of the rol'1"\-e root. Many !e'>b Can be used to assess the joml rJ\O\'ements """nt;oll,-d 3\)(1.·..: amons the pnnapal ones are the
Assessm~M IS the k~yslOM of dkctive, informati\'t tlutment, wit~O\ll wnid'1treatmo:nt ~UC=les and treatment failures lose all value as lurning expemnees.like tne keystone, a,,,,Slment i5 at the summit of treatment, Ioc:king th~ whol~ together
mo, emenl tests producro b\ Pl'l!Sllures on the palpable p.orls of till" \'~. ~ all! dl=lCObcd ill ddail in C""pter(,{pp.I50---162).
LISTEN AND BElIEVE ~ physiolherapi~t
mu'! ~ prep.lrO"d 10 listen!D the patient attenth--..l.y and bell".-ingl} II IS .. draordiRaf)' how ofm'a docto... and physwtheraposts do not 1J..Jero or do notlisto...., carefull) l'OOUgh, .. nd rert.1mly do not list~.....' 5uffK:ienl depth,. 10 their J'dl~b. It is "'rang IOmak<"<>ca.demic judg<menls un \,hat should bedone 10 help a p.o.b,,"1 ,n prefermcr to malln~ .. cl;nio;al judg<:menl based on information the patien! com give, rempl"red by wholt is known acadl"mkitUy A U-yl",r-old health)' woman who had been UI'IiIbk' Iocomb her hair Of do up her bra5Si""" fo, 6 'H'l'k:; bo.'Ciluse of .houlder weaknl"ss and di»C01T\tort ""S lold th;,t the only q:>bons (lpen to 1lL'I we", 'rna,..,r ~U'l;"ry' or 10 'put up with it'. This w",; based on gl"O.'<S arthritiC ch,mgt'S shown on the X·raY". She rdu"ro SU"M"ry, pl\'ferrinl; to put up with il Bccau"., h... SIster, who 'h,,<1 h,ld .. ~"cth' the same problem' wa~ 'cural by physiotherapy', she pn.·ss,'d. for lhl." ""me treatment. Th~ dialiloo"is w~s 'osteoarthrilis' and certainly ,he had gross joinl changl'S. which we", l*'\'ious bulh din;'-~lly atld radiologic311y. Phy5Kally, sho> had a :>5 per Cl'III n.xluetion In r~ng'" ""in on strrlch"'So and co""idl'I'ablc dry cn..-pitus during ach~" mu~e- menls. \\'hl"n the .ilould.,.. was m... ed P-U'J\·..lr with the glenohumeral joml surf.....es con,~-.,j, Cn.-Pltus """ increased and discomfort (not pain) was prm·oked. Prior to till" on..d of ~\'mpIOr1\.'> (, ,,«ls pw>'iously. although shl" """". shl" Iwd an arihritk should...., she dKl not haH> the d;".,.bilit.., 1hc' 'm.>jo<- surgery' "'as b.I"ed on the .adiologkal findinp mh.'f])r\.>Ioarthrilis) probk'IrL Her .shoukWr ,..,.;ponded quite satisfactorily. I~ ~ent liste~,ng lind pt'rcepllVl' qu ..sfo~ing lire =rotlal to gJln Infor'TIlltlOn m.t cannot be r...,~~lrcl by ary ctter torm cf eXllminJlio~
A I""''''-''I'S buly, IdO, alll/~ 11Ilrl. Iltal OJmbmr t<J f<Jml rr, 0111 tell the P"""'II a",'S" rlllllltli'dfl' ,Jjl"lIlmal!l"ID find ,,~I by unyform ~f e.mmi""t",,, olilrr tl,aPlIV irsltflll1g arId (2) askir;s P'''''l,liw ql""li~",; awl u;;,i:;t !rim 10 ""yOrr Hlillgs lie ft.",ls Wr""S<'llis <',GlIMer 1M 1~llalcVl7 pIIrt il is) is 1<,lIi".~ Ilim, Forn~"'l'ir, ti... 1"'$1"'" hodylR~III ils disorda) ls liNt 10 difftmlMlt r'1u'n''' d':ffrrml bnds of ",r~II,.;.s,
SS
S6
MAITlANO'S VERTE8RAl MANIPULATION
Figun 4,2
~ ....
of;he «l'Y'ali ...."" of
, 7~.... .......a~ Ct:MCd 'p.M. Th~ «,.,;a,ijl-t 'l<:UtVnl_~ tllllltno;n Thtft oS ~uitt rn:lrUd artt
C4-S'" th S ~hl ~n:.rio, S..tllwc31<111 of (4 on !;. With flh on !tit.. " 3bo,nlt~or ",bluJ.uhri"<: chang.s u/ ."ide"t '" tr.t un~rt"'r.ll jO,nt~ !>tlo.. tilt ~ofC2 b'd,ltfl1ly.lh.r<: il tncfO.dlmtfll on tho ,nltM'1tbral lo",m,,,, on Ih. loft:Wel. '1 C2-3, C3_4'~d C4-5, CS_6 "he-.: 's """'. ,')',.,,,,rt"1 01 tilt Solpm
""'llWi""
..-dlllt <:urnlw,",
ofl/>~
«lYIt:3 >j>Jt<.
~SNm~f1\...... dIa"'JCS'~ lht~'f'1Il'lJirt~~Wnt""'lt't'/ ~.;~ju'y'
mrd i/ is good '1>,,,,,,-,,,,,,,r tons! tiU' 'l"".nli:
fro'll
tmJ/lfll'f1l"
Ano#~nullrl"
1lCfi'1l PfllrnJl ,1«11' 1.'/" '" braNt' /(J arUIII IIml In'" bW.. if; 1t'II"'t hi", '" \\'t Nil, agrw Ih.ir _r"""""",,III, Iwtbrlln.l>ul .fIO".ofot'Sousl.,f«I Ih.ll \11'/,11 'V"II".....' ".tflllln!t brlln; "" l,oll aN.. lot'tpJolin '"-t II , II.I dutsIol frri /trlltTr. I"fanowt_ rtro1/",1 /1y 511('1, br!.'1:i"sql~"- ... rngll'" mrrol im'dlwNt illliJm~'J"'n. ~\'t u
"msillStrn. QnJll'1" nmst
n,., mJnipul"h.., ~'
smm'
ph~'siolher"pi51
musl be f\llly
of the C('r\ ic"l spino: Is ~ho",n in r':~l"f 4.2. SI\(> is 73 old. "n both from pallent'. co-<Jpl.... t>on ilnd 1110" """miner' sktll in inlerpm"'g Ih« patient'. ,effi,,1 "nu r>on-\l~rNlI ~ignals, of whi
r"".. .
h..s
ret
in Ihe Ih(.'<}n.'h.,,1 aspecl of dt"l':nosis nnd
"".ltmenl, bul she Illu,;l be e,'en "lon: nh,c<1!ed in lhe dil"llcJI pa;sibllilks, TI,e hum,on body has nIl cnormou, cap-,clly 10 "d~pl ,Ind 'lCoommodatc lulhe insults and disca"" inflicl"ll upon '\.,11Io:l lh« abo''t' ladr is a pl'ffoct e~aml'll." of th,!;. Sa ab;o is the l"d\' w~ radiugraph
Inlcr~srn~ly, as lrtiltmenl ,.aches say the Ihird Itssi"", Ih. p'lient rtaliz<"5 thai ht Is bl',ng tducatell n III how to lhin~ ,nd ofW.....l to take notice
A>~ument
1ne palientlS then able 10 lll.lk.,> "er:- pt."l1ull'Oll aOS\H'fS ~ ~ I pm<:""" becom~ uod moceaccuraIL' Jt IS ,mport.lnt fO'" the ph\'Siother"plSllo reali:re th,1I the polloertt ""Ie 10 'feel.. far lTK"Jn' thai tt.. marnpulati...~ ph)"SOo"ltt.,. ptst can "'.",. do,.'1ent\lne b\' a.mtiIlanoo - hl~ bodyc.on ulfum, hIm of' ......- finl'cNns~, and it ism respon';i1l1hl... 10 listen and.xknowled~e_ Therefore, il i~ ,mportantlo say the fal"'''in!> al lhe time of the first
I()
quo:o;.hons. and
~
TI:<'rl'
'WhM )'00 don't lell mc, I don't koow.' 'Yom bod}' can tell you thing, which I C~I\I1"t d('t.'rmine by e~nmininli you. so ,f you <101l'ltell m('.1 don't find
atilW:
3. 'You mu.1 not fe<.1 rou a~compla;ningwhen rou 1C1I1l1l.' about the >ympt(lffili or whal CilU5<'!i lhem. You must feel. that)'ou are m'imllin)(. not con'plaming' 'Yoo m.J} IhinL of thing>. tholt '00 dO'il t'--d art rel.,kd to >our prol>ll'l1l, or i1'" ummportant. You mUSl tell meaOOut them; let ml' bt.. tl ... judge.' 5. 'Can you""" wNI an importanl role you ha' e ill lho' lrealment of your disord"rr'
..
In mllnipulath'e physiotherapy, ",Sloss",enl has lI\itn} faCe!l;,llll of which will ~ d':.(Il'lSt'd. Il(l"~"'\",,r, th,,~ "re IWO dlffencnt kmds "I ,",'lOSSll1ellt thllt
two d;fftorffi: kInds of ~""'nt:
~Ioo. not~tNely. .....,'Y t~;rt!ffuurtll ~Ion, afle, a b'.i~ f,om lnonmcnt, at the (Omp!Uion of treatmenl ~ ~"ilytic~1 ~ument
consultation:
OI,t nboul il- and that mi#lt me,,,, I miss out 00 n:le'·.[I,t information.' 'So "00 (an~, rou can't I('l] ml' I"" much, but >"01 can ten me too little,' 2, 'llll!fl< is a big differffice betwcro ~not mlJCh~ (w ....'l1 ",f"rring 10 ~rmptOlm) and "nothing
a~
1. Ii.: 'nlt!al cxa""r.ation of a pal ent 2. """"'J'V>tIl ~ t/ft:~nl ~te; at tile bfglnning of ad! =5ion. dJ"llCJ the ~ of a ~..q ..., afie- ~ t((ll'*l""' hzo; btt" ~ at c:orrpletionrrfil ~atll1fl"l 5a'>IOn. onra 24-hour penod i......ed,ale '( foIloW'''9 t~e last t~il"'erl
ASSESSMENT AT INITIAL EXAMINATION Thl' fi.... t of th~ IWO applKllOOns ;s di,cuS5l,'
FEATURES FIT_
lha COl1Cl'J",making featull'S fit', comes lllio e"\1:'n' a'f"-'CI of eumm.:lhon alld t'l'atment,. and miD ",en> ""P"dOldSS<.':iSmcnt
tlalirg fl'itJrtS fit is one of Ih~ ,...ost e=nlial alopttlS of ~=,ment The rna~ipl> .. lil/C ph\'Slothe",pi" will lell the ~t,ent that his probl~ ,s ""e .. j;~-" PIlule, and it is ~er job to m~ke 'ill t~. plCCes fit'. She """ds hIS help 10 do t~,s, anod II,s he, ability to mmmunicaic Ihat male, Ihe dIfference tlctwcen her bring $lJe~"ful in helping hom wiln ~is problcm or nOI
1. Dum'l> the mltial ">.am",~li,'fI of ... p.ltient, ~n
assessment
i~
m...de of:
a) The diagrlO5is, indudmg lis hisroll in I"rms 01 the Siage of me di>Orcll'r and .ts p~t st._bih" b) 1ne ..·.. n; in ",hid! it atfl1Ct~ tlte pat"",t c) The:o\ nlplornaotic ... ~ tolt"'lt lTIO\ em""",.... being the ~ t p.ut of a tot.1Il?oOlnunahcn. 2. l'hroughout treatmenl "".....h a", made of th,., change> rhat ocr:ur, and lud!-..,menb arc m.ld~ as to their dO"gll'l", their n~k" ..ance. and the influmnl and mo.JI· fymg ludg<.>menb of dlasn05i5 .md prognOSIS. On r«hecklllg (i.e. a;;~inlt) the palu.",!'s original abnormal mo"ements, it should also be J'OS"ible Itl interprl't the "alue 01 Ih"l Il'Chnique aj applil'.1 10 th~1 particular joinl III th"t pMticul .. , ,tilk of th" dioordcr. This is the" hole purpos.! of i\s,es~ment
EVALUATli\'G THE EFFECTS OF EACH TREAT\-lENTTECH1\IQUE.
In trukUlga dial;fUl'>l~ thl' h'SlOrYoflhe onset' imporlant. and to ma~ an olCCuratediasnosis the onset mUSI FIr, that is, be rnmp.lt;blt with the objo.'(:t:J.,.(" dctcnni-
""lions found during "",minat>on. An """mr~ is gJ\l'tl in the S«lion on fuston t.lking.. ".~ a man Wet'k Out the answers is the bibi, of sIJcccs:.ful aSSCSSllll>nl in thi~
Mea
ThCI(' arc other pmbJ.. ms ns>oc;att..J with cli"'g,1(l'l'. For ...';"011'10', lin i"it;...l dinSnosis may nl.,;,d to 1'>.'
ch.lnSl'
In
rctrospt"Ct" h~"ll it is seen how the p;ttiWt's
51
58
MAITLAND'S VERTEBRAL MANIPULATION
symptoms and slgn~ alter with passi\'e mo\'...ment treatment An example will clarify this, A woman was I'l>f,'rn.'<:l from an orthopal'Clk surg~'On, who nXlucsted manipuLltiyc trNtment for 'disc prolapS<' ca,,~ing (7 nerve-root symptom~ and compressive signs', On examinallon, the thr<-'e cervical movements of eXt<.'nSlOn,lateral flcxion to the left and rotation to the left were all markedly r<-"Stricted ill\d all "-'Produced tingling in the patient's fm"",m and hand, She had diminished ",,,,",!ion in the p.ld of thl' terminal phalanx of the Index fing...r, mark<.'d weakness of the triceps, and a diminished tria:ps reflex, She WaS III conwferable pam. Tmchon was the treatment chosen, and bv continual a"",,,>sment over the first 4 days noticeable i";provement W<:lucing the diameter "f the interwrtebral foramen and thuo compressing the ll€rw. Clinical not~:. pati~nl's ,ym~tem, m.y ad,. lrom mere than on. SO\Irc~ [e.g. a sh\luld., ard a ~~rvi~al compon~ntl. whkh have both to b~ addressed in t,eatment
A furlher probl,o,lll related to making a diagnosis is lhe bet tho,t somf' doctors consider that a patient [an have Oll€d,,'gnosls only, n'ereare lll~LancCS, however. wh~re caref"l a,5CSsment and skilful planning of pa,siw: rnOV~lllent t,,-'atment will show that a patient ha"ing p.1i" (,...y)arlsingat the ba5f'ol lh"n""kand radiating to the shoulder and mid-upper "rm may haw J shoulder disurder cau,ing the shoulder and Urn pain, coupled with a c"IYieal joint dtsord~r causing th~ neck and sc"pul~r pain. Ex~mi""tiOll of Ihe joint signs for both theccTvicalspill€ and Ihe glenohumeral joint shollid be accumtely assessed at the initi"l examination, If joint signs are found both in the ,houJder and in the appropri.lte Inlervertebral joint, then ideally treatment should be appli~xl only to the cervical spine at firsl, The joint signs in th<: spine may imprO\e. resulting in the pati~'nt losing his neck and ocapubr pai" but retaining the shoulder and arm pain, RL'-C""min~tion of the glellOhumeral joint may re"eal Ihnt the glenohUlTl<.'ral joint's
signs howe remained unchanged. Unckr tllese circumtreatment should then be applied to the glenohumeral joint in an effort to elL,,, its jOlllt sigus, SO gaining an impro"...ment in the shoulder and arm pain. There an' many such !."Xamples of combined joint inmlvem~nt to explain the different p'Wl p.1tt<.'n\S m,d ,yndromes that oc~ur from p.,tient to p.lti~nt. Another example of mllitipl~ caUSL'S for a patient's pain is SL'en freq"ently with patl~nts having p~in in their back that radiates down the fulllen;;th of lhe k'g. In relahon to l~is an',' of pain, phy~iother"p}' sh,denis m"y fjnd themsch-es in a dilemma \,.h~n learning der· matomes. Confusion is rn,derst.""d"blc wh~'fl one diagram may show the LA dermatome as stilrting in the low back a,..,a and spm~ding lhrOl.ghout the bullock and leg to the lop of thc foot (S<"t' Fiswe 6.4), while another Olav ,how ttl<' LA dermalome starting below th" kn"" a,;d r.,dialing down the shin inlo the foot. Therf' is g[)",J r..ason for each of th~'" pr€s-ef1t"tlons. nle1"\' are variou, causo-'S of ,..,ferr~..,j pain fm'" pres· <: due to irritation Or compression of the nerve root alone. Another example, which is fnr morc rommon, is the patient who has a diagnosis of LA rd...ned pain cXk'f1ding from the centre back arN through the bUltock Md leg to the topol thf' fool. Th~ I<'ason for thi, m,ly be th,l! the extruded disc !l\IIterial is Irritating olhf'r p.linsensiti"e structures In the v~rlebral canal, such as the po:;t~rlor longitudinalli&'I1"-"t, th"Jur" the ,,,,rvl~ root sleeve. as well as the ",,"'e root. Under ttit'S<' circumstance~, wo: may have four contributory cau,,,," for the pati~nt"s pain II a p.,tient hati pai" radiating from ttit' buttock down the le-g: to the top of the foot and he complains that the worst part of the pain is III the tow~r leg, then one can confidently assume th"t the nerve root is involved, particularly if spinal movem"nts reprod"ce all of this p.lin (and in p,uticular thedislal pain). \Vhen pain is I"lt from the lower spine to the foot, Ihe di,;<; and ~djacent posterior longitudinal ligamenl ma}' be causing SOme of the pro"imal pain and the n~rve root and its slee've may b" the SOurc" of the distal symptoms. Therefore. mOl"<) than 0"" factor is causing tl'" p~tient's pain, From the foregoing it is ~asy to s~", thai there arf' many problems associated w,th diagl105is, and the'" is still much moll' that medicin" has yet to ullIavel, Howe"er, the problem musl be taekled, and st~nces
,,,,(1
Table 4.1
Taking the history flo",' 10"'] h."" vou had it'
Im;ly n,.d to follow
u~
with 'Haw king THIS TIME1
How did the pre..ot bout b.g,n> bpont,n.o""
I
Gr.d~al
I
InLid.nt I""",ily)
No
I
WMt did
r--~I_--, I I
-"-I_, Ir I Stuck
I
i~
qul(i:1y
Nut 5t~(k
W,k.o,d
Ou,ing am/pm
vmh
you
noticet"t?
From p'edi
Fmm inc,Mot I",o"ity Of
why r.l,ted)
I
PREDISPOSING FACTORS t. P'e
(b) he""", kI5~I~intd
pM:ur~
2,Vi,u, 3.0,."1I,,.d 4. Cold, d"mp, 5, F~milial
d,a~gh1<
2. Relate '.-
1
Fir<;t btlU! in ddail'
2.
Succ"",,,,, bout<:
C,u", Duwion
l.."lm.,t Frtqu.n<:y Ea~. 01 cau", R.CO\I.ry: rat. (Res!, f\
l
"c.I
M.dic.lhi'lOrrl,nd,ocio--~or>omic)
in the meantime when a d;agn05i5 i5 incomplete th" abilily to m"ke the proper "se of 'lwo-comp<>.rtment' lhinking make.; it possible to use manipul~lion within roul;ne medical C~I~, and lhe treatment i5 made safe and informative by ,'i,tue of good .,sse;,;menl
ASSESSMENT THROUGHOUT TREATMENT This ;5 an arc~ of multiple compl"xih', c5peciallr in interpreling the f;ndinp. It is one of the areas of the
grealest dewlopmenl in manipulative physiolher"py in ,",-'Cent years, ~nd ha5 become Iheone arm th~1 pich 'the wood from the trees' among manipulahve phY5iotherapisls. The aspects oi asses;;menl which have ,hone through us bdng lheoo ..", providing finest value Heinlhearea50f: 1. Communic.ltion 2. Beha,-;oUI of pain, stiffness ,md muscle spasm 3. 1'h" comp",i50n5 bd"'~"'o norm"l ,md abnom"ll examin"lion finding5
60
MAITlAND'S VERTEBRAL MANIPULATION
LKh of tl\('5(" need~ 10 be discussed in d(1,\il, but th3 is donl." an ouillne ut 'olS5C5ISmCfltlhrou¢loutt~..t""",r wiD bl!' .... ~ An Import'lllt pilrtof .ISSl'utnenllS tho;, abili1r kl n."('ogni..... p.oltern.~ of ~~"n(/romc.-- "1<0, ,t is 1lC'C"SS-.n to 1M' aware of the ~tent of Imrron-mmt ' ....1 rn.l\ bl> nchW\'ed ..,Ih tn'alml"rll Tho:! ool~ way kl gaUl this pruflClased on accu..,t., critical ;lSSl'SS1TlffiI. "tml.'d wIth this competency. and as:l member of ,I h:am, It\(, ph~'Siolheraplst can offer curbtnJ<;ti, e ,uSS""ljons 10 the ref"rring dOCtOr "'!larding the physi,,,l sid., of Ihe miln"gement "/Ih,; patient. Achie,'iT'lg Ihi" competenq is ,1 ~,ow pn>ress "nd is not to be r\J~lwd. Miss J"nnifer 11ic~ling, ,1 phy~ioth"rapi,t of nOle i" tIllS fielJ in Engldnd. ollCe li<1id lum,,: bej~
As=Sftr'1 of dII"9es '"
r....
Manil'ulation dl'Jl'<"'l'ds "pOOl clarity of lhought and cnllcallhought. reople hane to bl!' trained lit it in a mOlSt det.1i!ed It is ,;a";";" I" adtie\'e Ih~ \\ .th undergraduate sludmb tM" \\ith pcslgrad.... le jX'Opk because lhe lalll'!' h.l,P Sol min ~ h.1bll of lhml.mg in otht-r "iH~, and it ..
"'''v.
~h.lbils.
This blJSirloe.<~ crf nK'thodicaJ. critICal ttunlunj; ",'SUllmg in addIng bnc~ 10 b<1C~ is terribly important. "",'ice. mIr>t e~jX"Ct k) get fewer "",'Ui1S m(1I\' slowly Ihan the c:q>Crien«'d pcr:;on. and titer mu~t Tl.. ~tlhe Il>mplallon 10 !I)- ~hort-d !Ill')' MI' '"rla;n aboul wh.11 il i. lind what th" re~nlts M'(', adJ, up to" brick which I> dcar"<:ut; a fact thai I,. not only useful for thaI pall"nt bnt abo forolt...r P..tll"lllS lhey must meet, r..... ,-",amrle, iU1 I"XpcrK"IlC't.'d ~ ",ho is PI\." pa~ k) tak a cakulal<,1 for a particular t«hnique and say. do lOutlOO to lhe left iL5 .. V, right al!hc bcginningof I~al mcm•.nd..nem.oy get .. quid ",--_ltO!her.; .. hofL'\"I Itw;r way into it might flllillly rome w Ihl'rooclll>lOIl Ih.lttru:. \' IS ......,.",t1Il"r 10 ha,'., taken sri or ""'1'1'1 tn",t mcnl5 to gge i, the ngll! one. To ;m;\'c allnc ""'~I!l by gUP:§l;work dot'S ,\Oth",S for thc nu"ic,,'s future good rn:u"'gcml'nl of m.mip"!.,tlu,, I;""'-'fall)', wheR'a.' Mrh-ingallhl' right n"'llllllll'>R'
h.J",
t~
1ICC'IIf!.1hr"""}houllllttr~lm
palltnt's W'ftP10lft!> ... tproct!.S
1. Ir1li<1l u;ol"n;l!M)rl 2. At ltI< bl:9"ning of tac:h lmnroffl ~ 3. During p..-'or,urct of .. 1o:c:/lr1iqut 4. Aft" pt;r'o<marct of i tfdl'llqut 5. Aft" compltllOft of t"'illTtnl session 6. Retrosp«iM iSRSsrotnt .. l t
pro,,~n fach thl'y ",,11 cnd up with a w..rl('rof ralher ",i~hy·wa.hl'kno" k'
dnd
of cha~
tIl
the p.'1lie"t'~ ~ymptoms is ,""de altho! follow-
~1p1S Iltn)u~1 t"""alm",,1
inlllimes:
1. AI n... begumi,,!> 01 each t...atmenl ~IOO (so th.ot a Judgt-rnent can be m the lechniq_", h.1""I: on the p"ri<.'nl'~ symptoms" ltd.. II is l><.:intl; jX..fonnedl 3,
Afl
S. (ft'"r Ihe 2~·h()ur perioJ immediotd) followm& thl' lasl tl'l""ln>Clll Sl5SIOO (becausc this i. of'ten 1M most important infOfmllt;'.., period) 6, As a n'lnl>f"'C!i"e r.lSeSSment a) At the begtnrung of e",h fourth Of fifth I..,dl· lI1t.'f\l sesinn (ohct> 001 01 ;n_1 done 1<> con·
bl
finn the dav-Io-d.lv ~ t ) \\"hen thedmounl or ","'of progress has ~Iowcd or st"PP'---d (to determine the "'.bOAS and pt.1n
lh.. ""ioo~) c) Following a" ;l>6<'s"mcnl b.....k from tl'\Sltll\ellt (kle<>L,bl,sh lhe pl.tee of further tTe.. rmenl), 7. f\t the rompIL'IIOl> of lreatment (10 IIlil.l
ASTERISKS Ikforc discussing as!Oessmcnl undpr IhL><;l' l>cading~. the use and \'ill",; of .hlerisks (0) tIl the Il."Cnt'.:!ing of
examinMion ,'nd treatment n('('ds explaining and pll!ring into the prop<'rmnt"xt, In ord", to p'l'<:is (successfully) and C
A5t~rish ast~,is'
• • • •
Primary sympl~m~ or d"abil'lits/acti';ity limi13tions 5ign, th.t r<~rUliuc< ~ pali.nl's symptom~ Oth.. information thaI is impot"tam K.y iss,,.s th.t n• .,j to bt f~lIow~d up
There are 1
are an invaluabl. ~id in a5",ssm~nl. Use ~n to h,yhl,ght lh~ following in Ih~ f~c
thn~'
l,:,·l'!s of distinguishing n",rke,s;
it"ms that th,- pot,ml i,kl1t;fie~ as being primary sl mptpms or diS<.l>ilities
A~terisking
1 Ast"ri,king informotion that the clinici"" oonsid,:,-,; to 1x' aspects of major importanee,l'H'Il if Ih"I'"ti~.,'t does NOT ,.~: th,>m as being mJjor (e.g. tingling pins and needl,., f~11 imcrmittL'Iltly along the later,ll border of the foot). 3. Kcy issu,-s thdt must be followed up because of
doubtful di<,,,nosi~ ,md the possibility of e\·o!\·ing disca"", Thes<' can be mark"d "'ilh an a~terisk and br also 'highlightin~' the ,'ppropri,'le written SlXtinn A'terisks an: a rnNns to an cnd, not an end in themselves; tiler aT\! not jargon, neither l1('C..,;sa'r to nor f".'Culi", to maniplllati,"e physiotherapy; the'" a"" n~,"er lhele,;s, an ;m"aluJbJc aid in ~ss...ssnwnl. Th" ~st~r;"ks must be wriHen into the record JS th" infNmatioll is "'CordLod. By doing it this way, th... lh~,ap'''t ,ewl;"'~l-s whdt is \~orthy of an a~tl'rbk mOT\! <juickl}
COMPONENTS - 1 For each pJlient, astcrisks should be used to identify the ",ays in" hieh he l"aws h" i~ affected by his ~pil1~1 disorder ('subjecti"~ ~srerisks'). From among the point:; he menllons, asteri"ls should lJ<' "ppli'';n,, 'tis, For",x",al compon"nt. To ju,t mMk one of these two" ,th an ,lst"risk could [('Suit in not apprl'<:iating thJt, although one component of hi' d"order (as he ,ees it) is improVing, the other is not. If he h,,, " 'positionJI' compon"n! (11,,'1 is, he is unable to Ii" on his right side) and ~ 'mo,""mL-nt' component (he h.~s Sharp sta.bbing pain wh<:n dionbing .. ladder), eaLh must be identified with ~n asterisk fo' the Sn in (1) \\'h'.'I1 a pati"nt h.,~ mol'C than on" pam, at Icast one 'subt",t"" a,terJsk' ~hould be u""xl for e~ch pain. Some p~tknb' 'ymptoms ~l'C only of an intermittent nUL""n"" qtMlity. It mav be difficult for them, 011 first bt'i"g 'luestioned, 10 rrO\'idr a rcli~ble
Q
'H(\w \\'ill ,""0 be able to tell if von, Ilffk is impro,'in,:;" -
A
'1 don't really know'
Q
'How <;nn )'OU find out' - 'I"'hat priJ\"nkcs th,' unroll1fort"ble fedi"g?'
A
'It ju,t seems 10 come of it:;; own accord:
Q
'How often does this h,'ppen?'
A
'Oh. it's not rL'gular:
Q
'How long can "ou be withemt it"
A
'Oh I ha' e ",mething e'"cry day:
0' at th,., end of th~
Q
'15 it rcallr e,uly in th" da), day:'
:\
·It's usoallr there when I first get up in the mo'ningaru::l thct1 perhaps"t the end ofthed~y.'
Q
'I, thl>;\ fairly ....'gular p"ttem?'
A
'Well, J"", I SUPI""'" it is "OW th"t ypu put il that way'
62
MAITLAND'S VERTEBRAL MANIPULATION
u...
nus isan Olkampl"nt mental disripli"" It><.- "",niruI.,twe phy,.ioU......artSl must ")"'R:~10 Am"e Al lhe "1.01 issue-11M> pomt cannot be glO!\lied O'er
COMPONENTS - 2
'1AKNG FEATURES FIT
In tho? physICal eumination, some N"Ie,' am tests o:obif.' to one component 01 the patienl's di$<Jnk.,. olnd oIlwr lests ~1a:e ro other component>.. lust as ;t!;lerlSb at\' ..-ded few different components 01 the su1;ecb'" findings,
'>(\
are
~.
equAlly
~TV
fur
~
diffet\'TIt
components of the php;ical eJGIminatm finding$. This is m«II Il\ the ex.Jmple of a palient 'dw hitS pain ToldialinS from his bxlt down to his foot, ",h"re t~ i~ diminished sem.alion along its lateral an asterisk: OOrd"r. An of tlw follo" ing should
h/I,'"
1. A mew"m"nt th.,t pro,o~"s shack pain al()l1
,'I'
lho.~ at\'
I1Mny "lherlinds of rompo",~,l>. and, "'h"n 0"" can be id'~lifioo m a palient'~ d~"Jc.,.,
mon.· th.",
I'ach should be m.uk<--d by an
Although II is not .... ithout value to 1,'0 through the ol ~ I as a mechanical process, illacks il IS rJodi",rimll\llloo' and lead> ~t nowl'Jen> HQo,·{'\e..., if lhe findings lire relatOO to the ...-pectahoru. of lhe 1n.·atrr>o."'l tt.'<"hmque, tm- diagnosis hi5to~· ..00 prognosis, and lhe possibilities in the proce5IS
ql.l.1hl~;
"""lablhly of sclechon of
loIdu>iq~,
u... a5ses&Dl,.,.,t
bccrJr"",. ,{'p, d,SCf1mlllillon', m"lu", .. nd ,·aluabl". 1be paths for'lc"mmg 1.....1such.l pl''oI.'S h,,,·>! ''''' oouud"'ies_ It i5 in this area th"l as.>eS/iment wange'S to ~nJlyll",1 as>.es&rr>o.-niEarlIer in this chapter, th,' following "",as ",,,reslated as ocing th" a",a~of gn.'illl'!>l gn,wlh 1I1 :ll'6l~m""t I. Communication 2. I3eha,-iour of p"in, mist~ncc nnd muscl" spasm. 3, Identifying normal and llbnorrn~1 finding"
COMMUNICATION
aslen~k.
Following the physical e""minallon of Ih.: p..I;"'flt<,s mcn-aTlI.'flts, tilt main findmgs should be ldenllfied ~ llsterisks. HO\\~X'I', itb importanllAallhe"Ol' ~uld blo -.:l«ltd findirtgs; not "'-e.:" itnn i$ wor-Jly of an asterbk. To us(> aslcl"isl<s indis<:riminald\ dostm'''s darilV and indkllre.. bd< of ttoinlang_ Asierisks shook! ~ ustd to idft)Ill)' and luJ;lilight the dIfferent rom......"IS 01 a ~tient's symptoms. Tl\t foIlo"ing lire t.'....mples 01 diffemll components, some or aU ol whICh may ."isl Cl>rKUrJ8'Itly in a p.ot~t: 1. A"af\;\1 llo:J1lmmajoinlsign_ 2. A 'st""ch-pain· ~Igtl from 11 'compress-pain' sign (_p_II\6). 3. n '''n.ogular-p.ltlcm'mcr.crnenl ~gn 10 id''fllify II From among a rollect>on of '''1;ular·pMtl'm' O1()\.<ment signs (sn' p, 136). 4. A pain-through·rans" O1m'ement sign 10Ide"'lIfy it from an ·I.'lld..of-range-pain· 010\ ~menl SIgn when both arc fuund un e~"nJ1n,'lIon (51 p, 188). 5. When a pal,,-,,,t no,s more th,," Oil" co"'ptu ,t 10 jlls p.~in,
As l~atmenl progres6l.'S. thca;.l"rish-d ~1mptomsa"d icaJ Aslensb. this is another example O!
I' mon'lllt.'nt thot pro
sho"ld ~ identiiird with an astrrisk. An "xample of thib i, when cen'ical roLolion 10 the ri,.;hl pro'ht<"CS only scapular pain, dlld lateral flexion 10 lhe nl;lll producl.'S only tingling in th" ind">' finser.
Thit; subject has Ix""., dealt with in dl.'lail in Chapler 3.
BEHAVIOUR OF PAIN, RESISTANCE AND MUSClE SPASM BEHAVIOUR OF PAIN
Pain OiIn be~~ in • variety of ~ n """tiomhip til ........,,,,,,,rl, _nctudlng ~rv pa .... Il:ka51: pam. t~ttnt P"'n ~nd ~tttr paIn 0 ffntnl pain, can occur tn d,f'ntnt mO\'tlJltl"l~ w I~ tht samt pil ntl
Pain is A subjecti"e experience. it is influetlCl.'Cl by an etlormous ,ariety of factor<. and il presents in IThlny differenl ways. It is the mOSI common "'''SOil for a f"->tson """king.. or being ref",rrt,'d for, mmupulatin' physilltherapy- Rol'~ Imming can leach Olue-h about P.1in, but tu cXp"rien~ p"in o"'-"sdf, or 'ft"I' it vicariously with ('mpathy, is far ",ore '-alunble. Trlblr 6.1 m('nlions the il\fhl(~'c~ of p<>·choe.!lCil..l-(.'C•• nomi(: factors - ,uch jnfi"",,~.spali""l." ishlng III pl"al><:', the ,ariali"".
AsI~llm~nt
in patlent{
ps}chol~i(cal
and ph"Mologlea] p.lIn
thr<-'SholJ~ .. nd pOlIn",,"CC"l'tano']"'L'!s - ,,1101 \\hich ,aT) from pc to P"~- .>.sse5slng .. pat!cnr'.
threshold of paln , lX' .. >o$isled b~' firm!} -trelching one or t"n III th., patiomt's IIl'nJ!iII jo:nt'i;lnd noting their ~ _ Kl''l.'k-' (1967) statn:! lhat n J'I-'r Cl'T'l1 of po:opk Iw"ed ph~~iologic.l.llo\,·F"'in Ih~d. 17 "'.,. cent Iw,... .l. h'ilh f'lm 1h11"Shold,.md 60 per cent Iw,,. .on .., ....ag"'. nonn.>l pain Ihl'C5hold. For thoi! dinid,n, lilt-' ~ Il"lIU.I\.'Tl\l-nt IS to lJ5kn, 10 beIK-\,. ;mel bl' -a.... to ~ unJl'....t..nJinl; ,,!wllhe p,Jlienl is tl) i.ng W ""p~ If the m,ll"pulative phy,.iottw!l'3p"" c,mnot up b.>fore ....""tarh II learn to do lhi:>, shc.oould !he P.llic.'nt 5l hcavln.,,;o, no... !' 01, '110'" is th.. t ·,·k,." fe.-11I1K, no",7' If ..... uw Iheir words. they readily r''''ognLt.e III<: qUl""lioll;, nIl.:! call ,,,,~"-,,r ,m,m, .,Iuably and ,,-e c.. n ma~e a mOre fO<;Ilp"K,f .,_'Ssrn"n!. If til,. patienl'. tl'rll\in. ol"KY ~ .. nd l'ol,'onci.,ti"n) Me used, the assesSlTll'Tll is quichr, In"O' atf\,rately translated and gil'''" the patlel'll a fcdin!: of !.>ciOlg understoo.:!_ A p"'i"n' tl,,,-,,, not h., e 1"1'>" ~1\lpid ttl ha ...• bizarre symptom •• alld it is iniqui\(>l" 10 label h" ut !.home areothet-"'luall\' Important fdC\"tsof pain which n'luiR' ""P"ral., m~..,hon ho.>re.
!I'''''
Rtcovcry polin In this calo>j:on. the.- poll:\{'Ilt fl't--'b polin as .... bnnp h,. bod} bl\d. 10 lhe uprighl ~taninll position iollo\\ m.: IN mo, ,'m'-'Tlb FOI" ....... mple. dun~ ...... m'naf1Qn .,f tht-' I""nk nlO't'mt-nl~ of " polDent with Iral low b.>cl: pain hos lnInl.. o,."iQn is tested. The fanse rn.l~ be full and 1'"",1""". ,..,t,,~ he rt'tums to tU upright J'O'"" ilion from the full\' fk>.ed pos,tion II<> '-"'peri............ I"" bOld: pain dunnK an an: "r tht-' .... turn m", .. ~n,. From "n .,..,.........ITI'-'Tll ""1Il1 of ,-il''''-. if. folio" "'!: Ire~lttu:f\1 the pain fell on th.c rL-'tum mo",menl to the upright p",ill"n dfh'r n,."ioo i$less s..\"t'r~.orif the arc OOctlmes smaller, lhi!l inJiCl\tl-'s irnrron,rnenl.
Release pain ntis phcnomc"'>J1 ,scommon in thecervk~1 sl';nd~nd the thur.1Ck spi,,,,) ",ith r",t"tion, ,md III th" lumbar sl'''''' wilh I~t('r.ll fl('~irm_ It occurs .. Itnns!
solTlelime~
e\du.;wlv with elderl,' patients. Whl"l\ lhe spin<' is LIlkn to ~ limit of anI of the mo' ~'Tl\mb sug,gested abo\"l' and '" l!T-pn'SSUn' i~ aPf'hoo, the mo,·..,m"nl mal' be qUJb.' pain free; howe\"l.'r. 111'1.-' Ins!.mt lhe patn,nl st.,rts lhe n-tum mo' ............. 1 sh.lrp ~ l"l'l" moment,,,)' p.lin is e\peril!llITd. Such a -.ponsoe elnlj, abnormal..ond tredlnl'l.'f\l .houkl boo .aimed al dminatingitLatent pain 6ec.l.US<' mOSl t\1""> o'lat<.'t\t ~~"'rtom,ame from disorders which aR'diificulrTO Ilt-'lp. "~""",,,-..mcntlll-'eds to b<' pn~ to deled SlTldlJ ~q; ] p<'r ..... '1) ch.l"b'= Thl..... aA' m.Jn~ ,-"riM...... of latl"Tl' p.lln
\, ram occurring when ... tot mlwcment ,s su.tained_ For """flIpl". a pallenl rrt'-..;.,,15 wolh pQrne 0""'pr'<'5sur(' i, al'O maintained at the limit of it> r,mge, the p,lin m,ly bl' rcprodUCl'{1 onl}' ~t the ""d of 10 St.'OJnJs. 1\1'0, wh.,,, the patil·"r, h""d is rt;tufll,,,i to the upri!;ht p""itiol1 ,t m,w I~ke som.' «'C(1TWS for that p.ain In 'lJl'~ide. Thi, kmd 04 behaviour is .. "en' ,1ccuralc ml'asl!ring ,ock_ If tn~ltlTl\.."t 15succcssiul. t....... susl,'ining rime "-"'l.uired 10 reproduce the p.,in ,,-ill "lC"-~l5e. or thl' lime Lll..dl' ",ll art' continued or ", .. tc.\1 po;;i,i<\ro is su5!.lir'll'd_ It can .. 1~ occur \\ith repctiti,,, o.ciUato') rT\(l'\'..........1 4. A "urg<' of pain occur1'inj; .. rter a 8l'O<JP of tc.\t mo,·..menl5 ha"e been pt.'I'fonno..... This sUJ'S" of
pain ;" a n'dSOl\.lbty fn"qU('llI find'ng.. .mu ,.... l-;<;l'nple will help f<) l'~pl."n il_ A P.llIi.-'t\t rnav h",·., pam m h" ltfl """pula radialml\ mlo the b.>ck of the upper arm, Durin~ the e\~mination of his Ct.'T\ icaJ lTIo,·emt.'J'l!>, all arc full '~OlKe and painll'SS. Howe,-er, imnlooiatel\" following the (',<"minalion of his mo,'('ments, the p.'ticnl m.l)' h."" " ,urge of pain mlo thl' scapul~ ~"d Mrn_ WI",n ,his occurs the firsl time, it "'ill not bt: po;,:.iblv to lo-t",,,,,, hich of the tl'Si mm·""....nlS has ~timu]<'led Ihi.~ ]a!<'nt pain. TheCMmin"",hould ....... thi. phcnon....non as a
63
64
MAITLAND'S VERTEBRAL MANIPULATION
"ammg to be ger.11<:- "ilh " ....mll... tion InO\ emenlS and do f~'",,,,,, of them. Ii l!>l" p;ltio......1 5-lb quietl}" withoul mo. inK hl~ head, Itus 1a"-.,..Il4lf'l;" oi paUl will §lJb:.«lc lho.> Jenglh col hm<' t.>L,'fl £or the e"-"C"erl>a1Joon to lol."ItI,: .. i1I .. ~. from p.a1i.....1 \<) palK'nt. but "'ill becon_ISlenlw,th anyone p.. II''fl1. ~ is .. noth", e"3mpk ,,'ilL.,.. lhe lIme IJ ........ f.... Ih,: wmj>l<Jtl'b to ~ub",J.. " " ,·"llLibk ml'.\suring ~licL) When Ih.".., 1<.",1 mo"..nenb Arc r<.>pe,lIOO, Ihcy 5-hould bt· ~,,,mln.'ll III a ,lighlh ,h(f.. ,....,,1 m,mncr to elicit Ihe exacl "'-'ha' lOur of Ih.c 1"'111 wllh "ach dln.'Cti,m uf m",'emen!. Ll'l l" I,l~., examin,'!ion 01 eN' ',,11 l"tcral n.. ,ion r...,,1. This ow\'c,"c"l .11(\,,1.1 be IL"'IL-d lowMds Ihe side "f pain. and if no pain i. foWld al the lim'l of Ih" ranb"', O\"'1'''-,»ure should "'-' Jprli<.'<1 If Ih" mo,~'n..'nl I> "hI! PolmJC'>!o. tho., p<J5,tion should be su.tou....-d for a .hort lim~ ,""'" 10 'i<'<:ondsl Th,' p.lhent's h<.';td .h'.... kl lilL.,.. b.., return"" W lhe uprighl J'O"lllon. lll.l p"1JI."I1.1 i3 Iht:n ,,~ to remam Sl-tting for 10 or ITIOJl> second" 10 del.·nn",. "ilLother thcr-e I~ an~ "''''''lllog surge of poln riot. l.11•.,..t pam, from tNllIll'Imwnt. If IIloerel> no pain from !hi!; resl, then rotiItlon t<;n.Aro,. the l>Ide of pilII' :;houlJ be I""'k'd III lhe "..me 1TIolTlIlO."l', ,,'th C"1l' belng tAL..,.. to Allu.. fllOUgh lime f"r Ltll:nt paUl 10 show up If tho."", I.:"t Il\OI r,m c negati" .., ,,11 oIher mOI·Cm,'Il!:> would toe Ic...I,'<:I (~l in ~ c~lculdlcoJ ...' q"e'...." Jnd {1>1 wIlh sult"'iH'l1 lime fOf i.o;urdle M!0eS5m~'Il1 bctwl'('fl Nch I~"'I "',,'·emco!. When the pmticuLlr mOl"ml'flt pn:.. liucing lh.. blenl pdl" I' dcler",in'-' "'I~'f\.il}· ~nd.:uN of r~"'· Th.... 1m.... ta~en /Qr the larenl pain l\J subsidesoould al>o be.- nok'd. These fine a',.....",· ments of the bl'hal iour of p.linurl mo,.'JIl(~lt 01,1)' """""' tediou> And tIm.... consuming. They are Important. and filmiliaril}" with the dif· f"""'l way'" pain ,an belwl .. ,,;th JnO\cm......1 m.Jk..-.I"".....,mi".,... dL...1r'oll> in c.arryUl.g them out A!;'C5l'>mI"IlI '" madcollhc time ",J,."n for the surp' of pam lO occur, lis il1ll"llSil) .. I its ~al.: and Ihto lime .., bon for il tu I\.-'CO<.(.,..
""""'Is
hm.,'"""
S.
Lmgc.--ing p"in. which 1Yl.l~' take from 30 se<:""d~ 10 5 .ninule> IV ~uo.ld" dll,:r "'-'''I); producctl b" mm'"",,,nIS Or sU51alned positions
6.
L.lI..nl .. xac.. rbatiun f"l'" thJt appl.'a" in .11t incn:""'-'I1 form bel" .....n 30 min"tes and 5 h(l\l'~ Mter !realm"nt.
A,,~ing chang", in the fir:;! fi\'e types of lal~'Il1 p,1in dl......riOC'tl aool'e I\."lUIn.... Ih..... judgements I" 1:<0.' made
roch IIJ,.. ... The first I!> hmmg !hl.'on>;eI of l»·mptornsand lhe diIlllJlJSh,njo; of s}"mptums ,n seconds; tht ~ i~ ~ tht Si:'\"ffl1V cI the svmploms at tho.-'tr ~Jt.; and the rtUrd is a»!'Wng quabi} of lhe ."mptOfl15 calJS(C't,l n..."..." I;ost Iwo ..... po=onal judgement:;.,. I\."Iu'''"8 rn.u.imum arrrecialion t'>l the pallelll's ......... .......b.ol communlouiQn 1lJese th....... jud~...... muSI ~ intima lei" hn ....od 1"lIh th" caUS1llS ~I mo'..emenl or pos,tion -thai Ll'. w;lh j\5 stn:ngth, .mphluJ\!, sustainc!.
'After' pain
_
&",ausc this l",il1 le'S!""'",;" ocCllrs ·afler' the cau':lt', some "-,,dl!rS may link;1 with latenl p.1in_and "cronJ· ing 10 lhe dicti<mary def,n,IKKI of 'lat(-'l1". lhe word can be ~ lod<"'<."riN- Ih,~ '.. fl...-' ""in. Howe'·«, beca..-
00.:"", ..
It doeo.rmt 1 anr'lt.lgeduring the I...at""-"I ......• ~ and ( importantly) bccauSie II '" a deC",i'" ,...til)' thalc (J('(lll'ln Il'SpOOlSO'tolrea.lment, lheentity 15".,... n'IIdJ!,' rcmetnberoJd and identified if ~Ien a ~atl·l1d.. . After' piI,n IS .. pain l\"<~ thai rna, not OCCUr unhl ....aki~ on the morning follm.·lng tl...• day of ~Atmml, or "'tlhlll lho: Ii"t hollr 01 so of gelling OUI 01 bed. PAm thaI comes on 24 hour1I or mol\.' afler 1I\.",tmenl is a ""in response of th<:' ""me ~""d, bUI al IhM time inlcr~,ll it i:j easiC'r and dWI\.'r I" aS6l.~ as bo'ing a reo;uU of lre"lmL'1J1. Wht'll. il ocellI'!< Ihe follow· ing m"mlrlf;, it ib l<-s<; "asy to uoderstand II and 10 "'-' p"'parr.><'I 10 ",;"te Hln on(-". own lrealm,'''t. Ilo.....""r, it is nol M' "n"lInlnr", lMppen"'g. Among many dlf· [..",nl on>(15 of spilul pain 111M pat;"nt, h'll"" Irn:,re is one particular hi"lnry lindmg thai OCCIln; quite oommonlyand prm Idl!S proof thai the 'after· response Is a .....lity. A palK-'n1 towards thl' ..nd of a d"y's phy',," kal work. feel a ~i¢'1 1",,,,&,, of pail' or Illsi a blight ache, but the Sl'ml'IOm ~ quickly. The nexl morn· ing, 00.....,...-_ lhe pilbt.,..t is "naHe to b"ct oul of br..'(/ bec.>US<" 0>0\'....,....1 ~AlL<e5 !'e\'ere l"'''' Rel.,lInl\ llus 10 ~r, iI's impart.'111 to point oul thai 1...... lment ~ iid,OGItcd in dI", ......1 "ill not prm'okc ~ "00.',, dt.-g~ u~. Nr:erthele». the 'after' I'e:>fIQR;O.' ha .....lil1· and m""" bo' "--'ft1.""be.-.,d when one L5 plan· lUng an,1 car')lng oullrealmeJlt, and in asse.s-ing the effl'Cl of the last lreatmenl. During any lest ntu'·(>Inl'l,1 Ihal Ul'''''. pain. the mO\·.... menl and Its polin re;pon.es should bt: asso..'t«'d fully ,l"U wilh care 10 allow a~Sl'S>Ulcnl by """,,,,n'II1,,lion to show if Ihert hn, 1x"-"1 lIupro",'n1l-"'1 f(,llowing a tTl'M,,,,'nl t<.'Chlliqll~. 1'1'1''' if Ihis Improl'ement is only inlh"order of I pl.'rcent.An exarnpl.. of the (Il-plh of dl'to,] reqllired;s ewmplif>ed in a pal~nl who f~""ls
m,,",
Assessmenl
pam on the ...-.f1 side of his IW."Ck at lhe mid-cen'ical lenol. Du~ the o,anunallon he IS asked 10 tum hb head to the left unlil the s~ mptoms .lIe Iir5t fell T1us r.."u i5 C'5tim.1led and "",ortk"Cl (for eo:amp..... 70"). The physiolheTapist then guHJo the lTIO\"nnentthrou¢\ ;l further 5". arv:l judges ho... the pain briIa,..-s "ith Uus furthr.-!" lTlO\'~enl If !he patll.'f\t rTports that the pain ~ not dungN, tho- m"'TmeflI t, lalu!n further......."" to the extl.'l1.t of over-pl'l5O>UrT ~t the l'fld of the a,ail" ~b"" ranS" of mO\"l."ml.'1lt. Tln, furth•.,. m","ement may r..-sult in .. marked incre,,* on the left ru.'Ck pain. Some r""ders (1M}' doubt th~t sud, detail in ex"min.Uion i~ n(X"css,lry. The answer to these doubts is tfl.~t th" findings s:ive the physiothcr~pist I' !:\,ide .1S to the treat· mCf11 I~hni'lue to US<'. while IlItn'id",!: " ,'erl' fine rne.,.ure by whim theeffectil\~of lhech~n treatmenl t\'Chniques em be a~~" For example, MXing made the irutial ~'ru.·..1 of rotation as d""'iled ..boll'. lhe ph~-siotheraristarries OUt a 5Clected In'~t" ment technique. thefl sits lhe pabl'''' tv re~ the rotarioo, Uking noll' of I"" lhroe faMs of the T'Ot;lI>On "--"
same pa:n lD hedW:1alI.... lJllh...1teslo. "'--p11'§§.llJl' IS opplk'..,;;ng the pain. 2. II till' p..li"nl's ..cIi"", "'''S!' of roI~hon 10 Ihe left l~ unchanged although il bt.'COTnl" S} mplum fll..•• ~I,d Ihe rcspono;c to U\er-prl~"ru is as il ""as ~t the mitt ••1 any polin. \\1th firmeron'r'pre55Ure, },o,,"(.'n."1". pol'" ~ as 1l dId In the IJ'IitW IC:\I:. These findtngS...we..te S""'1et' unpro'l'emml than (2) obo\e. l .... l'fl though the P"ha\1 srill ft..'els the 5olID<."d~ oi neck ~n "itll the >otrong....-
If the f"'til.'flt CAn tum hi ~ ",;!hout p.tin .mel the Oq"'"PressuTC also dOl'S noI cause an} pain,. the paluml's .:l.~rde-r b olll'iou.;;lr impm,"ing fa\'ourably
If the tl"t'atml't,1 I.....hnique is of roo help, the signs fouoo on r... ""amin~tion will nOI hal 0' allcred Should the tre~tm{'l\t I\,<:hniqul! ha'·... mad" Ihero,'dilion ""D•.\-(', Ihen ";th,.,., l. The l'dtlenl's ce,"\'ic~l TOlarion 10 Ihe lefl will be
slighlly mOre limited and rain" III
2. The ;ld1\~ rangenf rot.. hon .md its associ~ted polin IN\' be uncha~ but with e'lell W shghte5t OI·....... pressure ~pplio.'d to !he m<J\'cmL'flt hi> p",n "ill incre..... more ~n al the tnill.lllesl. As the first use of the Wchnique is '...-r)' ge<>lle, ~nr wor......ing of thc ,,;gno "ill be minimal and noc h.lrmf\Jl and the chang<:S will be ;nforma!i,"e
Two or
mor~
pains
Thi'R' i> ret another pl\lblem a5SUCi.,tL'oJ hi>. I'ain. A p.lt,cnl may have two or more rains. One mOlemcnt ('" d group of combined mo, en",nls) may be (OIlnd Il' reprOOlice One pilrticular part of the pati"n"s ')lmpIoms. while a differ<:111 mo' \'ffi\'!'lt rcproducesn second nnd dIfferent part of Ihe pilhPnl's pdin. This is P.1rtl("u, larly importanlll weC~1l i>CCl1't thal il is lIm UJ1CW"'_ fUT a p~he"llo ha,,· mn/\' Ih.ln one kind of pain. either lJl the """,,,aWaOr lJl a do:sel)·Jinked iIIW. It is Important for- ~ rhp>otherar;~ to b<-'- fully aware of!tlesc J'OSSlbi.ilies iL.,,1 ditferenc:..-s be mISSed durmg "",mln.th.... For examp...., It IloC'Ommon for 0 patM.ntk>com· pI.lm of Iwo dlStinctl\' dJfiWrlt ~Inods of headache. The pall.,.,1 must be .1dequaldl q....."tioneod to det....mine till' diff~, and e.tCh p.lln should be eum.incd, tre.l~ and asso-ssed irl(kp"nd"ntl} Patients h~ve many de:l('riptions for p~in... )'\.'1,t IS ,urprising how often till....• U~ ,l1n;l.1r terms, mOISt of which an: ",.,dlly rI)COI;nI7.,ble, This ;s so even with 1'.111enls on dIfferent countrk'S and Wllh diffe~nl cultures.11 is probably stilting the ob"ioll' to S<'y that, if n "aiJl changes to an ache, the ch.lJlge is Ia"our"ble '1 f.....1rm ~tandingslraightl'1"', or'l feel more "'-'Cure'. an' (J"ou1"~ble comment>., wh""'as ·It f\'Cls dehcatc', 'II f('j>b r"-'C1ous' or '11 k·d, unsofe' urua"OIJrable romm""ts. ."t. p.lriem U\~ng. 'II rt'C()\"en.'d moll' qUldJy after rennls than f would han- e~p.-oct<'(r. i, anotMr kind 01 r.nou",b~rll.lnge. HOlv""""',a patienl ;" OIlen able to ans"'CT the question, How does 'I ft.'Cl 1lU\\''', onl~ by SOl}ins.·1 don"t know" I 6nd il Nord to npla.lll.lt',"". ibIUSldi{fernU'" lhequ""tJO;>n.1s ita fnourable difference or .... unfa'-ourab.... di~" ShoUld iol!ow automario.lly, and the paoc'fll (Ml ni'drly al,,",,~'S make ~ CleM distinction. \\"A,-'" a55e55ing p~.lhe phfslOlherap<s1 !ihoold be al"rt to .iluatinns" h~ implll,,~meniin symptoms "I>oJ signs donot occur synchronously.lhere .11\' hnws, p"'lio:uIarly if th" p'.ti.:'nl h.15 S"\'CTC p"in, when the Sil:l'lS m~y show improH''Ill~nl withoul the patienl lx,,,!: able 10 apprelSns indic~te Ih~1 lhe liame trealm.... l shoI.lld bE."
,,,t!
65
66
MAlTLAND'S VERTEBRAL MANIPULATION
t~---'':'''''';========------------l't'fJ'eol~d; impro·.....m ...m in the.- 5\ mplorns Wlll5ss In the joint s.igIl" b not 'loU r..",d. The ad~1 di~ k",1Oll1S a good eumpk-of this phenomenan. If ellher' lhe sub,.,rn,"e or tho! phl'SI(;/I1 ~.ent sho>\~ Impro<emenl,th<.", il c..n be COr\SidO!rW, ,,;th one I CT) ,",porlanl """"Pilon, Ih.. llh('1<'1"1' ntn.,..mol pain ..10 IlI!Urol..gic"l ch"ng"" Th,.....• l>.lhcnt:; 6houlrl be """rnilll'ci Ilcurol"I';ically doily br lhl' I'I1)'slOlherilp1st. ""d ,lUi W"T":>roming SI·mptom free or alm",,1 sy mpt(lm free. In lhew C........ pain does markedl\ and rapiJJy lC§OiCfl, .... hi)" the nt.'\Irolog:K;ll changes l.,t1~ appe.u or worsen (()IlSl,J,:rabl) As has aln'ady b«'fl ..tlled. the referrin~ doctor should bI.' notifioo oil one... btnll"l' the patit'nl ma\" require im£lediall' SUI).""t'l'\ \\-hen .. p;!ti"nl h.ls re<-1ri(tiT13 local pain aminl; from the ,ertebr..1 coIu'TUl, ~ m.." 5 pIIin "'IS nol Ch..ngL'lf .... he U.til,l1 un~bl~ to s",~" goIl club. The physiolherJpisl :>houId then dvxl ",thi.·r """'risk,'<:1 ~igru.. II may be Ihal this pilti<'nl can l\\lW lurn in bo--d wilhoul pdin Wh"r\',l~ it Wi" implK\',:d. Mmor ~~f"'ds of" p"li,,,,l's wmpl~int U~Il"lly i",pmH~ [xi",,' lhe m,'JM mmplaint.
i
t, I
made to ascessin!' d>angcs OIla~1 pilln "00 ''''n
I(d... rencc has l'lX'fl
..loons ~I t>Nr recoo-dlfl~, 1hl- firs! IS th.i.t a pallenl rna\" n..-"ort. at the~.. ninS trSion.. lhat his symptoms ~ undl.ln~ hlM......l......... hen hIS m,,'.-or..,nls a r e - t thequ,,"tyof .. particular m"'·...mcnl IJ1d)" "ppl'"ar fro",!". In bet I.... p"1i<.'f\1 "-....Is U/lCh,lnged OOI:.. us.: afll.... lia~. IUn,mg his t....oId -15 10 the k.1I, ho· Can go no further bee"IlSO.' of p,l;n. the "'kns,ty 01 which (and Ihc po6l' linn "I which it occur< mIll" r,m"O') is IhI.'".1I""as ,II his lastlrl-alm('fll On mo.... d"I~I1<'d \.'"~,l1l,in.lI101\ it may l:>c that pain felt bt.'lwc<," 2(1' and 35'· is much I,-':>/; liMn it was at his 10M IrelHm,'flI, Ordinary local pams nrc ,Iblc to change in man)' fal"ourJble ways. ,uch a, thc abo,,,, withoul Ih" p .. l;enl ~rilr being a"an: "f lhem. ReMting 1m, ~bo\"c ('>..ampl" to mm·crn""r
;--".~",c.--c"~,,-,,,t;-.-
Figu.. 4.3 Pre\~nlition of theldtooMood.V
ho.,.
Assessing changts in pain
P2ft".onuY)]'
c~__
~~in
felt ",itll cervical 'Ol.tion to
-
,
':l
Fi9~'"
•
'-
'.
4.4 Pt.~nlin,on 01 """, - n'pclrtw '" ·"nchi"!lro·f.lt witn c(""cat '01iticn 10 lhe kfl on I'IcdnesOiV di"Srams. F(,<'«( LJ would be th,-, p",-'s.mt"lion of I""i" felt wilh Ct'nicill rot;lli",n 10 th... lc't on Mon(l.lV and F',~"re J.4 would be lh<.' n.'P""",nlalion on \'I,-.lno.'sd .. )' wilen he reports it being 'unchang~'<:l' The,;econd i~ lhal, at the beginning of a lreatmenl ~'" t.... pallenl rna" y thai his ~\"fnpl(>mS ha\" r>nt d1.angt'\J becau<;(" mo ·n>enls or a f1\O\'emcnt 1Il.1}' be just as p"lnful or> .... 1 Ile beg.on lre.. rmenL or as I............ere he h;Kl hjenwonl. impro'·l.'ment ma~' be ind ....tt.,l b, tho- bct thai ..... uncl\lm~ pain c;; in fiKtexpenena.'it (fl~'TI" 4.5). or th.~l h", FIRST aW",,'Ol56 of p.>in wilh ~ 161 mO\l.'OTl<'nl is l.. leI" in !h<'r.1Ilgt' (FJ:I:"rr ~ 6). E,·en when both l'O"itiQn$ ha,·" impro\',-od anollh" pat· l<.T1l of po';o during Ihc m"'\{.",n""t h.l~ ,11;;0 In'Pro<',,J (Fi~rJTf4.l). till.' p.1licnl rna)" still >a)" that hb~}'milioms hav" not changed [x'Cn\IS/.' lhe inl...,,;;;tl' of Ihe pain IS unchang<'d. His statem('nt is corr('(l and sho\lld ""I Ill' ,ugU<.'<:1 against, bllt allheS
w"""
AsS<'S~m~t
c
o
i
1 ~
r,
.....
'"",e •. ~ Prt... "~tc~<>f\l"d':~"9~·poinfdt aft< ~""'}t ...,th ~I ,Otlll<;ln to I"e left on Wrd,,";rt
.'.
-
F"ogutt 4.1 l'I'... n~liona"tr:rlm~1 ""IIIfti1 .. th (ttvKlt ro:.tic.o to tOe le'i. on l"J~d'~
"';10<
manq., j~ ~ _motnl cli~9l'l1m ~ tit
~.ampl., 01 impro.~m~nl
of which
tn~ P~l
en!
m~y
tit unaw...
Gelling
......,
Fi~ .." •. 6 l"tnf:"lJl On of pi'" r,m f( tat.. n "'''S"'':to cervi<:.1 rot.tOll to I". eft on "'Ifflr~y
Weathel lI'Ia~"g.dIa.in~;>to-t",'1
u~~d
to
p~in
On il,......"ing ch.lng(-. in ') mpt(Jm~, pilt,,,,,ts quite freqU"ntly ....)'. 'I thin>: iI', just th", ...,me - I thinl< I'n, iu,t ~<1ting u<ed to it'. Du.ing till! roml'lrdh'c" short tim..' pilt'''nt. h.we trealment, they 00 '\JOT '1;<1 USo'."d to pain; the rcspon!il' lh"'"Cfore can boo.>
ha.,,,
Patic'ub ""110 'joint di5orcler.l ofren ronsider fho<m"eI\e< good OOror'l\('\o.--r.. b«"auw tho.-" 5\'mplums ch.onge ,vi!h chang~ in the weather,.md dli3 hi fuct. no/: lal"U". The fact thai some pl"OI'~'SSnJ1rlmnsrncro.-.:>sIl'
~,'§(lof
rrio:¥a'l(t to 1l$6S tr\.~ in d !o3bility n in ...... ' IV and q...nlJl"/ of ll'lM'IT .... t
rust~u.."ealt\.i>fcham;o,,,hik~ch.mg.'''' Weil!her changes or immedi.llcl~ following the
the
cn..nge. ma~e< ~smml d Ifhcull II"" ..nr. the hdpRelJlIng themo.>\'-"1WI'l1 d",s,arn to the th ..... "'N,II;(W\~
fu1 f,alun.> for ~t is that. ~1though the pt'TSOO'~
S" ....'I'Il1bl,lH·,.:lnd l.I:Ilng F-gun'44 aslheorigin.ll presm-
joint
laoeHl.the mo\"rnent is stilllimlll.'d by tho!' lI,rerunh" of the kx";ol ~in but the positions of P, and P:lLj h..~,c cha"l;N, as lIb
"&'1-' do NOT I'".
f'.>(u/Y>
4.4-1.7 n", all "Mmp.",; of
irnpro\l~menl
of
whll:h tht· patl~'11\ ll1.ly bc 10Iul1\' unJ"'Me. Ewn when he is awnrc of II"" changes, their signiiicancc will ~ inlerp"'k"l ,hffc.,~,tl}' by the paliel1l aoo Ihe mampulali,-., phy.iotllo,'rapist. 11 the manipulati'~ ph\'.iothcrapisl re,,1i~c' Ihm tht,> impro""m"nt is of ~reat<'r 5i&nific~n<:,> to h"r d5.essmenl thall docs Ih., pilt'';'''l, il will help h". in he. allitude to,,"ards him.
s~'mptomS ;n
tn.,.
ilS<><XIilIOO movement
T,eatment so.eness and disorder sorO"~"'",-
_
P.ll,ent:s often reporl .'I(lreness /ollow"'g a pre,'ions trea:ment 5C>.io", ThlS 111\l51 illl-t'IV~ bo.> c1anf,,'d, Is it the ct "'-'''-~1~'''5 from the m"nual h.l"dli"S of Ih~ lre~tmi!nt technique? 'Is it a $urface brUl'>l'd f....·I"'f: frum my h,me!, or i~ it "the thing" th,1t you hal'" gOI 'Hong ",itn you which is !oOrC?' (this is another e~amrle of an 'm"'l~-diate aulom,llic follow-up' que-t,on).
61
68
MAITLAItO'S VERTEBRAL MANlf'ULATION
Wrong t«hniquc On lhcocca~ions" hen 1IlSdt'tlTmined thai a patient's S)'II'IptOll\5 ha\e Mn dgJ;fd\dted b\· tho? rn."I'OUS trrotmerll, it is 001 alwa~~ thdl the '\l'on~ t~'(:hnique was USI.'d - it lTIdy be that II "<15 Pfiformcd too ..trongl.... w'lh too much mon·.........t,. tor too Iong.../W in the ...'~ pll6IborL Therefore. an clTort must be IlIilOfo Ir) ~ if ttw p"'lient ;§ ,,,,..'" of wtwl.t w.i§ about the
Iedlmque thai
"a~ the
cau>t". This i§ particulnty...-k-
'ani., pre"'lOUIi USol" of the- techruque hdd1J,;.(,n produ· on~ ~al
prog.-..
BEHAVIOUR OF RESISTANCE ResrsIafICC to IrI(WmImt ""1 man;fcS! I i I loss of tllc fn(tlo1-f~ f«ling Ihrou~h the 'ang<: of s\lHn05S, 'n<:.e"'"g 'I the mQYCment i5 carT,ell furthe, into
1'---r--r--7;,c,.=~CI·"
'ange
", Considl'r now the diff,',,'n(('S >n Ih" N,ha\"iOHr of ~}inl .Iiffnolss, In the normal p.erson, the mo,enwn! "~I Onl' Jllinl surfllre Ull it. wmpanioo\ is ~ rompletdy (ridionfA-'C mo\"(m'l~\1. Howe""... ",~"min.lt",n of a p;,til'Ol's joint
may ~how that while the range is full, r,>t on
osc,ILll('~y
through 1'MIgt' it I.1cM this Feel 0( fncti<"," l~nj:nt. With C-\p'-"rience it i5 ~k' to red a
fn:oe slight
~t't.nce kllIIO\.,...,.,.,1
as descrit>eod ablwe, e'\'en
rho\Jgh the r.>ngc IS full. Th... ,e,,~bntt ma" be .K'nllTlponied by crq>itus. although Ihis is by no ll'Io<.lI'IS alWlly~ the C3!>l' II is imporUr11 thai ph~~rlpistsde\~ the ~ldl 01 "-~,~ tht;, lad of frictioIl-frft' smoothness. When a joint is lirnitro b\' s1Iffne..s. there d~ 1..-0 common Wll)'S in which ttis relS~ IIUI ... behan'
1, In the fir
r..nbc If,S""~.B} 2.
~e-.i<.r ..oce md)
be: fell [,,,i)' in the r"nse and rhe furlJl"", the mO\"'m(mt is carried into the ""'!>"e the §tronger the .... i~laI1<.'e ~ , unbl a romt IS R'll(h..... ,,!'>ere me physiotherapisll$ '\OJ1 pn'pared. to ~ln.>tch the joinl further. In other ....·ords, lhe r"te "f inCl'(~,'..e of ~Irt:'ngth of Ihe rL'S,~tanc.,,, proportional to the mo\'emrot thmuSh range (Fisurr ~.~)
Tho: physj"thcrapist must be Ow",,, lhilt tho.'SC lariati""s in joint stiff,..,,;s can and do ",x;st; proficiency ill as&.'S.~mo'llt of lI>eir d,fference.< will come ""ly witr. clinical ex~r~l'I(e.
,
h
111O\~l.'f1ts
togu", 4.!I 1'ICJ't2)t n ~I mG"oICI""C"lt""'"'Ih ra...,e
"-
ffno~
ol P"l pmportion.llo
BEHAVIOUR OF MUSCLE SPASM Muscle SjSdW I"lay be fdl d'S • qvid: rdlu ~ i""""'ntary plotectM'
kll'o',n"';il; a wnlraWon
",ooq
There are two ~ ca"'l;ond of mu,dc spasm lhat can"" found on """rnll>lllicn ollOU't UlOwment,. and
thes..ared'-"'Criho:l in detAil in AN'f""d'" 1 The firs! of thcooe is a mll!'(1e ronrraction that comes "'flo..... R""Pl"~ to pain P'O"oked by 1TlO'I•...-nent. The p.lin mar be pmmlcd oc'Cause the movement i;; jerkily performed or boeause the joinl is poorly supported. Ho",c"l.'r. if II.... is handled w('il. this spa= docs not mJke ,t;;.elf Db'I',ous.. i'\('\'"rthdc;s. when ,t does occur, it 's~" ;"dic,'tur of the intensity of the p.lin.1tcan be diffcl'CnliJwd from a volunt.'I)' muscle contracti"n by "irtue of the 5p<.'Cd ",ilh which il i~ i"""ked by th" provoking mO".,mL-.,ll; Ih" refI",~ spa~m contract,; mL><;h moro rapidly than till.' "ulunwI)' ~pasm. Inlrl l'ffeo:l as a
;"mt
As~ent
TIll' sernnd c.JIl'gOI'\' at mlNie sp.tsm 15 tcl~ted ffi()f(' to" hat is wron.g with ltIejoinll'3tho.·r than berng dtn!dl\ rel.<1 in till' 10m ~m""t di"l:r~nl rep1'I."'<.'Iltatkm of these two sp",,,,s, lhey ~rc de,;crib.-d in App('r>dix 1
n..."., "' ,moth",. t}'llOt of muscle ~portS<." thai is found one is examinim: joinl JnO\C'men!,. .. 00 this is " 'holdIng' ralhef than 01 <pasr.'_ Although" smdll mioorily of p.1DenI5" 111 \"ollmldril} cmlrMct Ihcm~ thaI support thejoi"110 Pl'\'\cnl its bI.>ing mon'd, thl:!i c.m ,-en ell-.. rly- boo s<'l.'" ...... 'oluntoll)' mUKULu oontractiun. No romp.1I\.'\l ""llh tlu5, the 'holdmg' is~t II;" 001 a "udden muocul.lr..rnon. but r~tlwr an inab.hl} on tlx! ""Denl's p.lrt to be .. ble to Ict th.. muscles 1t'11I"- P,lhl'llts "dlibilin!: lhl~ "holding' arc USIJ.llly lotall> U''''''Ml' oflheir urlrcl"",-d state 60lh th(' musel,- 'p,1oIdirlfl', impmwment on f('-.t':-amln;ltion ;s demunstrolro by an impn",eml'lll m thequ,1hl' of Ihl' JnO\enwnt through which the> musek- holiimes
"h,,,,
IDENTIFYING NORMAL AND ABNORMAL FINDINGS - WHAT IS NORMAL? WHAT IS ABNORMAL? HOW CAN THEY BE DEFINEO? U~lul hVjlOt~,ical l~ine
calegories art: to
[I is~edasbem.:: normallD
had an,'
~,-mpt
S not (''''''' <1 da\- of ",il" _t,ft""""or
.on""';, ~rb>ng from hol'r l"Il'Ck,. up to the Wl'\..... pnor to the film N'\llg lall'll Dif/l·renli.Jlmg lht'l\'lelant from tl.... 1",,10" ant findinlr~ 1~ t/>('rdon' "en' dlfflCUll n... follm·,ing de/ill<' Ihe 'id..ar 'pmt!, Ille 'an'1'''I;e' ,pine ,lnd the '"bnorm"l ~rine,
l~ink of l~e
as(x:'MQ:
• 'deal - normal in e""ff'( rnpttl • a~a"" - d1S3d'arlagell but IIialfy sent! • abnor"'" ~ d UdvJ~tfp lind sv",,:ornaltC
han-""" kog urooeann shortoer than the other, wt this is in fact ,loommoll bcG1uS(' lhey art'<>synml\'1ricalln J ~hJo;hll, different vein, J person rn.1\' hano an i
Figure 4.10 Rodl"'l13p11 of «"ical ',,,nf of a 76-~e31-ok! Worniln. lho... '~ con~n;tll fulion tx:lv,.~n sc~od and ,~ird !IVc:il1 ""[,,bra, C~I'J!'M:Thrrt: Isa CO"QCMI fullon of C2 a"d J C6 and 1 a06 Tl.'ld 2, F• .
IDEAL SPINE 'id""l' Spill" refo!l"" l<\ ~ "'-'T"ies of tnt,..... ,ort!.·bral ",,'111m ..-hi<:h ~n> nnrm.al in l"\'l'f)" "''Sp«1: m..t is, nflnl' i> di>.ld'4I1tal:,:d Il1 olny' ""y b~ inl"'-l)', ...........00 Iftr,
"J'h('
AVERAGE SPINE The '''\'.. ra~e' ,pme is nOl 'ide,1!' 11 doo.'_' nOI consisl of .....ri<'5 "f perket m"t"r ~"l>"'c"ts. One or more of them is "b""rmol III ,",me ".n, C"l'n If Ih." ,1'" not e<1lhlnS am ~ ..mp'om• ••f ntdjoT ~ ... en"e,
69
70
MAITLAND'S VERTEBRAL MANIPULATION
Although the 'a'erage' "1''''''' h.u been dcf1no.'d a~ h.... inr; roo s)"mptomsof majorcon5l'quence, this Ol.'t'ds qualifICation. Some prople han' roo symptoms wh.atso> l"\et", "hlie others h.a\(' mulOf symptoms of a J"",d ",hl(h ttM:y accq>t;l5 being ·nonnal·. Thc thrw Io.tnds of unpene<:bon in the aU'r"!;,, spme al'l' exp1amed ilS follo....s: I, CooSftUtaloracqu,rodMNClural.mom..llics.
2. lJrLogenerati'echang..... ).Diseasep~orch.;lngcsl"C5uJtingfrom
,rauma Congcnita!or acquircd structural anomalies Thcre are peoplc wh""" ~pine i~ d;';.ad'antag~od by a congcm'al or acquin.od structural anomaly. Ex"mpk$ ",dude- a bifid spinous process th.;l, lacks one of 'b pr'IX...,..;,es,aspinousp~lha'inclinestoward~the lcftortheright.orcongo.·l1ltalfusion~·""",thl.'5l'COOd
.and Ihud '·ertebr...... ,,'hKh ~ not uncommon (Frg~n' ~ 10). Such anomalJes are of lhem§el\e.s pam~, but Uwy do mdi<:al<' ~thct" .as\"mmctry, or tNt """" stre... ~ pbred on ad)aO"flt "'tl"Oertt'bral segments. AnomalM'!> of IlCUral ..1t'"...."b must also be' con$Idcred_n........arem.tn)·,,~inmcdicalli"""atun'
C\id"""", of difk.n'nCl'S of """"·...-root (>rig; from the spinal ront "nd ,heir c~its from the, ert,...."l Col""!. Such anomali"" mu~t be' taken "'to conslder-
gi''''s
atloo"hcnassessingtheO"S'Jtiofap"hcnt·srd.'r~
pain. Figurr8.1 i.a good cMmplc. I'l\'fi"ed andpo>t·fl\('d pl('~"",-'Salsoform partuf the anom"li('S 'hat ('"i<;1. According to Br,lin and Wilkinson (1967), 12.1 f"'r 0'1l1 of people hal'c a prefi".-d brachial plc"usand 107p"'rn."Iltofp<.'Oplch.1v(' ,1post·fiu"CIpl,,-~U5.
Thc.... are other cl<"mlll"tion finding» thai should be' COfISldcrodo>sbl-"'Snorm.ilorrommon,ore',m .abnormal, I-et do noC ""lUI"" I"""lmen!.; I.\l.an)~a~unablctotouchtheirtoe<,and
tru,.dpplieo.r.l'f\toduldren. 2. DlffeM'ltbod,typesh.11 .. differenlroonn.ol ~
ran"""tJilIl(l\'emeRl On e>.>min'ng the rango.' (If fIlO\ement auibblc inlhe'er1ebralc.a""lsltvcture.s(lheslump~t
"'I'f\
,lescnbed 00 p, loWl, SQr'Jle people, the \QUng. ha"ea marh-d I'l",tri,t;on \\ithout" ll('C("iS,lnlycaosingp.''''
~ tobo-
so"J'ho> spirksofpropk-m the first.subdilisionareonl,·'dlSol(h'anlaged·,MaUSf.'IIl"lIother "-'S"nblht',ndl,lduals..-gmentsfittho.>'ide..rglUUp Elderly peoplt'on) WIthout I'e\jUlnng trNtrnenl Th~ slatement nl'<'ds some quahhnbon and e~pallSlOr\ bcciluse il applies to J"'h.,'fI"'The "kk'rly po..'fliOI1 who tw; no Cft'llCal \'mptoms
"""I"
l'l'Ihasn.'St~t.'<1rotatlOn',",llfl'l'idl!;«'mforllftn..
mo..... rncnliSQn Ih.. S,dt· to which it ,s,lri'tdlCd. Th,s is perfectly IlOrmJI provided that. when tl.... ~t""lch i:> Jppli,-d in th" oppos,tc direction, th., di!oComfort i~ as"io fclt 00 Ih" side to which th" h""d b torn,-d. llow"vcr,itmaybetholtwheotherotdtioo's~t ....tchcd toonesidc the discomfort is felton thc oppo!i,lo.' s,de 11I.i.s is "<juan, norm"l. plUI·id.-d that when tn.. strekh IS applied in the OP~II" din.'Clion it too ('"dUS<':> dIScomfort 011 the oppt itc side "The eJlsbemg norm.tl IS wilen the dISrurnfort is fdt onll' 00 0I"Ie side ",'he!het" the rotaliOCl is Strl'tdlN tgwards It or "",al· from it. Aflllolhet".ibnor· mal pain Il'SpOf'SCIS thl.' '",leaoe pa,n", ",hKh IS felt \\hen'O'ter-p~un'·toafllO\emmttsn.-Ie.l!ll'd
Thcquahtyoftn..sen>;ttionCll'atcdb)SIl"i'khing the ;:en icll rotatl(ln ;as discussed in lhe pn'('fs>stm a~<;("'ISIOg the d'(f"ll'Oti.."on of normal from abnoI'Tn<11. Who"n the """ ..mt.'fIt is >Ill'tch<.-d, discomfort IS norm,ll and "hurt' ma)- be norm~l Or ~bnorm~l (d"!'t'",,I"'K on Ihepen;on·~p.,inthrt'Shold,pall1 ,lCceptance, p"'"",n,ll. ;ty,c1c.),butwhcnlh"personexp"'ri"nc~'Sa_llarp'bit.··
I1fpain.lhisisnot'lOrmal DiseastproctsStsorchangtsrtsultingfrom trallmil
!>p''''''' ~ho'" el i· dcnceofjoonlch.1ng~,:>ductod~a"",or trallm.l and "'ho hal"sI'mptoms for ",hid> the-. ma\ or mal root N,'t"l\adadeq.... l<>tre..tmt'l\!.)·et""ho.Ka"ptthe;;e sl'mplonts oIlS ~ng thcu" normal dcsplW the lact that they LOt..nen.· w,lh their normal !if... On "",mUl.ition. thrir joint mo\"l'ml'lll an' pamful when ~In'l"wd .antl palpalionfindmgsan.>ob,ious.
This group LOdlldcs peopk- "ho;;.e
ABNORMAL SPINE l1lc 'abnormal' .pinc is a .I·ml'lomatic SPlI'IC for whICh
Degtntrativtchanges Th~'
first (If th.. thl'l,(, subdll'l'ions 0,0.'. congcni1.l1 "r ,.Ct]uil\'d struclural ,1nOmJ!leo;) is quitc diffcrent ii' kmd 10 the other two, ..ndsllOUld bl-thoughtof and
tllep"'rsons.-",k.lrcatm'11t_Ot1examm..'hon,~iKnificant
romp.\r"ble s;gns will be p.llp.lbie at lhe"I'prt'l'nat" inle""'rte!lr;,IIc,d.l1lctitlc·abnormal'iso><.xltn,igl1ifr an abnormal d~1ln.'C of s}'mpfoms rall....r tl1.>I' ,lh""mlal joints,which.ilSho'lSb'-'(11_l.lloo,llldybctot.1UVp.llnl(";.s
This w.e.lling into "omup5 IS 11(It J f.-.:riIOUs acl, II ;,. a re.u,~t1( Slluation and h'6hlighh Important dink.JJ rnnnt'ctIOllS bctw~,"", S\'mptoms .md e\.a!ll""'hon finding.~ lholt c.m be~. "The ,.\lUI" of the dil'ti'O". ~TlI ~r,ng5lies in our ~bilil\· to roerogn..." thedifkleroc<"o betw«n finiling> 11>.11 rel rel.:Jt<>d 10 In';olmenl .,'pectaho"",. For ,·>.amrl,·, (t is ~ible to n.'«>g. lll~", thn.lugh lhe inlt'Tpreta.tion of th., findings, Ihal Ih,· n',lli'tic Iolwl of lrL'alm«'ll m"y be n minimally sympl"nl.ltic 'a,oo.. g,,' ,I,ll" 0' ,I pain·fn.... 'a,,'ra6'" stal" rMhcr lh.w an 'ide'll' St,lt". Unforiurlaldy, very fe'" p"opl" ,n',,, th" age of ,j.(] ha"c" 10t,,1 wrnplcmcnl of 'ideal' inlcncrt"br,,1 joint>. Mo>t I"-~'Ple, for one reason or another, fit inlo one of th,· 'a'cr.,sc' groups. If" ~;roup ~(}.rcar-<,Id p.·opk' "ho h~\<' no pa,n or disoeomfort and ron:;ider I~.. neels 10 be I\Olll'IiII ....en;> ,"'Jmlllt.'d b} palpdllon, abnormahl,"", would be found In Ile.lrk aU oi them. '""-"q,*"",ion is,. "hen _tlCh a p"......... h.u.1 sponta""""~ 0f>!Iel of",-"'(].. pain.md seet..s treatmenl for It. how does '1>0' e""RUI1I..,. differenlLuc bet\,cro I,,", fmdings !hJ,1 n~I;1t~ 10 !he p~1 probk'nl dod lhe fiodings tNl ,,·c..... p~'1 ""for<" the ;;pontanoo~ on>eI of the IlIId< pa.in' A .. milar difficull" .. ""eo, ,,'hen altempliJl,l! 10 dRl......,.... lilt' d~'g"'" of diS.lbLli~' thai can be allnb· uled 10 a l"\.'C.,nl,nlul') and Ih<.· dcgrw Ihat is ,Ittribut"l.>I.. to) p~.,.i~lu1g rei painJ~~, .~, ..mg..• joinl finJiJI~.
m
",If>.lble Ii$\1'\'
chang~
"'QUId not haw:' beeft as 'old'
a, those in tho> pair>-~ ·a......./:.·· group. Diff......... l;.. ..hon ~-wn u..,·new' and 'old' ,"",nses under the:.t.'
ornunstant:6 b much "1Ofl'difficull. The abnorm.1liht.~ sought b,' palpation a.... ot tho> foIlowi"S kind$: t SOtl·II'suechanl;l.... 2. Bon" .."omalo.._.
3. \lnH'mlTlldb"",mJlihes.
SCft-timu.· Ch3ng .. ~ Till"'" ch"n!;e. ;lrt> to be f,,"nd in th" Ii~ar"e"tou~, c~p· sul~" muscular and c(>I1,1t."ti,,, l~"""l'!i as Ihickening or lIlu>cle sp,1>m. Pdlp.,tion Ii th{'m will 'eveal Il'tlderr"..s:.. Th" abMrmalities .~f 'fl.'el' in hgJfllentous, ca!",ular and CQnlll'<:ri\'t' li"u.", d~ tt"'l the older Ihey ,,~ Ihl' han.J.e1- lhe,· feel. and the more ""'lTlt Ihe" aI\.' Ihe ;,ofter I,,",~: fecI For ,"'lmrlc, p.>lpaling oli capsular thlCk1Un~ around lhe J'\-gaporh,~~1 joinl ",U be 1oJ,.,rn"~,r,:: J.;.Jinst IeJI!M;I. the~ are •••..en "~ria!Klns in the NmJ1('!;; 01 the leather) 1'1,,,1- Thico..rong from roOA' rea-nt,;~" III a!>Oftcr or SJI'O"f."" fccl, "h"h ",...-tie.m OIdt.T k.lt""" iM. lln.:I.e;'ing wilhin the mll'ICU~' lissue is usually m<'rl' dlliuse dnd 1l4'\t.'l" feel>. like hMd leather. :'\c"(1"lhel.."." when thickenin~ i.> pre..cl1l'l ha" a slrill~}' fed il il ~ 'old' ;md .. ,moother Noel if il is 'new'
m.J,-
g"""
Bony anomalit~
NEW{OlD TISSUE CHANGES Ob\'iously If an jnter\'ert,>br~1 joint ~uddl'l'lly sta't, to r.lU!>e p.lin for 1100/"·"),,,, re.",.'" sometlling mu"t h,nc 1I.1PI''-''''-'lI 10 II, and therefore ~ ...... changes of ""me kind will be present
t""""
II reaTlt "--.sue ,1ta~f"> ha,~ oo::urred m an 'idel'll' joint, I,,",onh- fi"d,,>t;:5 th.ol "ill be d..-:ti"d by palf"'h..... e>;.lmi"",lion Wlli boo oi the 'Ile'\'" "" '"",,,,,1' "'nd. ~ with,. for e;ympJ.e a 'P'~"ll'd anUe 1£ ~ recmt tt".sue chang..'" ha,e occurred in an ol!iymptomali~ ·~Hr.U;e cenic..1 ""nt then on "..... m· illation b). palf\illlOO ~ ,,,II be Ill'" Ii."u" chanSO' sUl'lY'in'p'''''''' on l"",oM,,,r 'a,~rase lb,U<' chang""'StKC\"'en lilt' new and old d""""l.", males progno;;i.>. n;>1.-.tcd bolh to the 5"<:C~'!iS of presenl tl"t'Jtmenl and I" Ill.. 1Il.elih"od of fUlure n.='I1.'I"',-,", l~"il'r to J""",,s. If till'S<" n"enl liS611t' (lI~nfl •.,. I",,",, occurred in a 'y"'p""n,ll'C ',werag'" ~!;meT1l, tlle!"l' "'ill be 'recent" ti""., ch,'n!;{'l; ~uperimPW<.'d ,)1\ the changes 1r..'1 "·"n' all1.'.1d" painful ",hen stl"t'telled 0' p.1Ipak'll. Bt.".m....' the pdlk'tll ""d symploms bclun' th" "",Kerb-,li"n. I~
L·"dN IhlS h,,"ding Ihe fe,ll.,m thai (,In be det....minl'(,'SS from Ihe (""'Iralline w;tllo"t (Or with \ ",t,obr,,1 rotittion; abscfIC€ of une pnxl'S§ of the b,fid SPll\OUS process; abr,om",1 ",... ilion of Olll' ce,,.iCilI,,crk.vr.l reInri\'~ 10 its nL';ghbour; and the ostt..'(,.uthrilOC ""tl'Ol'h)"~ fcmndlion of lhe margIns oft~ zy~pophy~l jomts. The .lbnorma.ilie~ of d... lalion of sp",ou> prol't..."i!i and po>.Il0R5<>f ,....nebrae,.." bt.> (Onfirmal by X-rd'''' If" Jl'O"'itional finding IS IongsLlndmg. Ih<-"Jup"ot' lhl' lbslJCidtl'ti \-..rtebrae \,,11 h.l •..., changed from Ihdr ~~ mmri...... l 3PJ't'i1r.. nre 10 .ocrornmoda'" the chanlo--ed
pos't,uns. The articuJ.IIr pilJ~r abnormalities thai ind'cat" OSk'C ..'" ",ad'ly dctennined by palPJhon, .111(\ Ca" .. L.... be cunfirlUl.'d b~ "·rays If the dldnRes 3re '"Id' dnd lotally inaCli\'e, Ihe bony ""'
Thl''''' abnormalities COt"'st of Ihc following: hyper- or h"pomooiJity;abnormdl qualit\· of nllwemenl th .... u/Sh
72
MAlTlANO'S VEIIH811AL MANIPULATION
romsI'; and
\Illf!N.os>,
and spa"",. Such abnolllu.lIt;"'S
can be dclermint>d by palpation being applll."d in "
II\dnlli"l" lhat prudo«!'! Intervl'l"tl'ln'al mo'.emml Abnor· m"lilleof Tl"IO\'ClI1CI1t should be qu"lIfied in terlTb not ani} 01 t~ available range of mo\t',nenl. but .. t.;.o cI anv (h;m~ ;n the llOI"ma1 ftec-runmng mO\t'mtnt through the r .. up 10 the end of the .l\ai.J.lble ranI:\' This may be dbNrbed b., SIKh fiKlOl'!l U Mthnb( ~ , stlffneso. ,n suppom:n· capsular and li&,mf'TItow ,;tructUI'8,O€ prot..ct",e mus.::1r spasm An 'old' l\\'pornobiht~ h.>s .. hard end,ft..~ .. I I~ hm!t of the r.. n~e, "lIh ffiO\ement before the lurut of the r,lnge bcmg a smooth. fricrion..f...... mo\tm,',l1 A 'new' hypomobilily. on the other nand, tws sllfrtlCsent during mo."t'Tnl'l1t, it will be painless;( it ~ una;;.r.ociated with pR'Sl'nting symploms and rainful if it i, aS5OCial"" In 'id<"al' iuints, wht." the s\,,,o,,,,,] joint surf.Kt'S"'1l' slro""ly c<)ll\pre~>ed and m~'e, Ihe mm'"ment will be p,'inl"05 (M"itl,md, 1980.1). There Me d.-.:umstann." whC'n pain i. cx~rienced durmg a la'll" amplil"de of Illc joinl surfdcl'S flrm1y COmpR'SM.'ti ",h,l.. ,no\ the jninl throogh lhe <.lme amplilude of
nv
""rI'er
"'I;
th"TJ"~.
Pain rtspOnSC' """ pain n::;ponse felt by the palienldunng the p ..lpaboo e .... minahOO 01 h ...~ues and mm'''m<'I11 i~ ....»1 ,mport1nt, 1'hc pain or d",.;omfort m.l~ b.1 fdt ('Iu..". through rans" or at the end of ranb"; it m.:ly be.- fel! dol'q)l)'.Of it """y reprodU('l;' The p.>ricnI'ssymptoms. SupeThci.JJ and 00.,:. local p.lm cr",le pressun.' is applocd 1o .. soft 105sue, or JPJ'1ioOO 10 prod....e mo....menl.1Salwa\'1i 'new', When '" p.>lJ'-"'l ""s rri
ASSESSMENT AT IliE BEGINNING OF EACH TREATMENT SESSION ASSL-;'~Inpnl "I chdnl't'S m ,ymploms and s;"n~ at e,,,h trL'iltmml session ",,-,,-'tis to be carried ool in a particular m~nner. Ther" art' lh~ time:; when the p.1tit~!l's
;"terpretation of the clh.'d of lre,otme,,1 (i.e. the symp10f1bhe fee~).'" most .."IOllbltr.
I, Immo.'l.,. fotl",,·,"K 1......lm.E'e5'sion. the lim q....--stion ,,",ouhJ ix', 'How ha~" you """""n,.,,,,,,,WtY ..-111 t'en ""pressed, If lhe fin;t 'lUL'SUOLl proou.1 'lul'stion should bl', 'Wk,lIdo you fl",1 ",aslh" effecl of the last t",.1tm"nl?', The ,,,ply. 'Bootie" or 'Worse', ,,",-'Cds further clarification. Fo' ('''dmple .1 pM;,;nl mdY, in ",ishill!!: to I'mph,1Si~" the d<'gT'('t· of his present pa;ll, gi,l' the impn..;;;i"u Ihdt he is wo,..;e, ",IK'",,,s on d05tY qllestioninll it may b.1 prowd that he was betlt'l" .rltl'T hi,; lreatm.,,,1 until he pt--rformed some activity wluch ,lggTilVatt.,j his pain. lindl" thes-e (,rcumsI.1no:e'S, t"'dtmenl hdped ,..,ther than mad" him WOI"Sl"_ This kind ofinformdrion may bl~g.>.ilK'd Ihl'OUf;h Ihe follo",ing: qUC'IIOIl.~: 'In what W")' is lhe !"un w~' (is i111\Of"e SC'o'ere, sharper, d""nged 10 '" throbbing P'un. or has II in
'Whal do you thll\l: made: II
"'00'1:'"
'Was" Mill<.-d 10 lreatmentordid vou dosomelhing which may ha\e aggr;lulcd II"
"""" physiotherapist must be prepared 10 accept IJ..o p 10 feel d '>COIl,-,crted and d",heilrtened. She wHl lind it "a,i"r ill a(cept the bllun.. if ,he can reply,'Good -oot thM] "'Mted to make you ",orst'. bUI il shows m<.' "xactly" I~t Il) do and how 10 do it'; or she may >.1),. 'If 1 can m"ke you Wllme by too much or too hed")' mubi1i~ing 0/ your spine then I should ,t"nd a good chancl' of bo.>jn!!: ~bk In imp""''' ,I'. Th<' seq"enL"" of qUl'ShUl\i"g 10 dcl<>rmll1e "~..:,, dnd wl,y a p.1t~nt·s s)'mptoms "'t'rc ",orse is important.
AS
The fin>t questions <"iln toe. 'When did \'ou ~ il .tlIrting Iu "omen?', and, 'Do:>}OU knl)\«' what matk.t
boocome WOIS<"r' Assuming lhl.' arlS\Oo~ be,ng OIOUgtlt,,~ not dutidJred by Inc, ,,1xn--equesllOOS, till' nnt step, re! purpose oi the .."...:-s:;1ltcnl is to detcrmint wh~lh"r the worsening w"s due 10 lreatment (which is ., known quantll,,) or to other faclors. Ii it is du~ to olher faclOr!;, the degn'(' oi th.' cau...• mu~1 be deter· rnir'l<.>d SO thai il can oc rdall"d 10 tlu>d,'p,,,,,, of WOIlief>' ing. b)' Ihls lhe dq;reeof ..1.. biJitl' of the disorder being lreat{'(l m.. " be laml.1f tllc p;ohl'nt's;lr\sw"" 10 '''''!>en' is. 'Who:n I gQl out oIbcd ne~1 nlO)r"TlIng'. thl'auIDlJ\iloc immedi.:l~~ is, 'Does 11 Ol,mcti",es lluctual<' I:b< this, beln" b.d ooe morning for no known ""olson,. or is ttus unusu.U".IfIheMl5\Oo.... i!, th~isunusual'. tt.> quoestion has to be pursl>l'd; 'DId ..uu do anything rtstero..), ",hieh might hoI\(' Jggrilull"d it?', 'W_ rou more bl'\"d I.... n usual ,·estd to gamlhe infor..... lion bl..~ng soughl, and 10 show lhe<.re~'in UlIefpMmg Ihcpatimt s ~ The palienl,a }"o.mg man. had seo,'Cf'l' low bad< p;oin '" Ith a ,".. gue rei"...... 1 "'to me rlghl buttock ..rod rl#>1 po6t.,,-ol.. tnal ttu /II Ius fir.>t \isit 1.1"'- Fnd.:ly. follo"'in8 • limIted """"',....t"'" he "o1S !matl"d u.lng .. grad.. oi lumb.lr l'\btioo foe suff",ienl Ii..... 10 prodU(e a change in the 5}'mptoms CIt' 'I~'Tl5 if il "''''re lht.- nghllaitmque to ..... ~ "'JS a..mall but dl'finite ,mpnnemenl, showing th.llil muJd be the righllechnique'. The ~ trNtmcnl "as on Mood..". and lhe fol· IOWlllfi is the conYl'fsahon Ih"1 was n.-q~11'\"d to determ",,, the e/fe<1 otlhe trcalmff\l.
'5
'0.
IT
Q A
TIItII is.m unqwllfird -l..Ifflft',l! ..,W IflU>/ &rron !'r1W to .... irtlimmtill'C<>rnpdriso,," '~th.ln""~?· '~th.on
s"tutdar. bul then 11u' .....·1 been
doing anrlhiflg: ET
73
I ,Iill don't kn;)ou. Illorlhn t......I"""'lm,friJ.:iy.
""s
brlltT lhun
/JtfM'
Q
'How do you fl!1i1 nuw compared .... ilh when )''-'u " ..re III here ocfore lrealment nn rrid"r~'
A
'Oh,ldon·lkno\\· ... ilboutw.;lme might be n bit betler.'
(lr ..
ET Tlw! m,'t rrolly 'ilrcll'flr·w' J::'",lllf n'l'fI:'ll'l' I'm lool:;"g.f~r ",Id Ihi' I",i' (', qUi'5Iioni"x;~ "o1 gl'I' ling "''Y I
"IA'
"'r,
5tJt:lrd"Y pa71""d )/(\' if IJwl g;;n, mt' ""II m{t>r
n>aI .....
Q
'Ynu -.lid 11\111 \'Ou were bad 00 Saturday ",i1ft100 Sarutd.l\'7'
A
'I dun'l knO'....•
Q
'Did you ".am ...., 'lin3 bad 00 tho.Salutd~y momingCH' "i>S il Late. in the d.. v?'
A
"I don't lu"",. I Ihlnk I w .. s all righl in Illt morning, Ilhln~ It ",..S I~tef in t!u'day.'
Q
'Dld you do ~n} Ih;,,!! that could
h~l"e mMf'
il
b~dr
1\
IT
Q
':\0.1'1'1' only been .... ,Iing .
d«l>lI....,'ilh lti5 N'GIIV '" lw.nJ :l'l'tJ::.
He' i; 'lIJ/ IY",
IlllSleYrs;
litis
'l-.lIal ""ere you dOlllg during lfwo aft"fTlQOTl?'
A
·Oh.~bn&:
Q
'Did~ougetupatalP'
A
'\\d!. now ~·OU como!' 10 menrion 't. m, WIfe did ga OUI about mldd,;;,yand I w,"" at ~ 00 mv O".-n, The phone ... ng four Iimt.~ .. nd I h.ad to MIS".... il. That lTIt'iUll bending do....'f110 redCh the bClephone b.'G1lZS
While M;.ing Ihis hoe dem~'tTJIt.'
Q
·Il"wha'·eyoubc...n?·
Q
A
'11 was terrible nn 5.ltun:l.. ) but it's better now:
IT At la.t I"Y .~ot I/l( an<"..... P'" I ;;}lOnlJ
'Thank
)'Oll •
littlr r"r'hrr tobi' s"re,
/Ilu il Q
74
MAITLAND'S VERTEBRAL MANIPULATION
Q
'Was it hdur{) tl"'t or afl{)r, th,lt rom hack worOCllt"{l?,
A
'\'('S, it
Q
'How did you
A
'Oh, I was" bit sore Sundav morning, but it gut bMtcr as the day ",,,nt on '
Q
'And now VOU'f
A
'y...,lthinkso:
W;lS
after the phone calls' f~'C1
'Well, I don't rmlly know, because 'lly wlf" drow me home whil.. lIar on th" ba,k scat and that WJS11't nrr oomlortahle:
1:."1'
At I~,I I hWll', Irs ,1f!'Crs..'lV'].; is /"A',ll'le, idr~rf my InWnJi'm stallds i" ,,'Iatio" 10M, 'y",,,I""'s, m,,1 I kJww 1111I'" 'lilies.' 1fin,1 rilnl hi, 1",;1 m~,",Il""r/, m, ('.mminn/iOP' nrf IlV,,"-', I llW:il (0"1",,,,' .dlll tI'e roMllm' jor nl Imsl I1Ile more tnwlm""t if I ~,,'
gvin,;;
Q
'How did you f",,1 alter treatment un Friday o,mpmL'Cl with befm" the trro,ltmenl?'
,\
') ~rtai"ly knew I'd lair bit.'
Q
'Do you mean that )'ou had mur" pain than when you CJme Inr'
1x'l'Il
mOH'Cl rOlUld a
A
'I don't think so, I was about the sam".'
Q
'Well, "'hat ,,'en' you a"'Me of, when you rd~r to knowing rou had Ix'l-n "mO\'L'Cl Mo,md a fair bit"?,
A
'It iust felt differ~nt:
Q
'What felt dilf"rmt?'
A
'My hack' it dilfer(~'t"
Q
'In what W,l!,
A
'ltfdt.1bitsore'
Q
'How long did itl,,,t?'
A
'Only lor.1ooul5 minut"s,'
Q
'And then how did you k",l?'
A 'Back to the lIsu"l' £T
'How Ion!; did It remain better?'
,\
on SundJy?'
ET Hilvi"g got tlwi elmr I ","si ".01'<' 0>1 It> my IIl'XI I'''rt of QS5t'SS;"X,
\\",~
Q
Till, lS Im,,1 !l'(Jrk al,d /,,,, ,wi Wllillg lYry fM,
Q 'Dv you "~m,,mber ttwt during trmtment on Frida}' you were lying on your side ,'nd T W,lS twisting your b,.,ck?' A
'Yes, I certainly do.'
Q
'At th" lime, I thought you ""i
A
'Y,,~,
Q
'Despite the 5 minutes of s<)f
that's right'
u\'111d
10 ream II, nl[w. 7(, d,m,S" Il'dlPJiqw'S bt'a wnmg dffi,;;,,,,, b«"",.." ,tage hns ",11
"''t~' n:ad"oJ ",I,m II,~ ""III<' aj
rol"rit",
',<6 I.y"
"rom!. The extent and depth of the suhj<--ctive questioning may .eem to some p'-'UpIL' t" be t<-'d,ous, U""{'("l'SS.1rY ""d a wa5t~of time_ TL'le of time it is not. It is \'italto the interpretation of thc dfed of t""atmen! to be at>le to underst,'nd th" "ffrxtof the treatment in the p"tienl', terms. It is not tedious, it is challenging and stimulating Ii the vital spontaneous inform"lion sought is not torthcoming, it may bc nL'CL"lS.lry tu ask the di ...." t qUL'StiOJ" 'How did yOIl I~...l when you got up first thin):; the next morning cornpilf<:d with huw yo" f,·1t wncn j-Ou carne in for the la,t treatment?' 'How did you f('Cllor the res! ollhe d"y and lhat ni!,:ht?' 'How did j'U\l IL",1 wh"" you got up first thing the lIe,t Tl1orning~' Should the~n"wersstill not gi'"eil de~r J,s~'Ssment, the phy,iotherJpist may nL'l'{1 to ",k, '[-las your pain ,11Iel"L'd ,11 all JS ~ result of t'C
Assessment
was the imn",diilte ('ff('(:1 of thl.' lrealment?'. Such a commItment frequent!) giles a bl."tterbal.ln<:ed ~ InI.'f\I of the 0\ ('rail ..ffect of hNtmml lila" ,~ dl:·terminftl by 8Sking ~~ifw: questions aboul spt.'C1f.< sl.1gesdUril.g lhl.' "'1\"I"\al bdwecn lhe two ~ Writtl.'n rttOfds by the
n.,.., are
~tient
\\t..-n it i.5 no:l'S5olry for d patient ro IIT"~ a runrnnf; rommmtar) of lhe bclwliouf of his ~ymptonb. for l"'.lmpk. patient IN}" be .. I'en poor hisloridn. in which case he may be ilSked to \'\ nle dO\\'n how h(- f('('ls lmmediatdy foUO><>'ing tTt'\1tmo.. ..l. how he feoels Itwlt nihil!. .nd how he fucls on flrsl gctting out of bed Ih" ....·,,1 mornml>. There an! al50 timt'S \'\h('n III~ critic.lto know pn.'ClseI)' IvtllU happens to a hllll!S
pa"t."Ilt'~ svmplom~ for lht.. finlt 4 hour> immediately following .. l'''rlkulM treatment. Wlu.:n .. patient is ha"ing 10 interrupl a ""'IU\'1>'(' of tn.~~I""'nl fur bu~illl~ or ulh,'r ,('a,;o.)n~, it IS useful to ask him III writ" down Ih<.- Ix·h.,,-]o,,' of hi, ~ympl"ms oll'r Ill" fif)t 48 hou .... from the time of Ihe last treatmell!. Some ,eaders may f\'I'l th1s i, enco,,"allllll! a palientto 1:>I:«>",e a h),pochondriac. bm thi, i~ not Sfl. .. nd el'en if it we,t.' the ad,-anta"l'$ of the '"Ittl''' re<:oni f.u outw{'lgh Ml)' ~uppo6<'d dls.ld' ..ntagl.... Whl'n a \I "U,,,, ",-'Cord IS u>Cd ••t should be handled by the manlpulali", ph~~iotherdpi~t in .. parli(Ular
>e<jlll!rlO'.
I. On "'Cei'in!: 11 from the patient, il should be pl<>ced faa do...n. 2- The pahl'l\t should be..,,1U'c\ to w'e .. !l-l"fM"f"al ;mp~~;on of IN! l!f/<'Ct 01 the last tmIIlm<."nt. of lhe effec'l of the l..st tn.... tmef>1 should be takn tnrQtl,gh l(\ it!l omdusion. 4. Thc"'ritlml'l'C'OO.l(ilnlhcnbe~and ..n' d~repa.ncicsc1.lnneJ
l. lbe ,;ut,«"ti'e ol$sessm".'fll
pamcuJM the pallcnl'Sopinion of ttl(' changes dfed,..:!. Itl~ lherefore ltIilooatory for Ihe m.101pulati,c pnysiolm-r"plSt to dP\·~ lhe Mb,l of beglnn,"j; the ...ntlen ~rd wilh I\urds ttut lhe pilhL'flt usei C ..bbn." Idled if rM.'Cl'SSlIry) to e:<J'1"'SS HIS opinim of the cltect. This ~lbt be Il"COrded;n quotation m.;orksso a~ 10 IndlGtlenh Dplmon It IN} not be lhe m.;onipulali,... ph,~"'-.,.arISlsoplmon. but It cerI.. ml, ;., the palil!Ot'~. If th<>no b a H1ridncc of Of'imon. "hid> cannot be resolnd, botll opmions m\bt be
"""""'.
C>ccasion.ally a patient will ('Qn\rI'I('llt that toIlowing ttlc Ias.t lreablent he fdt e~ln'mdl t..~, "nd p. fact mdn, ha, I-' ~ for as Ion!; Ib 3 hours.. Thh (!{fuct usu..Il.. occurs lolkl\\ing the imhallre.ltmMllS. and can be rons,dcred to be a fa\"Ourab~ re-ponse to the lreatmenl The abo\"(' is the ~,,!'i<"C~i;,. ~nl of the effect of the pre\'~ day·. treatmenl This 1$ followed by re·to.'S!IOS The pr<>\'iousJy ,.hm.rm,,1 mo\'ements aOLl ,\';,;t..... lIIS thl-' qu .. hty of ~"y chang" ",-'!>ulting from t""atml'n!. ChangL'" in thL'S(' Sl~ns will hIJp
ASSESSMENT DURING THE PERFORMANCE OF A TREATMENT TECHNIQUE Two points are imrorl.1nt here; one i. the inl
,'1'ie§!","'"t d~r'ng a 1rr:Miquf: • Mgo;r'.;oct.n-nI' • Oars no ~mles."'" ~ 5UIt ~ffect oca.-~
ror ..
It I~ not uncom.-non wnt!\'fl ~ 10 gil-.. a wrong imprbSion beouse it is ",ad OUt of cont~1 "ill, all otl\('r dCrt\("11b (>I the dS5eSSm''f)t. It ma,' n.'old as though 'ho' p.>hmllS worse. "h<'mas, bK.. ~§l' he h.ls not roc."dc'd """"" import,ml facts (not asJ..al for), he ha~ m f.let Impron..:!. So this is ,,·here the manipuJ.lli'·e ph)sinther"pisl muM be<-omc skilled ,)j int\'rpretation and uS!' hoer ilStl.'risks from the initial cOllMlllatlon ch.ut.
Patient records Afkr C()"'p1eILon (If the ~ubJl'Cti\e as>t'Ssm{'nt '1"",. lionin!;. il m,,,t be ",-'C"rdL"" on th" case not"". Tho: FIRST "nt')· at "'-"f} trcatmenl ,",s"on is alll"a)". th" ass<''!o)ment ()llho! subje':Ji\"e changes, including in
Intc:ntlQn of ltchniquc: FoJIo'~iJlS
the I-'~amination and a.~nt of the p.ltl\"Or. dL...-mi.,- II 01,"- be the intentiol1 to ".,leel the poslt.on and m,atmenlleclullque that prul"0 be rcmember<xf "hen m,.king tho! ••sSf.'SSments followlOg the U5<' 01 the tL'Chni<jI'''')
Kind of change l'n> pain n.'!>pon,",,~ C,1O oocur whIle performing .1 tl'CIUlique; I;rsl, i~ that palO ma, he iellln mythm with
75
76
MAITLAND'S VERTEBRAL MANIPULATION
the ~ill~lions of liM.' t~'l:h.niq .....; and >«ond, an act.. rna, de\ clop during lhe performinS C>f thl! ledmiquc Pam (O!'II in rhythm ",ilh the lechniqu..., I.e. p"-"-nl (3), may d .., ng... in lhe follO\\'lng ,.."-~~, L
From a pain-fn.~ .tMt. th... dioorder mar begm to hurl in rhythm ",ilh Ihe 1I.'<:hnique. The technique ~hould b<- ce-Jhnuco:l without "n\, cnan"... whatso",cr oc,ng allowed to to,", pl.lce 10 Its:
OIl Spo.'Cd hI Rhvthm
c) A~p1itude d) Position in range
Tooch",,-e thIS po.-rfectJ..... ""lUIrl'S lOt>Il Concenlra"on. After 10 'iI,'O,}nds, while lhe l;xhmque is sllU oonnn"l'd, ;> comparNm is made of It.. rhythmic pam. If it i, ;nc"-'ilSlIlg. the t<'ehnique mar be continuoo pro\'ide.:1 ~ c~IT'ful w~lch is ","pi"", th"t il d",.os nol conlinoe lQ wors<:.-n Ih... S)'mptoms. If il dOlS, lhe techniqu... must be slopf't'd. 2. A rtll'thmK p;ltn lTI4~ do=ea9l' "-5 the ll'Clmique I-'> eontinum with IheconstilIJl spet'd, rtll'thm. amplilttde~nd f'O'SIhon In raose, Ajudgt!lllf:llli;; madcof !tie lUTIOUnt ...-.d mlc of change ",LllN to Ih" amount ,Uld land of techruqui': reqwred to e1iect theeh.lnge. This gi\"l."I1lll id..-a of the hkelv p~no 5;5, parti<:ulMly '" hen the peKcnt.-,~c of impnwem...nl rt1laine<J o\--;:r 2~ hours b ",I"ll>d to Ihe ki".t of IN-alment and the amount of Ir..."tmcnl.
3. n .., rh\thmic pain In,iI' increase /Qr the fiNt IlJ-.3O S«'OI>ds}x,fore then sl.3nbg 10 OOcrw~. 1l>e ~in m.>\ ronlln<>e In ci«rN5ol' .. nd eo.cn dbaPp"'ar. 11 lhl> 11llti.lUy irrrn,ins pain;'" Q!Ilf p<>m of tt'G.'I.1 origin.. ll"l' rodVUqUl' l~ not eontmued fo< the 30 sccnods. Howl!'\--er if it b local Sr"lill p..l1n or ne~rby n..iem,-'<1 p.110 (p.ortJ.cularly If 'I IS ~hronic in n"lull'!), lhe <:OIISl.3nt sf""""l. rhylhm, ~mrlitu,le ~nd l'>OSition in t~ngc dre conlmued for the JO second~, prm'idL'<1 of cou •.., it is not .leAdily wor;.en· in" as ~ach "'-"<:(,,,,<1 ~<X!S by If the rnli~nt is """ble to !he returns 10 the offendingjoinl it .. i11 "f...'11 be ICflS hortful. AS6L"SS-inl'l,ueh d",ngC5 n>qu~ not only verb,,1 communirntJOll bul also .-."'".........'$.~ of lhe non-verb.:ll nuances of beh~"iQUr, Ihe pJllomfs abilily to) relax rno", and tl", IL"Chnique being ';~.l ...r top.-o<;luc.... - all I'Lly Ih....ir part The deg"'" of coo<:enlnti(lfl ~nd skin required under Ihes.: circumstances is dem"OOins. and tt... extenl 01 (il) tallang to tiM.' joInl and lbl feelmg for
the joinl ~Ie, that of the piolmst plapng. con-cerIu in OOOluoctie-J ..'ilh ton ordlestra and, 11.1 the .....me time, being a",,,A' of Ihe compos<'r's emotions. 4. The 1""1 rhylhmic I'~in n.-spon>e i:,
wh.·"
II;" pain
",orso..,lS as !he tcchnique progres.... and {""Hinu"'"
10 pmg_. just as much mre is "'qllin.'\! under I ....... citnlmslanres as m p) ab"".. c. b.......".."" il i5 n~' to a!jSi'SS ......... h.·. the disonkr.,. ~IJmg the nuonJpulall\e ph)'SlOlherapist, 'I don't ",.anllD be """00 Ilk tJus. please lOp-yoo re """kong me WQl'l;e', or saying. 'Yoo're mOt mg me too qUIckly'. 'Youre pushing me too f
"0$<"'' ' <1
When the phy:.iotherapi!;t i:l; CAITying oul a pa5Si"e """ernent techmque on a psmenl purposes) after a In.... lmcnl lechmq\Oil! hu JU5t been COI11pk,b~' 'How does il feell1(7W compared w,th bel"0I'l" I dKl th.lt tcchniquer.11><.... lest tt.: n..'quin.od frlO'..,men15 for lhe ph)~I.-...so!SSmt'nl
Specialcarci:> .-..quirru who..on lhe p.otiml has Ialt'rllor Imgcring paIn. 1lIe lcduuque is then P"rformed ,11 ~ chosen grad", and lhe patil~>l isaskoo ....hdh.,r lhc lechnique is caus",!> any all~-'t','liOOl 10 th" symplums. nus inlonnali"n is n"",~sary from thn.'" points of vi,'w; I. Th" p..ltie-nl may hen tt.: ph~herapi;ll
As,~"m~nt
should discontinu" that technique. She should stand the patient and "'ilss.ess th" other movement signs before going on to the next technique. b) On the other ha"d, if the condition is more chronic in natufl.'. it may b" nl'Cl'SSoMy to proyoke this calf pain with the t",atment teehniqul' to gain impro"l'men\. On rl>,lsses.sment, it would be hoped tn,,1 Ihe prck pain. It shouJd be determined whether it is the symptoms b<'ing reprodun-d, whether what is b<'ing felt ""ars any ll.'SCrnbl,,"ce (itl kind or site) 10 the patient's symptoms, and it should also "" dcterminl>d whether the fXlin isdue to the pr","u{\' ""ing U5'->d or Ih" mOVl-ments bein!'; c"'ilted, The physiotherilpist mar choo"'-' tu LOIltjnue with the some technique ill Ihe Silme grad.'. and a,k the patienl S('ver,,1 time> during the perform,,
TIlt'''' is on,' other ">sponse that can be determined during treatment, II is a difficult as""S,ment to make, because ""';:'understandings lx1ween ph)'si<>therapisl .md Pi,ti"nt occur eil,ilr- It is usefuJ to know wh"n performitl!' il tl'Chnique whether pilin is pro"oked at the limit uf the oscilliltion only. and the easie>! Wil} for th<' ph)'siotherapi>1 to make thit; assessmenl is tn 5.1Y to the pilti"nt, \\'hilep"rforming the tl'Chnique, ·Dvt-s _ 11 _ Imrl - cad, - Ii",,, - fp,,,'I,?', Anothl'r way to ilsk is 'ls it in rhythm with wh"t I'm doing or is it " constant feeling that is increasing as J conlinue?'. The word, in ilali~s are ..,id in rhythm wilh the stronge,t part of thc' I"",'tment t<::dmique. The pati<::ntlheneasily underslands Ihis queslion and has nO hesitMion itl ,mswe,mg dearl)"
Tht.'Sl' as,;o:.'SSm"nts of \\'hilt is hap!""n",,; while every techniqu<~ is being performed "''''l {)lilndalorily "" recorded on the teNlment record (pp. 75, l08-t09, 225).
AFTER THE TECHNIQUE HAS BEEN PERFORM EO (TO DETERMINE THE IMMEDIATE EffECT OF A TECHNIQUE AND MAKE A JUDGEMENT ABOUT WHAT SHOULD BE DONE NOW) Th" main pomts to be coosidered "nder this heading ful\'e atn)adj' bt."'tl con,,,-'Cl in the "'-'Clion on '1"""'menl ilt the begiruli'\g of each treatment ses-'ion (s.-e p, 71). Care must be taken; fir:st ,n tI", manner of qlil"Stinning, and secondlr in the Jccuraer of le>ting mon-melllS. willeh form the I),,,,, of comparison Having carri,>d o"t a lreatmenl technique at ilchOSl'I'l grade long enough to achie"e the expectation f,om Ihe technique chosen. the phy,iOIlll'rilpist 'd that ony statement made in ",spun,., to these question5 must be com erted to a comparison and clarified, The pilHenl's m",',-ment5 are then rc-tC'Stt!d, and" comp",ison made with th05<e present bcf"", the treillm.'nl technique was used When reasses.~ing the mo,·ement 5igns, the 5.lme Sl.'q,,,,nce of test mo\'ements must be ",.,.J ~,«h tim" Th" 1"('8son forthis is that one movement th"t provokes pam "'ill" olter the signs for the next movement tl'St.x!, Simll"rly, if ~r"i(al mo\ em,>nts were tesled in sland· int; ilt th" bt.-ginning. they should be reilssessed in stilnding, It is inconsist"nt to test movements one time in standing, another whil~ 5itling in a dl.lir, ilnd a third time with the fXlt;~nl ,itling on the treatment couch wilhoul fOOl support II is hoped lfu,t the subje<:live alld physical assessments will agK'" In principJe, when a physiolherapist is m the ICJrnmg stages of tre,lt{)l~nl br p'1S-~ive mm'ement, this ,lsscssmenl should be made following eilch use of every I~",hnique. As experience is gained, she learns to expect a certain impro"em£tll when particuldr k'Chnique, are 'pplil>d to p"rtic"IM disorder,. For example, if she is treating an eJd"'ly pilt;cnt with genemJ neck pilin tfull c~n be reprodlleed "' Ih,' limil of ,11 mo\'emenls, all of which M~ stiff. she can a,;.sum" Ih"t the......... iII not be much ch'll\ge during One treMme"t 'l.,,~ion although there milY be considerable impro,·ement o\'er two trNtml~lt ,essions, In th<::s<~ circum,I"n~es il would not"" necessar\' to assess ,fter each kchnique, but ,lSSt',;,m""t should be made by comparing th.. symptoms and signs at Ih" ''Ild of the sl'COnd t....atment s.ession with those ilt the b<'ginning of Ihe first treatment Sl'S5ion
77
78
MAITLAND'S VERTEBRAl MANIPULAliON
II the ph~tK'Rptst IS ..loa.. lD ludge Ih.ol changt.'S in ,,'ympt0m5 and .'>Ign" may"" l?i['ff"llod to takl" pIaa quicki}: slIe should ""'*....,. Iht'rn ilfwr f\Jdl ilrrlicMioo of ~ Itrlmiqu..; if lhc fll~ of dunge is not il" rnudo as dc:>,r..'<:hnique 10 find the 0 ..... Ihal produc,-", the qUlck",t ,,,,d lx'St ;mprov('m('nt
ASSESSMENT OVER A 24-HOUR PERIOD IMMWIATH Y FOLLOWING THE LAST TREATMENT SESSION (BECAUSE THIS IS OFTEN THE MOST IMPORTANT INFORMATION PERrOO} ANO SUBSEOUENT 24-HOUR PERIODS UP TO THE NEXT TREATMENT SESSION When a pah,,"t's p,'('menl (Ot
pt.-rh.,ps two). and immediately "'1..." · 1on ",le.1Sing the m",emenl. th..., it i> 1iM'I,· lhal tW
ASSESSMENT AT THE COMPLETION OF THE TREATMENT SESSION (SO THAT THE PRESENT EFFECT OF THE WHOLE TREATMENT SESSION IS KNOWN, AS DISTINCT FROM WHAT MAY APPEAR TO HAVE CHANGED WITH EACH TECHNIQUE) Thl" ilmountof tn:alm('nt thai can I;l(' und~ko.'Il al anr On" 5<$sion deT'.:nd~ up"n" I Th" "''''""Iy nf th" patient's pai ... 2, The nMurc and ~I"biht} of ttll' pilto...nt·s disotder c"u""'S th<' Pilon. 3. The 'itrit"bilil" of the p"mful disorder.
Tho<' more care requ;rro in trealment b<'ca1Lq> of IhI> (Ot'l"S0mg facto,.... the t...".,c..n be done"l (JIlt' _ _ ion. If the "ffi(>Ull1 of I.... almenl i.. linutt.-.,j, Ih<:n "'-' ..1...... h thoe nummof cha~ III tcdmique thdt Coln tJ.. ..Ii<'mp'...... Un U-h<>lIt ~mcnl is critic.. L beuu".e t~ .oR' thep;>t..."'b- woo"", likely lD "ulfet ex.aecri:latlon of th<.-lr ~ymrtvm~ following 100 much lrealmenl. Si!Cn~ 01 nan·rf>.lll'''' ma~ flOt ~ ~pp~",nt ..lth" time oi Iwalment ,\C,th II p.ll; ... "t lillH1g Ihe JOO'C eJh'}:Ny, not onlr sho.,lo an a,s<''SSrne'nt be m"dc "f Ih... dr~-.:li\"c[l[.oss of a /r.'Clm'il"r. bul als<> at the l'nd of thl' l,""tment s""""i",, a (omparison l)i lhe- "bJ"d"'c and phYsinl findin,!:s "hould be 1t41d,' \\1111 those Illat 1'.'0'''' present ..t the ~mnin& of the IT\'Jlmcnl """"ilm. In tht:> COIll",,1 il is helpful it the palK'l11 Gln ,.ummari71· his rtlCULn Icdmiq.......... heiplul or wlvth<... he rn.ght""J""CI-om<:tll .'Ilt'Ss(>f the tol"lt,e.otment a" do patients in 111" f"TI.'~oing cilh"j;orY. 110"'-"""', it is oft..." "",fullo know II the pati"nllhink-< anyone patticul.or t('(hmq~l" hdpt.od mot"(' lhan anothe'. 1I ma" thnl he can .,15<)
oc
of a nrlmiqut" rna" tJ..'.'''l~gh to .. ~~ il!t~e:;li,.."...,,). Ifth.. palient hMtlOSigru.of iOn) OlChmg .."hillSOe\·er. nowmplOffiS at ni!;ht... IOtiIll)' k- dienl. thcrl m.u>y d",ng~'" In 1•..::h,,"'1.... un be made atone m.... :mem "-",,,.on. "nd Ih,' 2-1·hour ~ m""t I~ Ie:,., imf"'rlJnl \\ith all pil' .......,t~ who do not fit into lhe abme catl'j;ory. aS5e>Sing tIx·eU.....lof the'lrealln~'fl1(J011 Juds,·ment.4._ 10 the effect of n treatmenl " .....~ion am bo:- made All of thl" d"I"I1s "-1:"'rding .my atlillylleal _ _ menl ollhe ~.w,en,,<, m.nges O"cr thi:. interval hil\"e alrNc" bNon d."d (p. 72). 1M analytical as:><......... tncnl of iht' ph~sic..l findi~s. p;>rticul.1tfy as lhe\ ""ale todiff...... "l components of the p;>lll""'S dis<>nk..., h.J\'e also be<.'Il ~bt."J (aste.."i..s. pp. 6O-iilJ_
AS A RETROSPECTIVE ASSESSMENT ISO THAT AN OVERALL ASSESSMENT CAN BE MADE OVER THREE OR FOUR TREATMENT SESSIONS) ["m wh""
it is pllSS.t
i~al.bsoeS~m<."'1 th.,t
progress h.1s bt.'('f\ 1t\Ilde, it isst.H 01
,,,Iue to know ""-"" tho> ratil'fll
fl~'b he
0,;
rrogressing.
r, rn~ing I~e rlfect 01 .. l~al ....t't..1 ~ fUmtial to eva~~ate p
as we
is
from plly;K:;Il uam,,'lat,on findi~q~
WI",n qll... lioned n'J,;Mdil1g his symptom>, " piltien\'s an.\\'er may well be inf1"e~ICl.J i:lr facmt~ rdal.'
A»o:umtm
I.... pallenll;; gl\ ing .occuril!eilll5wer.;.., her qUtilxlnS interprets them as he mcilns ''''-'Ttl, In the allllext of 'qtil"'>t'OIl and ,,""""'....., ~h." must JII"t\'T ~",""~ a"y,iliuli. At me begmning of t",,,hnenl ,t i> not lmCumnwm for~ p.~l;enll" l'l'Ply d"y "fl~r d~y thlllllt": is f""ling much belt.'r. Tlwn, when asked "fk'l". >.'y, four t"'"Iments, '110""' do}OlJ. fl",1 noW«(>fIlp"rc.:l with too.'fo", ",e Sl~rtn:t rn,.,Imc:nt?', he may Sl il n'l'lainl~ ",n'l any" ....... '. Su<:h a ll'lro5pect1H' answer mal.c> ttw ph"......-:JIherap.:ot moliZ<' thai W is nQI: rnal..ng& mueh .lady P"'&"-"-" a-< l pt.'IU.'I\I,lgt' of progreso do "OU thinl you haH m.odo.' COfflpiln.-d with when we bl'i:'.m tn.'alm,."t?· Oft..... th..· p,Urnt finds it difficuillo us<' p'-"TL""'I"~,-"', but h" rna .. an<wer by Some "Ih.'r '-"I""lly u,ef,,1 COtl1pJri".-:m - c,,.::. 'On a Ileale of ()...lO, if Q ",as I,h"", l'Ou ",ere ",hl'll I fir:,t saw you Oil ,\lundil}'lne 2Jrd of&'Pwmbt>r and 10 ",a, no rain dl all, "hel'<' would Yilt, rul ~ou~lf on Ih..1 .collc.- nov.'?' The phy 'iot.... rapisl ~kl rnall' her own agc as5<SSn'IeI\t bclolP pulli"l; the qusst.'S6mo'l'llar,]' good Somebmes lhe subj«tke ~nd physical a,."....~m'-'I\ls do not "I\n~. For '->XJlml'le. iI p.ll;"nt's pleAing It i" pocor pohq 10 jusl continue Il'<'db:nt.'I'l1 time dtler time w,thOUI milling this '''-'1mspectioc a,"C'SSmenl' It IS 0' ....' rosy to COI1IlnU" t"'dtmenl 11"",-'O...,."..ril\, 1.,,,,Jmg to p'--'I'po.."u"I,on of the Joint dl'''JrJer. T" ",'oid Ihi, ~il",Jtion, " j:;ap of I\I'icc as 10"11 as us,,,,1 beh"e.>n I~Mmcnts can elMif)" the s\,mrl<)nl"tic revo,'S<'.md ckllr the "",nipul"tin' phy~i"lhcr.lr,..t' .. Ihjnlin~ rrore<-
.md th.ll
w
rerc-ert-
"e
When the amount or rate of progress hilS slownl or stopped (to cktermine the teLoci,d"t m,lI\'plll,l!tlt' ph}siother.lpist, 1",rtkuJorly If her goal is to be a consultant, "",,1 bt: pt'rfL·d. It i, the , .•""sment lh"t .... quires the b......"~"! mental Jlgilil)', alerll\CSS and d'seiplmt' in Ihe whol" field of milnlpulati,,' phy.wlher"ry
In .ct~.M: ~nl,ronl ... ~r call1fl ~'" lobe it'~ "'osl s~CttSSful
cfllngtl h.".,
evd in ortlrl to .:ermlr< the pit1em ind 10
I~t pt~e of
(rtl delermin. further
tr~.tm.nt ~!s
In this "'trOSpecriH' asscssm<'nt, 11 " Ihe sul'/i-'(t" e lh.Jt rl~}'~ the g",alo,'5t rok. It is lhe Mt'a mu" be al ,Iz; """,I st.IL~ful ...... d. and ,I,s an ,,"-"-I wlwn- e~~e makes juJj;L'lI'Il.'r\t e.bi<.'I' and mor,]' rehable. The- «'CMiq.... 01 ,,"'ing I.... qu.-slions. and In(l\\inf: the rvnnn.., why lho.· qut-..... lion.• ....-.ed to be .l>"-ed. CJI11 be 1rom..>J by an}'orM' " ho nas>e<:n or wiln<"''''''d ,j,> unport..nc.· Jnd is willing 10 bl.'I',llient WIth p.lhl11l<'. In the ,dl'I;",t "'-Xlio" nf Ch,'pkr 3 (p. SO) the dia· IO!:Ul' u,,-'1:I for '''In''I'lI;'("lh'e as..'l!'iSm~nt \\',,, u",iu,-d, bl.-..:auSo:': il "'liS consid"red mol'<' ,mpc>rt.,nllo be able 10 in<;lude in the t..~t at 11>1. -lao... ,ht, kind "f informallon bcin~ 0>001'1"_ TIl<> ml"rmarioo bl.'mg <;Sm<'nt
'''""n' c-..mmunicat'oo
I. \\ hen does lhe p.ttit.~tC'Ofuki'-'I'.... ,t"P'f"-'
'It'
2. \\11\ tkoe. «".",tder L!"e ilnpro\~t "torf'<'d? 3, PKI he HII\"itkr he h.>d mitde progn..'SOo ",th ~
eArlier m",llmenl '
Did hemrbid"r prugre;;.s "itS bmughtaoout bv 'he treatm"nl'
5. At \\'holl ,t"Ii" "f ll'<'atmmt did the imprm'em,,"t tilke pl'K-e? 6. \\'A' th" impr'l\'Cmenl rmgl"C"'io e~
i. II In'atment "dp..~ h,m. "ell' then.·an) p.lrticular K'dtniqu,"" 0. hm,'S th>! hdJ"'d him mort' Ihdn
tlIhel'1'~
8. W',,, It a I<.'\:hmquedoni< in it f'Q,tic"l.r, MJllnn tNt helped. him~
9. \\'as meT\.' any p."ticuldr I"",hnl,!ut', or kchll"l"e don(- in" rarl'NL,. man""., 111.'1 ,'~Til"JlI,-'(\ h" ,,)'mplom. al "''' St,'!:""
10. I !e>I' is he no\\' bep;all?
ClImp~rt'd
\\'ilh bt!f"", rn,atrn,'1l1
11. 11,,\\' do..." h(' oompare now with how he wa, before the Of\st.'l of lhis erLes) ()n(y\'Qu h.1o·edC'll:'rmIfl<-' III ",ldllOn 10Jil of IhI.' abo'e q""Slil!O.~ it i, the right ~tJlg" 10 stdrt iI full re-o;amin.'tion, both ~llbi'-"Clio .. and phl"Jeal, ,l> lhough he we,..,,, new P.1Ilt'nt. Ttl'-' '1nc.tlons wuuld then be '\\ hal b your pmbJ.·m .. t Ihis sta,l:
'\\'hro doe< il bother rou m""t'
79
80
MAITLAND'S VeRTEBRAL MANIPULATION
'Is lhere anylhj,'g you can do here and now to demonstrale 10 me a Wili' in which you can provoke Ihe symptoms?' 'Are there anv other aspt-><:t, oi your symploms. ur the ways in which th.~} afi."t IOU. th..lt you Hun!< might bl' helpful lu my undersl;rnding of your probl,'m?' A ""lro.p""li,·" asoessmenl a. outlined above ,an l.. h as long as, if nOllonger thm, ..ny inilial examinalion. The ,;earching 1M delail is much more imporlani at thi, point. tx'Cal''*' till' h,lure mana~ement01 the p.ltient's disorder m"y 1><, a big ,nd import,1nt decision to rna""'. On it hang factors th~t m,,}' molke all the diff"'~~1(" to his lultJn~ life. This may Si'<'m a ,'ery dr.l"",tic sl;,!c''''eTlt to make, anti it i, a major d.:xi,ion only with ~ small percentage of patients. Newrlheless Ihe decision, when it has W be taken, is a "ery important One both 10 the patil~ll and to the phy,iolh<:r,'pist, he,;;:ause her repulation on the one hand and her ~kilJ as '1 pr
Following a planned assessment-tlrc~k from (to ~st~blish the pla~ of further trtatment)
trtatm~nt
Many p"ti"nts have a disorder that the manipul~ti,'c l'hy~ioth"r~pi5t realizes c"nnot bf.' mad~ normal in evcry r"ga,d, UwJ", Mll'h cirn"n~l"nce" the t.'nJresult of lreSt.'SSment. The folTowlng,,~"~xampl€ of ,uch a pr<;>oX>s
~nd pain can bE' ,·xpected. Lller during l"'~tml"", a point will be r~"'lChed when the pati""t'" symptoms remain static and il is difficult to be ,ure whdh"r the rallgl·ol movem~",t is improving \'Cry slightly or not at all The physiother,'pi,t should kllow that a stage (~n be reached when, in fact. the mobilizing ;s perpetuating the cnmpbinl. Al this point Ihe p<'lietlt ("n be asked Ihe direct qucstion, 'Do you I~'CI you hm'e amlinued to tmpro,'e o"er the tJ,t thT>'<' or lour lre"Imenl~~' 11 t~ answer is 'NO', tlwIl tI,.. tn,atll",nt should be disco"tinu~' action~ t.lken:
1. If lhe symptom:; ha,'c improved. II", p.,ti,,"t sho\lld be Iell for ~ f"rther 2-3 weeks and thc·" re,'sse,sed Ii there;'; then additional impro,·cment. thc pati,;nt Can be di>elml'};l'd on the assumption Ihalthe sy"'J-'toms will contimwlO imp"we ,,,ithout tccatment. 2. 11 the symptoms and signs have remained till" 'JIlle, the pMie"t ,ho"ld be given four Or five more trealments and lhen taketl off treatment ~gain for 2 w""h. At the end of th,:; period it will be possible to determine whether 111<' extra tl'L~ltm<'ll1 produaxl ony impron:ment, and whC'lher a further f"w treatments should be "dministered This p,lltem of m"n.lg~>n,ent must be ,,,rr accurately asses><.xl if it is to be tl'>('d con,trucli,·e1y. It may be of interl,,;t to mention here th~t when these patients ha~e fC'Currella'S (<1t,d they "Iway" do ha\'e recurrenc~'S), usually: They "",k trealment at an e;ldi~'T stng~ of the (·xacerbatioll 2. They resp"nd morc "!,,dily to trl'atmenl 3. They ha,'e pr<>gT..s~i\'ely long.'r periods bdw('Cn exacNbations. 4. M""y of the.. eXolcerb<1lions l'L'Co,'er quite 'lutekly withoul treatment. t
ATTHE COMPLETION OF TREATMENT (TO MAKE JUDGEMENTS ON PROGNOSIS AND PROPHYLAXIS)
EXAMPLE This reIJl~-s to a p<1Iil"11 who presents with symptoms arising fmm a luw-grJde aclive arlhrili" where it IS known thai to regain a full painless range of joint mowment is impossible, TI'e questioll i" when do<.'" one dis<:onlil1l,e treatment? In tlwl'mly sta,;c'Sof p,,:>s;\'C mo"eml~,ll",atmcnt for such p.,ticnts, a gratifying impro,'ement in mo"ement
A point to be cons,del'Lod in relation 10 a~se,sml-nl <1t the end of trealrnl-nt is, 'What Is normal in the w,'y of p<'in ilnd movement for this patient'· People ha,·c widely dl/ferin~ normS. For eXempte, forwfird flexion or the tntnk in standing can ,'ary from one person bein!> able ollly to re;>eh jL,,'t beyond the knees, to WTll('()OC else being ablc to put lr<1l1ds fl<1t on th" flo"r Sucll \'arratrons al", occur in other movements.
Assessmt:nt
II I!o flC(I"i"ary lo I>o.·.. r in mind I~ on11l...~n "ariationt. if ,lin ad..... te ob:oe»mcnt is to bl.• .-.:hl('\ ~ [mill/lit 1. Considl'l" .. p.lbef11 ,,00 pMll..... ts for ...... lrnenl of low bal:k pain. On ""amlllll!j; forward fk:"ion il;" found !holt hecan onl" Jl'ach h~ knees. "nd "I Ihls pomt his back p;tin is rep~uct'd. On fi~t see'ug lh,,; it mighl be con~iden.,j Ihm f1e~i.," h m<1Tkl'(lIr lilll'kd .. nJ P',inflll, "od therd(,rt' thl' p"lIcnt's cond,· tion is aS5esSlxl as b,,'ing quik t><"l. Howe, er, if this p"licnt h.,d a.,k",l, '1 low far oo"ld )'ou bend before lhe on.'i<'t of yuur pain?", he nllght Jw,"e replied, 'I'H' nt.. .·er 1>0.""" abk' lu benJ much further lh.m Ill" """-,,...'. This information pub the lIlt<:-rpreblJon uf!he flexion d's.o.bi!lly "'to a difi.,..",1 p<.-rSl~'m.,nt m~1 I"h inlo account th" r.lnlt" uf mo,·emenl th,lt ;s likely h' t>... nurm"l fflr 111i, p~li"nl. Th" role of treatmmt wHi be to .'liminal" the painf"l a,jX'CI ot loint nln"emenl 11,,, "",d-re;ull "ill be ,hghlly imrrm-oo mo'emcnt, ..lthuugh m.wements ,,·ilI T\.'fll3in shit in all d,n...:hons lmportanll,. me nLock p"lIl" III !la,e !'on<.'. "The Ile>'t flO",t to bl·1Il.lde undo>r thb h"adUlY;" lh.J.t tho.- efft.'C1 of lrl"il cannot be de..rl\· known until an inlcnal of2-3" eeks h.u p.b->«l tot""," illS !.he y>t treatment session.. Ii a. patlrol has """'Il<.'l1 ruU-ranl':" p.ru.. fn."C mun'mo>nls and .... ~ oonrinucd lobes' ffil'kwn fra' oyer tIus inK.......... thcefl,'Ct of ITNtnwnt h,·l..ar-Gl1. ·1 N>IT arc occasion> wh...... pali~"ll Wllh chronic 'y mploms yet JiUI" t" find on e",lJll,nal,Of'l of mo,",,mL1lts m...y nol sl,m,· an~' 