Maitland's Vertebral Manipulation

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� � � � � � � � � � � � �I,E,,·E"A/·:"
MAITLAND'S.. mmmJ I
Vertebral
MANIPULATION
Edited by
GEOFF MAITLAND
ELLY HENGEVELD
KEVIN BANKS
KAY ENGLISH
SEVENTH EDITION
Maitland's Vertebral
Manipulation
Seventh Edition
Geoffrey DMaitland MSE. AUA. FCSP. TACP. SASP Mapplsc
Edited by
Elly Hengeveld MSc, BPT. PTOMT. SVOMP, IMTA Memb"
SellPor � � � � � � � � � � � � � � � � � � � Maitland � � � � � � � � � � � � � � � � � � � � � � Obcrcntfcldcn, Swiller/and
Kevin Banks SA. MMACP. MCSP. SRP. IMTA Memb"
� � � � � � � � � � � � � � � � � ROlherlJom, UK
Kay English 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
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Contents
� � � � � � � � 10 the seventh edition vii
Prdace to lhe first edition � �
Biography � �
Glcssary J('(
1. Introduction 1
2. The lIoctor's role in diagnosis and referral for
manipulaliW' phyo;iolherapy 17
� � � � � � � � � � � � �
J. Communication 23
wieh Q contribution l:IyJ. Graham
4. AnesSmtnl 53
5.. PrognosIs 85
6. Eumin.tion 97
wirh 0 conui/)cjtiOll bra C fdwunJs
7. Principles of � � � � � � � � � 111
8. � � � � � � � � of techniques 183
9. Application of tcchniqu($ 213
willi 0 ('OIIw!Jutioo by B. C. Edwards
10. CCr'IIica! spine 229
11. Thoracic spme 301
12. lumbar spine 337
13. Silcroiliac region; sacroiliac jei ...I,
syml'hysis pUbis 401
14. Sacrococcygeal and intercoccygeal
rcgioos 411
15. Examples of tn:atmcnt 413
� � � � � � � � 1. MovclMnl diagram theory and
compiling a r!lOYf'mcnt diagram 445
� � � � � � � � 2. Clinical C:lilmples of � � � � � �
diagf1lllTll; 459
AppendIX 3. Examirution � � � � � � � � � and
moYelTl(nt dillgf1llms 46S
Appendix 4. Oinical lips 469
Appendix 5. � � � � � � � � � � � � � for animals 475
with 0 contribution by r 1. Ahrm
Bibliography 481
Index 487
Preface to the seventh edition
vii
� � � � � � � � � � � � � � � � � ..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" � � � � � � � � � � � � � � � � � � � � �
� � � � � � d,sonl,.,... Manipu"'li,·.. Ml)'liiotherapy, il is
de-.u,lus an Important role to pta\ Wllmn!he � � � � � �
and � � � � � � � � � � � � proceso>-
Tk ablbty 10 identify and "leal" Ith sr,,,,,1 s..--grnent.>!
mobili!) U!V"inncnl, ni!UlOOyn.utuC d)'Sfuncti<I> and
musoele ,mlxlL1nc{', for .,...mple, "-'quires finely hml-'<i
sk,lls 04 dlnlCilI ",",minahon, duucaJ � � and
t<-'duuc.. l1v a<:(uraleand dl,'Ctive tft'aUTlCllt techniques.
"Th.c r.t:"itland Coocept h.>s bl.'t.'ll 0I1C of lhe con"-.,--
ston<:S of rnQ<I.,m marupuL'IJ'e ph}<IOIh<-npy. Those
who f\.wl' been pnvilcged l'll'-"'gl, IO;l<."c.....,f{M.lUbnJ
"I w(>r\( will "nl"" how mUch � � � � � � � � � � "nd detail goes
mlO � � � � .\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
� � � � � � � � � and appl}' n",mplllat"e phnio!heTapl
� � � � � � � � � � � � � � � � � � � � � II' lhecluuc.l setlIng
Wh,lsl le,lbooks can ne\'d" � � � � � � � the- rcal-timo.'
acquisition of lIlo1I1ipu1l.h\"C skU]", they <an act '" a sian·
dard and a rl.ltlio<rn from which the dirnci.ln can
contmue t" impro",' \', ith � � � � In mInd. the Il!' l!O'.od
7th I'd·bOn of l-Crt..i>l;M � � � � � � � � � � � � � � although hal'ing
cxacth \hie ....1TM' te<l and dcsrnplion of Il.'dmkJue-, is
nuw � � � � � � � � J*>otosr'.lpl'os and a DVDshow-
ing \id«I dIps or aU rdc\OUII !I,'Chrnques_ 1lus shoukJ
hdp the n'ilder I"see and � � � � � mon·d.:arl} asf"-'Cbof
'-"'<:h l...Jmique sucft .... sWrtln" � � � � � � � � 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 � � � � 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
Preface to the first edition
;.
M"l>ipu!Jtion (It the spi"e i>, aS6(ld:llro so oft"" with
� � � diagnosis at\Cl 'hit or � � � � methods 0; bruh'
force. � � � � � � � � � � � � � � � � h.a,·c rnulk'<l in the ",,,Iu"on
of "",,,,puLah'" treatment from rourine phY5'cal ""-,,h·
eine. Ilw caul;0U5 and � � � � att,tude lownds
this t....atment .. oul.l be largely � � � � � � � � � if � � � � �
r\.'Cognized that rl'll)Sl patient<; can be relie\'ed br the
gl.'flt!er procedun"'<.
Thef-e Me m'o war-; of lIMImpulallng the � � � � � �
� � � � � � � � � 11le first, bo.oU",r thought of as mobilQ,lnon, i,
the gentl", � � � � � � � � of a mOYCml'TIl by p"",i,-" m} th-
mk,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 dif-
ference between � 1"'0 technique- IN.)" '"l'eIJll"ll'7'ili-
siMI' "·!-.... comp;oring .. stronglv apphl."d moblli/..lhOfl
...lh a GOOtle manipulative thrwot, but � i!; an
Important � � � � � "The patient ("In ..lw... � � � 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 � � � � � � � �
� lu th" ",.., of � � � � � � � � � � � is
I" rdate treatm""1 to � � � � � � � � � � � � � symptoms and siilns
rather Ihan to dia"noses, Such a plan "Yoid, bolh the
amfusion ,,",u§«! br diagno5tic � � � � � calling to mind
dilkrenl � � mplums 10 d,f{("l\'nt people, and me (on-
troHr5y .......... pathology. lmieN, 11 i5 often impos...-ib....
10 In...... ..-Nt the In1<' patholog). ;, AI60 " "Ill be
� � lh.at und.....,. the umbrella of one dlo1gnostic ti:lt>.
fol' ('XiImp...., 'disc � � � � � � <vmptoms and � � � � � �
'ill) •.,del}" and n!qu,,,,diffi'l'l'nllrealrnl...ts.
Only th... spinal Ioint>; from I"" occiput to thl"
,,;,crUZll arC discU5!led in this 1xx,1:. ""d !hI' � � � hM
been planned lu 111"d Ihe reader in logical <t.'<jllCncC
frum the cXil11l111alion of Il,e different inlcnerkbroll
le'cls to the Ier:hnique$ of mobili/.ation applocabl" in
each col><c, Th" way � � then prcp"""l for furth"r de"'<,\-
opment inlo lhe mdr" for<:l'ful nu.nipulative pl'OC't"d-
urcs arod their application. Guiding pnnclpb uf
,reatmt'fll iollow and � then applied 10 :<op<riflC CilSe
hisrorie> in the final (Npl(>r. II should be undet"5l00d
tNt .. II � � � � � � � � � in mis boo!< when dOllll." b) physio-
thc-..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 � � � � � � � � � grahl\lJ.. i1dequatdy. Will'"ul the con_
� � � � � � � � � help of tho,;,: co,><:emro wilh the Iypin!l ",>(1
po,i0!l for Ihe � � � � � � � � � � 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 � � � � � � � � my ";n<:....-c ltunl<s
lo )lbi \I J. H"mmOl1d, ,\UA, MC5r [Teachers
C"rt.), Mis, 1·-\1 � � � � � MCSI' rr"..chers eerl),
� � � � � � � 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.
� � � � � � � � � � � � /('1...11I1 of Pll'l"-ii.'l/lffllpll). T"hcsI' persons by
their indi' idual comments and crillos.rn!> � .... ronsod-
� � � � � guid.aoce conammg � � � � � � � � � of the
work. � � � � � � � � 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 � � � � � � � � � � � � � � � 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 � � � � � � W,]T In
� � � � � � Imlain.
His � � � � job "'Mallhe Royal Adclaid" Ilosp,t,,1 and
tl'le Adelaide Children's Hospital. with il � � � � � � � � � �
on Ill\, trealm('nt 01 orlhopi>l.,lic and neurological dis-
ordl'N;. Later he oonlinuro working part-time m the
hospital and p"r1-hme on hIS 0....." pri' "lccllnic. After ..
fe.... � � � � � � he b«-a"l-.e a parNIm<' pri' at" practitioner
and part-time clinICal tutor at the School of � � � � � � �
� � � � � � � � in IhcSouth A..slr"JWl � � � � � � � � � � � � � � � � � � � � � � �
nOW the Un;"('I"S,I) of South AuslralJ.. lie continu-
ously stud""l ,,"J spent "',If a day Neh w''''k ill the
Barr-Smilh tibrMj' and the exceU"nl library 011 the
Ml"dic,ll School of the Uni""n.ily of � � � � � � � �
He immediatdy showed ",n intere;l in careful dm-
ICaI {':\.aminalion al'ld as;es;m....'Ilt of patJenb WIth """,m-
� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �
tr'eo1tJn('n1 by li"X'fw: � � � � � � � movementS � � � � � un<k...-
A.'f"\'S""lto.'<I in phySiotherApy practK\'. G D \-faillo1nd
I.. � � � � � � � from OSloop.1lhic, dllropr",clic and
bonesetter boo"s.l5 well "'S lrom medical books such
"" thusc of M"r)in, jo;;te.., � � � � � � � � � B. lI-fl'f11'l'1l. Jrlhn
McMillan "kl\fldl, Alan Stoddud, lI.ob<!rt � � � � � � � � �
Edg..,r � � � � � � � � )am("<; erriax and manl' olher<;,
As ,l Ioxtun..... h" � � � � � � � � clinicdl t'>:amino1lilm
and � � � � He � � � � � � � � � 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 � � � � � � � �
WMI one is dOIng' In 1954 he- � � � � � � � with mampula·
the Ihc.apy leachjnG � � � � � � � � � �
I" 1%1 he � � � � � � � � � � an ",,,,m; from a Spl'Ci,ll studlClo
fund, which """bled hj", at1d hi, wife A"t1c 10 !il1
O\ers<-",s for a studr tour. 1'1ll1' 'lSlb•...J 06teopaths,
chin'pr<>ctors, mecbcal doctors .,nd phvsiotherap\
fflileagues "'hom the)'lwd helIrd and read about and
corresponded with in IhI> p.-..cl'ding � � � � � � � In London.
Groff h.>J � � � � � � � � lunchtimt' climea! SleSiSions and
� � � � � � With James C",""" ..noJ � � � staff From this
tour G D, \-laltlilnd � � � � � � � � � a friendship with
Gregory P Gri..� � � � tron1 1110.. UK. They had � � � � � � � � � � �
correspondence about Iheir dmic,11 ('xpctiencl's and
this conh"u<'d for !l1,.ny y"ars
\-faitland � � � � � � � � � � � a p.lper. in 1962. 10 Ihe Physio-
therapy SocIety ofAUSlralia enlliled '"The ProbIMru. of
Tmdting \'t'tkbral Manipulation', in which he p"'"
.....nl<'<I a den difh.'Tt'Illiilllon bchn..... manipulation
,JIlt! mobilizanon and Marne a strong advocale of the
usc of genii... p.lssin, mon'menl in the 1"",1"",-,,1 of
pain, in addition 10 the mOre ITad,I,ona] forcelullech·
niqu<'S u",'<i loincR.'a,;(' r,lngenf "1ol,,,n.ln Ihis con\('xt
it may be suilable 10 quol" Jam<."S C:yriax, a f,,\lt1dcr of
orthop.ll!dic mediCIne and of majOr influence on the
dC\'elopmenl of rrwnlpulali\'e therllpy pro\'ick'<1 by
physlOlhl'rapi5ts;
""'" rrr....ll.v .\Iol'IJ.U1J•• � � � � � � � � � � � � � Jrom
A"SlmJiIl, /fa- Mn � � � � � � � � � � � � � � � � � � � � � � � � � � � oJj
J/'<M'r/millmcy !mlll'I/lr mart' ,'rr'lglhMind � � � � � � �
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..<l''..... 11"',1:"'111 "jrlue
rf fl.1l/l/afuls WorK � � � � � tfWmJlim HchJJs fMl
1'J1kf,:dr:f IllS m.1n1l'ld.zlii'f" /tOlll/qur'S ;11/'''' cull, /rto
dJim.; tlafhl'r QIlIOflWlir- tffrd' /lOt tmlllJl'yQrI'''
poirt.1,t'II tndtni.J" got< au! OJ hI) """ Iolar-'.
11r..",.ttml.'Su"""lslIlld '''''',,1><11,11.. prllrlical
rffi>rt ofmalllp"lat'Oll 11r,' ""IWII j, ex<>mi"",f
rrl frrquml i/1lff"iwl, � � � � � � � Ill/' 1il'S.'lClIl, � � � � � � � � Ih,'
llUwjlm/alnr 1<1 a,><,:;S tit" n':'l1ll '111i, trcnlmC/I1
50 � � � Heron/m,,'" or allers hi, lce/""''Ila in
IXcordfllCt' ll'i/Il ,h,remlsr, IN a/J«'ICfO!dl/lll,l:f,
lklcdeJ � � � � � � � � � � � cJCQrly p"",i,k 1M
� � � � � � � � � � � � � � � � � � !he Brilish Empi .... in 191\1.
FtlJo>,-,;hip .." � � � � � � � � ..n College uf
Ph)...iotherilptsts by I-1<.>n<.>gr..pb in 1970, ..-iII1 a
furl""," Fello"-"hip by specWizAtion in 196-1
IioooraJ}' � � � � � � � uf Mas'l'r of Applied 5ctencc
in � � � � � � � � � � � � � � � 1m", Ill<: University "fSouth
� � � � � � � � � � � '" 1986_
tiooorilry rdlow of th"Ck;'r1"n..xl Serlet}' 0(
Phvsi<.>therapy (CD)
� � � � � � � � � � � II(e ...emb"nlll!", ui the Se.•J1h Ahirnn
� � � � � '" � � � � � � � � � � � � � � � including the Group 01
\bnipulab ..,(' � � � � � � � � � � � � � � � M......pulab\'t'
rhv.wthc..apy Association
orAustQ.l1. � � � � � � � �
Sw,ss � � � � � � � � � � � � � 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$ .......� � � � � � I..� � � � � � � � � from;1$ foun,btion
\llIdred Own Award b\ Ihe World ConkdcT-atioJ'l
01 � � � � � � � � � � � � � � � � � � � � (Wc:rn for his life's work in
19'95' -
Austrnlian 1"Y"'oolh".aM'A-.ci.Jlioo {APM whcft,
he "-015 on IheSlate branch comnunec � � � � � \'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 � � � � � 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
� � � � � � � � � � � � � � � � fors" )'''U"S and a " ....-mlx.... o/lhe
Cl.,,,ncil fora furth<.... s;",p,"''S.
Member o( � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � Uoord
of500.lth � � � � � � � � � fur 22 Wilrs
Chairman ,>I rhe &pt'M I'anef for � � � � � � � � � � � � � � � �
for Ausl... � � � � 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 � � � � � � � � � � � � "bndardscommitf('(' for
.111".her fil'e r"MS
For hlJ; work he � � � hon.)u .......J wilh � � � � � � � � � � � � � � � �
in 1M '" Zur.wch, � � � � � � � � � � � � the 11l1"m.,tional
Mulland T,"..d ....-no' A'>SOC;i1l1on (l:\IT,\) .....as found...,j,
G. D, Maitland I:>o!c.",., .. subst"",i,,1 contributor 10 th..
AII!>/",t.", j'lIlr>l1l1 <"f PI'Y'J",/IWl1lj'll ..s ...,,11 � � to other
m..-di<:lol an.! ptl\'5olothe1ap\ joumab ""OfW" id.. On
the instigation ofMonica M<l,tin-JOIWS 06E. a Iead...-
of the Clwtcmt Sodet\ of l'hy,...� � � � � � � In Cre.ll
Bnla,n. M':lI''''''''' was � � � � � � � 10 publO<h � ..."Oli<,
which "-",ult..,,j In th<.· � � � � ,-od,tlon of \hlrl>/lll MIl"'I""
Inrum in 1%-1. whIch � � � 10110\\,('(1 by J !'oC<ond ,-.,j,lioo
io 1968. Tf\c fir>1 c'dihon (If � � � � � � � � � � � � 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 � � � � � � � � � � �
M...tLmd kepi tINting patients ill> thto clmical � � � �
",mallled � � � m.l1n SOU= of learnIng ..nd adaptu'8
ide"•. Geoff tre"tlod pati('JllS in his pri"M" prM'h«1 for0\-'" � yean; Jllli although h" doscd hi, pr"clI,,' 111
1965. "" r<:maintd Jcti,'e in treatingp.lti"nt> � � � � � � � � � �
In 1965, one of M..Jlbnd'ji wishes Came h11..; With
the hdp 01 � � 0 ...... C.......a..'Y, Hei\d of !he PhHlo-
lhcrap> School South A=Ir..i...n In',,ululI!.'' of Techno!·
OS)' and thl' South Ausl1'lIli<'In Brandl of the A""trahan
� � � � � � � � � � � � � ..p)' ... � � � � � � the fiN titrel.' ITU\lhs OOUI'lll.'
on M"llIpu!.>tlQn of tll.. Spi...• was n..ld In AdeLudc. In
� � � � 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" phy<iulhc.... � � � atlill' South AUStralian Instltut"
01 Technology, no.... a :\loOSkn � <OUt'5<.' ..I the
� � � � � � � � � � � of50ll,h Alblrall3.
H.. WlIS ON' nf Ih<- co-Iouod....-s.. III 1974.. of I.....
Inr......... rional f-edcr..hon 01 OrthoJ'al.'dic M,}Jlu,,1
1ll<'.apy (IFOMT), a branch <.>i the Workl Conf.xl.....•
at,,,,, of l'hysi"llwlOlpy (wei'll
Only in � � � � � � � hilc tl'aching one oi hi!; fi,."t ""uN'S
in cuuhnental Europe in B"d � � � � � � � � S",uerldI1od, llid
he � � through � � � � ....·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
� � � � � � than a methQd <.>f appl)lng lJIolnlpulatke lech·
ruq\ll-'S. T..... MaitlM'Id C<'>llccpt of\lallipulati\'e Phys.o-
thcr,lpy 'IS il!x-eame !.:nown emphiiSILCS a "P"Cifi< w,ly
(II Ihmking, cQT1rinl>Ous c\'ah",li"" ..nd � � � � � � � � � � � � � � �
r � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �
MtllOpanlic � � � � � � � � � � a",I-I"'ft,'I' � � � � � � u'ill,.OJ wh.."" how lInd � � � � � � � � � � � � � � � � � � to pcrfonn. nnd
;"Irrxf"c/i<m II) ,I,nll. � � � � smIJ, rmifi<t<'llC<'f"'''' � � � � � � th.-'SC to tile individual situation of the patient')
MillS � � ... � � � � IJWI"""""'" ,,,,d. if/I'" C""" ""po",I, and .. total (ommitm..'n' to Ihe patient.
8\'11 ,..Yl1 -«Ii IW furtl'" M.liUal1d 1\.;>5 held " � .md ""h...ui...· comm,t-
C. � � � � 1 /19'4) T..... lbooL 01 Orthop.K'dic " ...",llo , ..riou:; prnfCffiion.,1 lIS.'lOO.1hOf>S:
� � � � ..:.."" Pari II - Treatl1\l"111 b\-
Manipulalil.... '\fitSSolgt'.nd � � � � � � � � �
11th Ed,U<m.
� � � � � � � � � � � � � � � � � � � � umdon. P"S'" -10-11)
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 � � � � � � 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<npb and ndcotaped J1\dny of hi_
rours&. Tlw1r continuous fc!Idbad; di"",-p1int is ont'of
m., \"'" � � � � � � � � � � � � of the M...itlands, who an' pracl1t'-
ally illSt"parable SUlC\: II.-') mel in England during
:;aund World W,lf Anne wilS aw",rdcd m.:- pruloc-
I"'less of the Dutch As5ociation of Orthop.-.cd1C
M..nipul.1I"·... Ther-..py (' � � � � � � �
M"itbnd's work, <'!lpeciall\ through I"'" mod.. or
thinking lind the � � � � � � � � of conlinuo"," ,l5'ieSo""-'rlt,
has l<lid the foundation for the � � � � � � � � � � � � � � � nf con·
k'11lpordry � � � � � � � � � � aOO d\'SCriptiolls of the physio-
therapy proct'SS.
Within this � � � � � � � � it S('\'ms suitable 10 conclude
with a q""h.' f""n1 � � � � � � � � L,nce � � � � � � � Vice
eh,"'cdlor, � � � � � � � � � � I'tly"mtherapy, CurtLll UJ1I' l'r-
sily of Te<:hnoloflY, l'i'rlh, Australia:
Mail/mld'_ ,'IJII,lwsi' PH ;'Cry.areful and
Ci''''I'I'f'llrJ'5il'<' ""'mllma/i,m � � � � � � � � � 10111"I"''l:i""
� � � � � � � � � � � � � � � 'iflr(l1lm",,1 by m01't'mmll1nd foJlolr'/"li
ill IlI,n by lI'fll_<r<SM'J!I oJ:l/;, ''!(.'f:< � � � � � � �
"""'("Intlll 011 tiN' pilllt'lll. /Vl'''' lire !J:J,,,,{iJ, Ille
n.uffll riillieo/ IIPI'roWell, TillS b l'robIlbly'hdlN' I'
1Iu' � � � � � � � � � � nll'lhcJ 11>'''' po1>;,/['/1' u·;thin tilt di,fi(nJ
,..odin' c{ � � � � � � � � � � � � � � � � � � � � � � ulld ...� "" If mMrl1'll'
oil," � � � � � � � � � � of II.' prP//'5<ifpll.
Furt-""ord in � � � � � � � � � � � K&Gass [
(1995) MJ,<cItlo4r!tIO! l'h!,-"",IIImII"'·
But!('fWorth-lleinemann.O\fcrd Pag" IX
810graphy xiii
Eatii"r in 1987, TImml'\'. � � � � � � � � � � � � � � � � � Maitlaoo
� � � � � � � � ,,'rill' about hIS WfItnbuhOfl s.ud:
/11 myl'ito1'. thl'A-1JJit..llIdtq:pnlIlfIllOlll'flll'lt'T"
di'frrsfron' � � � � "d i>1 tI", IntdldPll('S iffl.
I«J",iqlli'. M,I � � � � � � � 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 � � "/Jill"'" in
pI'lf"lUl/ fl>mzl"f /uw /l'(iic';" .. UVrlll spclllll;( 01/1
ill <tJ'fl{'drl.:l,;;
1/1(' dm-k'V,.1<'tf1 i:" lfl)U' 0111''1''. if_'rmll
IIJld ImlTr'lml;
tIl'llT � � � � � � � � � � ('II ",,,,,,Jfi.",tJ.lI. 1I<'oflolsK
bioIogicul � � � � � � � � � � � � � ...;
iI,e 'r«rs':;llffo, l,i;;11 I.· ."" ,t!slil/.
tr,,·n.'t1ulum
rftl/f","'....pto. II JIJ mll w,,'t:' I"
.¥"" fllllyJrn'/0I".J /"" � � If linus IIJI"';.
� � � � � � � � � � � � � ""J nkll.l",s;
II", IJff,'S,illffi" .Id'Iilt'd i'.m'IIIJ1,III"" mIdfor 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". � � � � � � � � � � � � � ..I!'''''lf'/I.1i11l1,IIl.r'
1\\T.ml'\·, L 1. � � � � � � � � � � � j, K (1987) 11,1' � � � � � � � �
O>nn'pt: As:;essml'fll'. E>..1D\inaII0l'l, .1nd T",alment
by I'as:;i,'c � � � � � � � � � � � � � � � PiI.lf.'iml TIK'nlI'Y of II...
Lou..., Burk Churchill Li"ingslone
t'JI}' H{'flge,·etd
� � � � � �
Ke\in BanI.,.
Glossary
ACCESSOIO' MOVEMENTS. (a) � � � � � � � � � ae<riSOrv
� � � � � � � � � � � � � � mm,,--menls, I'AIVM; (b) Pa:;:;i,'" intc;-
costal n'o,"errw.'flIS, PAICM.
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.,.,
l'l."lUln!d Ie) rn.:aIoc- a diagno>is. Some (O\.Illtrie!; use
the term [V,\I.UATIO:-.l f;;w Ihl> aspo.'Ct
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.. treat-
menl Sl.'SSiOll> on the disonk•.
3. ANALYTICAL � � � � � � � � � � � � j, ,," il-<,,«menl made
durin);" Ir(>illme"t or ilt the rontlusio" of � � � � � � � � �
It take!; into acrount all d.-t;ub of th,- patient's pil.S1
ilnd pre5Cll1 history. IN.> di.1l:n.l<!lc rle\.il,ls and the
resp0ns<5 to the d,ffert.'fll I",..Iments which ...i11hi,..., been adminisll"nXl. ThIS mllecbon of mfor·
",,"hon IS analysed so a' 10 alkn.' under!;taJ\dmg of
the hkt"ly fuwwoi the p..I;...... 'S disorder
ASTDUSKS. The use at � ;1' !he n=rding of
each palll!fli se.=UnabOf'l findmgs<lnd IlUItmenl �
has onh' one rurpose; it is to /''S'''lSlrl Ihe milu' riements
found. n.cu l$' saves recording lim<> ,,00 m.o"-o the
thl'filPlSt quickly ........... of ....senlIilJ romts ...h8lmilkirf;
� � ..
COMPRESSION. This is � � � � � � � � � � � � � � � � � � � � of OPpoli-
ing ;oi"l sUr!:t<es, either in a positiun or duri"g .1
� � � � � � � � � � � � 10 asse,s the .>ource of '1'1l1plorns and to IJ"
used as a � � � � � � � � � � !<-'Chni,!ue
DtFFEKENTIATION. This arplkos to examination
� � � � � � Ih"l assess which joint or � � � � � � � � � is Ihe
<.ot,1"Cl".' of symptoms "'hen rnO"" Ihan one joint or
"truclure is ul\"oh'oo in a mO\'\!lJll'f\1
DISORDERS. � � � � � a Spe"CirK diagnosis IS an � �
of d"lo>nnination which is In!<lu=tly ,""ry dilr.cuJI to
!YUle, the d.,,;criplin· IL'1"m � <lS 'the patienl's d ....
order' 15 used in many pl.>o:-.. m the led of Ihis bolllk.
The .....-...on fOJ" u_mg such II term is � � � � � � � � ,t IS m;,>,lnt
[<) Ie", .. 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 counter-
prodUCII'!, b)" clouding lhe ,mpocl of lhe relatLod lext
thu" losinS the key of Ihal rel,'IOO � � � �
[VALUATION, This term is not u:>ed in Ille 1".\1 of
Ihis book. but it ;s understood to mean a form 01
� � � � � � � � � � � � � � (see A,se-smt'nll
GRADES OF MOVEMENT, 5.,... M.,"e"'''T1t
HYPERMOBILITY. Sec lT1stabllity. Hyper-mOOlhl)" � �
,In � � � � � � � � .. � � � � � of mCl\emC'1lt (e>."mples bein!;
hype"",IL'1lSioo of th....lbo" Of � � � � � for which the.... is
romp"'te mUSClJLuronlrol � � � � � � � � � � � � � � � � � � � � � �
li\STA8IlITY. This lenn is USt'd onl) 10 meao <In
ncl5SI'"" range of "b0()l'lTl.11 mOH'm..'Il1 for "hlCh
lho.'n.''' no prole<:II, .. mU>oCulolrrontrol.
IRRITABILITY. � � � � � � � � � � � � 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 <:iIU-
Iioo � � T\.'quired dUTlng ......,lUllolhon and t.-mIn"",1
� � �
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'"
� � � � � � � � � � � � � � 116-117).
JOt NT. This word rd'-'n> to all lllol intra-articular slrue·
tur('<;, tilt- capsule ,,00 all Ill.. nOl'-eOT1lraclit" t!.'>,UC5
xvi � � � � � � � �
!h.>! move during "'''''ry pas.siV"dOO dcl,,,(' mO,'Cllll'nl.
1'-TRA-ART1CULAR refcrs to llw.'slfUeture(S) (f1) from
� � � � � � � � � � � � � bone to th<> subchondral bone of � � � � �
a'lll joinl surfaces, .nd (b) including � � � � � � � � � � � � ",ilhin
the joint � � � � � � ,ncluding � � � innl'f c"P"u1". PERI·
ARTICLlAR ref...... to 5lructures � � � � � � tIlE' joint. act....-
enol 10 ,..ld mduding tho! au",," rnpsule
LATE.'\lT PAIN. s.,.. I'"in.
LIST. � J'roiol'di"e I:lI'formil)".
� � � � � � � � � � � � 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
� � � � � � � � � � � � (",. J',,,.,j"l' � � � � � � � � � � � � and
� � � � � � � � � � � � � �
2. In a restricted definition, it is � � � � l<l mean.
small-amrlllude rapid � � � � � � � � � � (not nl'CC'5,;,lril)'
!"'rf(lrml'<l .lIthe hmil of a rang.. of movement),
whl(h th,' Il,ltknt cann"t p.... ,' ..nt t.lkil1g pl.k;,'.
MANII'ULATtVE PHYSIOTHERAPISTS This term
111c11111es m,lrlll;llthcrapists, c1,nlclan, ,'nd � � � � � � � � � � �
MOBll.IZATION � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �
but Its rhythm (X'I' p;lges 5, 176, 179);lOd � � � � � (SlT
p,'g<55, 176) "'" such IMI the p"ti"nl (OT mvdcl) GIn
p"" .....t ,'''' be,ng perlO<'med
� � � � � � � � � � � Thh is synonymous WIth the tcml
\fOTIO' which i.> used in ;;()IJU.' EngIisb.-spcaking
countrios. GRt\D£S OF \IOVD1EJ\,T RHITHMS or
\10VE.\I[NT; fhe:!,e MO ter=; SoeI'\'" � � � � � one pur-
post', thilt � � � � d,·"cribe mol.. � � � � � � � � � � � � � � form the
qUilhty of p;>ssl'" treatmenl lIlO\"mrot hems u>ed.
11ll' h.::1"ITlll are not essentLilllO the pr<K1ice of pas.i\';:-
DlO\'emmt � � � � � � � � � � � � a", � � � U!oed.as iI mlYl\S
of quick l'lX'Ording .u'od � � � � � ..tk.n.
� � � � � � � � � DIAGRAMS. The!;e;are txpl.o,no:d in
deMiI,n t"" .ppmdices. � � � � � � � nul l...� � � � � � � the
pr;>('l,o' <If I"'illment. lhey do, howe,'er, 1M,.... t"" dl....
lind ...h-anlilse ot fon::ing th" !her..pilit to <lnaho("
whilt .he finds when passi,·"ly moving ;a jo'nl. Thus
the:-' � � � iI self-le.minJ; � � � � � � • toi'<t<hing nl<->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.. tho-
bi"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<! c"rtail, � � � � � � � � � �
f.... tu"--'S such <os tlw f".r of mOl'ing.
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 � � � ULTT � � � � � 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' � � � � � � � � � limb neural t"sts',
ULNT, "'''''' llSL'Cl,
OVER-PRESSURE. Every � � � � � � has a J><l'6i\"e r.ng..
of motion, which l';'\c\',>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 � � � � � � � � � � � � � � This O\'cr-
p"",,"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 � � 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.:iny prt'Sf.'flb-
lion;; ('"" ""Ses 166, 167. 190-19:!1, refers to ""in and
tile other S<.'flSIborls which do not rome 00 imrnedi-
atclva mo·cement occurs. but ",ther ocnu � � "arymg
� � � � � � lhc InO\cmenl, or after a position is sus-
tained. 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 � � � � � � "hich is &eno.,.ally recog-
nized (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,lil-
abl" ran&, of 1l1<l"el1'l'''! and whleh � � � � � � � � unhl
lhe limit of th" r""6" is "-",,h,'<I. END OF RANGE
I'AIN, th;, differs from thl' above it1 that the p.,in i, felt
only when a mO"COlent ha, rl'"chl'<l, Or almost
....',]chOO, it, limit of rang". An AFrI;R E1'FECT is quite
mmmon, and ,f pR""",tIS Huh"at;"c of" d,sc dlS()Td..r.
What is meant by the 'I\ft"r "ffl'Ct' is th<ol, having
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 � � � mroll5 otho!!" thdn
the pdrlicuLlr � � � � � � � � 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,
PHYSIOLOGICAL MOVEMENTS, TI>o.'.c a.... adi,,,
and pa""i,;> funclional mowmenls. P,'>oS,,-e physIlr
� � � � � � � 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 ">:am-
inatllm is Iv provoke, with lest mO"eml"llIS, etttler an
abronrm.'] I\.'tipol'L<e in an appropriate � � � � or. whcn
� � � � � � � to lllI! diso<dc<-. ""Production of the � � � � � � � � � �
G1<»>a"l xvii
PKOTECTIVE DEFORI\UTV. A ('Ommon 'pmteo::ti'"e
� � � � � � � � � � � in tho! � � � � � � � � � � � � � � � � � the 'WRY XECK',
",nd m the � � � � � � � ,!,,,'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).
RADICULAR PAIN. � I'ain.
REFERRED PAIN. Sco.' I'"in.
SCIATIC SCOLIOSIS. 50...: r"'I<'(!ive Deformity.
SI:VFIUTY_ A .ymptom 1S <ldilled as s<'VC'" if the
i>elivil)' 111", Caus<:'> � � � pam n",-ods to be interrurtcd
and � � � � � � � � � � � � � � � � � � of the intensily of the rain In
many (,1'><'5 this is an indicalion that(aulion is ne«ic.'d
wllh � � � � � � � � � � and tre<ltmml prucc<lu"",
� � � � � &..: Protectll<' DI,'!onnll)'
Chapter 1
Introduction
CHAPTER CONTENTS
� � � � � � � � � 3
Manipulatio'> 3
Mobilization 4
Manipul<Jt,w: Ihffapy 4
� relationship bctw«n � � � � � � � � � and
� � � � � � � � � � 4
� � � � � � � � � 5I . � � � mode of thinking. the primacy of cJini<:alLdence 6
MunipllL1lion is NOT as man)' \\'lIulJ II,.,,' � � � � � � � � � � � � � � � �
an � � � � � � � � � � t"",lm.,nt. � � � � is largdy duo.'10 ad,aoclS
in mockm tI.'dInoJogr. � � � � � � � � � � � � � � "ilh th<> capabilities
ol' mod..'m rompulet'S.- Although � � � � authors on tlw
� dt5Cr,bc ll'Chmques and technique! only. lhe 002:1.err' of this book is .digno.od ""th UIO: foUowmS'luot1lion:
Dt$p,u � � � J.... � � pflnr /vmg <.,'IfIU'lhing U; Il
'/>*t wx', ,.mdl,-"'l � � � � � � � � � lfilnwlr rlrli,>11TSS.
� � � � � � � � � � � � � � � � � � � � � � � � lm...� � � � � � � �
lMllmnll ,>{ktu·!lIKt p.;in � � � � � � � � � � � � � � �
� � � � � � � � � � � � � � � � � � � � � � � � n",."a..q..ny
,mJMrlJt<.;J;.-"Uyai¥yi"i tlmr -.t,ll. flJll'u/,'- to
� � � � � � a"-'tlt _jrr...-..mllJ/roll/ro".... TM � � � � � � � � � �
r!Ju""lllmpI_"'" � � I/Ii' 'bl""t /lux' M"C"1l"' � �
mf'lvlJI r.TcrpI III /rlOO<' IIls/al/,n U"k'" rrli"blr
ptlllk1IO:S'C'IIJ.'"niols
(!mi' &"'k � � � � � Prn",,,ri.m, Tn'Mnlwl, R""'rl,..h
� � � � � � � � � � � � � � � � The /IIanipulali\'C I'hysiOlhempis15'
Association of Australia (MI'_\II), M.lrdl, 1%4)
Although Ihis book is ori ..nled � � � � � � � � � � � � � � � 10
trnlmcnl by m.nipulalion (i,e, pass;>', mo".. � � � � � � il
Dealing with problems of diagnosis � � � �
'BRICK WAll') 6
Th«>. ,
� � � � � � � � � � � wording 9
listenif'g 10
wmmation 11
R,lat'''9 m .. � � � � � to the history. symplomsJ
and !>19m 12
� � � � � ..lId anatytj(al ilssesment 12
Two � � � � � � � � � � � � � � � � � � � of � � � body 13
� � � � � � � � the 'C(mccpt' 14 _
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<l1 � � � � � � � � � How", ...r, tho.'SCOf'" of appli-
(allon � � � the sk.lllsofmanipul,'hon .'''' not sufficiL.,t1)'
....,,11 .lppll.ooaled m many doctor- <100 � � � � � �
dpiMo. II ;,; important, therdafl.'. tnat � � � � � � � � � � � � �
� � � be gi\ "" ""ITa emrhOl5is so Nt the dpproprbtI,'
� � � � � � the � � � � � � and lhe U!lll't'5, will use maniJ'Ula-
non III lis propt'T conlnt and to it" fullest ",,1<-,,1
� � � � � � � � � � � � � i5 not lik" S"me of l;OIf (Fig"" I,ll
when! the � � � � � Ux'S a tKhmqlM' to h,t;) batt III III<'
dU1'C'hon hl' wallIS it tu go. allhough most � � � � � lmd
to \b(' l<-'Chniqu"", of � � � � � � � � � � � � in thIS ....ay.
r. � � � � � � � � � � � 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 � � � game of Conlra(1
Bndge (FiKW'1' 1,3/. Here (tlmmlluicatim" in Ihe 'bid-
ding', plays an import."'t mil,', � � abo dot'S the a,S"Ss-
menl of whe", importanl kc" CMOS are hkel)' 10 lx" In
lhe � � � � th.. technique of plal'ing the cards requires
e---------------------
2 MAllLAND'S VERTEBRAL MANIPULATION
Fog".. 1.1 � � � � � � � � � � � � � � � � � �
,o",idl'red. thoughtful pLuming. E;,(h facd is UllpDrt-
ant 10 the whole_ and � � � � � nl"l.'ds to be integrated with
the others with knowledge, skill � � � experience
The 'conc<->pt', as it has come to "" known, of m,lI\;pU-
lati,·.,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 � � � � � � � � � � 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
� � � � � � � � � � � � � � � It is tl.., analvtirul u>Sl.,;smenl that ,.,,,<'als
thl' � � � � � � � in the pain!mmemcnt l"e;p<IfI.WS during
t"'"lmrnt.
� � � � � � � � � 01 the 'conctpt':
� � � � � � � �
� � � � � � � � � � � � f(SpOnSe .nd � � adaptation in
� � � � � � � � to thr patknt's current episode
Sr><citk mode of � � � � � � � � � � � � � � � � � � � wilh a
� � � � � di'9nosis
Figu," 1.3 (onl"."t � � � � �
The ",rowlh and � � � � � � � � � � 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 � � � � � � � � � 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 � � � wnl;nuous analylkal a..essment before,
during arid � � � � � the application of � � � � lechnique
during � � � � � � � � � � � � � session, from session to ses-
sion Ihr(n,!;houl trcalmerll, and � � � � � I"'<ltmenl � �
dis<;(mlinul>J
2. The gentleness of the inilial 1"',1tment lcchniqucs,
wilh stronger k>o;;lmiquC$ � � � � 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.
TM � � � � � � � � Kttplancr '" mar PI> al<Oll is du. 10:
� � � � � � � IINIytJaJ � � � � �
Gtn\ tnei6 ",fin;w' � � � � � � � � � � � � � � � �
Et'ttU of &e rr.:.!J1ICnt ",lid nn � � � � � � � � �
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 � � � � � � � � � � � � � � still far from "'-oing:
US('(! 10 ils full"'l potenl;a!. There are IWO reason,;. for
Ihis, Firsl, Ihe diagno:>lic � � � � � � � u;;ed b}' sum" m<lnipu·
lalON, on which lhey ha"" b,I....� Iheir manipuI3li"('
treatml'nl. arc unacceplabk 10 Ihe m,liLJrily of the mL'<I-
ical � � � � � � � � � � � � � � S<.'crmd "'''SOl' is IMt !l<'me manipu-
latio"," II"." bL,,-'ll performed � � � � � � � � � � � � � � � resulting;n
dlSobl..... - Ih. liIcTi.lur" � � � � � � � � � thoe e\ idcnce.
HoWl'H'r, such ill(;idcnts >hould bo:' � � m their nghl
conw..1 Toquot" Brewerton � � � � �
Ch'sp'tr ,Itt � of11_Clt$<">, t/try mllst br ltJ'l
i" P'l'PI""iot'; Ii l<tRSlJ IO"¥"Jpall.lJ I<'rll. Ihr
"TXulIfm' IIttJI un1!1fi!¥ srNfl,oJ!.IS � � � � � r'. � �
A",,"lal" liUntl""C>YT II � (1(10 ........
Dun'llJ ,111$ N1V IIrnr ........ 16 (.lX} _';ipII&iIOO
lI'1lrt",s rrgu14rly .... rh<!M1""T1I � � � � � � � � � � � be � � � �
upon to Mtmi""lt.lr "I JtusI � � � rr«t tDdI dar;; 1Ir..f
Illb lWlilJ "",""11 illrrJrnu(l( 1 III 10000000
ItID"'J'ull1",ms.
More 111.'11 40 }·..� � OIl, IIti.> I> >lilI � � � � � � � � � � � � unchang<-d
D,....slers C,lI' be a\'oided by adhering 10 the lollow_
ing three rule>
1. COlllmuOllS � � � � � � � � � � as;('Ssm"nl � � � � be carried
oul during Ihe � � � � � � � � � � � � (Of a Il'(hnique and
lhroughoul treatmenl
2. nu, in;tial � � � � � � � � � � of a Il.'<.hmque must be
g.....tl('.
l. The � � � � � � � � � � � � � � � � both during Mel aIti'"
apphc;r.1ion of tn>atment, � � � bt·aSo5C"..ro and
anal\-sed beftm.> � � There musl bean
awal'l'f"lCl6 of Lllenl """"""Nliooru.lhal were not
t'\ idePI al the time of the JOllnl consultation and
must � clanfied befl:R seloe<ting treatmellt
"""""""s..>f"re L'Illbartting on the 'concept' 01 manipuLoti\...
lrealmt"'t. \\hich lhis 1>001< � � � � to dC5CTibO', tl>ere are
I"rm_ related to thO' word 'm,lmpul"tIOil which
requ;n'dMilicalion.
PASSIVE MOVEMENT
� � � � � � � ",o,""menl meanS any movemenl of any part
of one person which is perf"rrfl('(1 OIl Inal persOn bl'
Introduction J
another person or pieeO' or eqUipment. Pass;\/, rom'l!-
IY\('flI rna\ ref...- to the ,01ll1'S.o«essor)· � � � � � � �
II!; ph\<,ologkal fI\O\·cmcnts. Physiologic... move-
� � � � � are tho5o> """""'<MIS that patients can perform
Kti\·e...· br t!I.l'm5el\'ol"); K(K50ry mcn-nnenbii af(>
tho5oe IT><nL'IYlt!I"IlS of tlwtr JOInts thai individuals (.an-
not ptrlonn aeli\ � � � ""I \\ ruch (.1fI 00 perfornu.od on
them b\ anolt..... p<'IWll. For t'umple. il is impossible
l\l mlal" am interphalangcal joint "'th ely, but il can
be n:;Kall.'Cl b} somC'bod\ l"Ise.1l\en.10"", rotalion "f lhe
lllt"rphalangeal joint is I\n accl'SSOry rnovellK'l\l fur
thai joint. An)' of Ih."., mO\'eml'l1l!; <-an Iw pcrfo'mt'ti
slllwl} '" al sJX'<.'\!, £"Ilily or vigoro"sly and through
iMge ,,, ,m,,11 amplilude:; mld ,Ill! b<.' cal1<'d p"s<ive
llIll\"menls.
� � � � � � � � � � � � � ft'Ia\I � � � � tell". pnls' acrnsory Of
� � � � � � � � � � � � � � � � � � � �
MANIPULATION
l1w word 'm.lJUpul.:lt>on' can be> usN ;n man:" wa}"$.
� � � � � � � � � � � il can be used loosely 10 mO'an � � � �
m<:'\'..menl vi am lind. 1here are English � � � � � � � � � � � �
dl'flO;IIO£IS or manipulallon. and medical dictlOf\,lry
dettnilioru:. Medic-al dclin;lion, ""1)" ffUm � � � � � � � � � � � � �
lorr,lClilioo<-r <md from ochooll05dloo1. "lampulahon..
moblli2dhon and pa*l.... � � � � � � � � � � � � can be, and oflen
MC, ".,..'<1 synonymoush'. t'e\'erth..less, the manipuJa-
I"" phrSLolherapi,t is in a ).'OSllion 10 ,U&;e.l prcci:,('
definitions for lernu usN. In � � � � bool<, Ihe "'oret
'manipulation' will be u-.ed in IWo ways
As a gene,al I"rm 10 row, any form of � � � � � � �
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 � � � formsoipas>o;\'" ......·erncnl
lblN abon', as "'cU as the <J"-"OflC defin,hO<l of
manipu1:ttion \\"hlCh fol],o\\5.
2. .... � � � � � � perlortntd ,It a ..".....J such ......1 il has
l.>kn place before the JX'I'lOn on .. hom II is per.
formed is ilh.., 10 preH'1I1 II � a � � � � � � � � � � � � � � � h:.>ch-
mq"" Such � � � � � � � � � aT\! often !,flltle, ..IWa}lI
� � � � � � � in ,ange. and .a...l\ forceful (Oft" P....i"'" 10
for,1 Edihon).
� � � � � � � � � � � � � � � � � � embrace:; 0111 � � � � � of � � � � � � �
mOVl:m.nl, Of can be viewrti more $p<':C1fically as a
:>m.11 8mpliwde � � � � � � � � � � � � thfLlSt le<:hn,qu.
perfOlmrti ""Iln speed
4 MAITLAND'S VERTEBRAL MANIPULATION
MOBILIZATION
� � � � � � � � � � ,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
� � p-,tM'fl1 10 p",,'enl the mon,."..,,1 if he 'II'" ''''-'.10
d\OOSe$ («< PTe!"'ce to Fil"5t Edition).
lI!obzal � � � � � � � performed ,n such � IIlinntr INI
lheyan lit: � � � � � bv tile poItJmt
Tho:' IWO type.; ofmobilization ..n>:
I. ['"S.<l''' � � � � � � � � pt'Tfurmed for lhe pllrplll5t' of
� � � � � � � poi" "JW.I .-e5Ioring hdl."'''Sf:', pain·flft.
functional mO\emenlS. TheSl";l1\' o.f two kinds:
a) t'assiv" � � � � � � � � � � m",'emenIS pcrforml'd
sl"wl)' (0.... in 2 5<-,,<onds) or qUK:ld}' (Ihree f'L'T
Sl?«(>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""'y � !",rfunned wlule lh" )Oint � � � � � � � � � � � � �
dislr.lCtl'Cl Or � � � � � � � � � � � � � \)i,traclion i< Ih"
!K'parallon of opposing joint � � � � � � � � � and com·
pre%ion i5 lhe .ppro"imalion, or � � � � � � � �
� � � � � � � � � of Ihe opp'",ing joinl surf,lCt'!>
hI Sustained slretching p<lS6i,·.. mo\'em.-mK may
bo' performed ,,-ith tin)' ampblude � � � � � � � � � � � � �
al the limil 01 !hi.' range_
2 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 "'" � � � � � � � � � � � or who ""n' <t"
.:ldJ\O:- ;':'ml d,sea:;e � � � ol!o rtvNm.lloId arthnl15.
� � � � � � � � � � � � � � � � � � � � .... � � � � �
euorpe min-'<19 pain or � � � � � � � � � � � � � � � � � � � in(!
pilir-'ru � � � � � � � � � � � _mmL
They C1r Ix PftfOl'lMd n ilI1 OlocilJillOr'y l'IIilfllltl or
ilSsmil¥dstrr:t&·"'I
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.., � � � � � � � � � � � � t"'"'' compM'
in8 thost.! 11S<.>d by different practitioners .lnd <ll1thors.
� � � � b 111(",1 unfortun,lte. because it � � � � � � � � � Ihelr .....-c.
ing 11", "'/r<:>l"picr"n' of, treatm..nl conc<,'pt, r.,,,,, 'ur·
,-ey5 or � � � � � � � � projects wmetimes miss the point
wh..'rt Ir} ing to weigh up the "alue of a p.,rtK:ular
group of !<.-..:hn'que>o. II � � I>«llU5(' of this mlSCl:>fl«'Ptioo
lholl 1hi5 irltrodlKtorv chapl""- S<.'!S oul 10 ""plain til<'
<Oll«.l't of loIal ffiilllol!o":ert>enL w,th lhe tccluUq....'S and
their itdap"'-bilil)' koiOl; 1;1\"" lheirCOl'Tect relationship
10 the ...-hole. In tact. the ('(InC\.'" r"""'" greal emphdsos
on pam and other alllCd s),mptoms. This ('ffiphasls ....
eXrLlmed. 10000000hl.. wllh the other aspo."C15 of It\I' con·
n-pLWlder the � ...Itl h<"admg5 thai folio».
THE RElATIONSHIP BETWEEN TECHNIQUES
AND ASSESSMENT
Marupulal,,·.. lrNtmenl c.ln be di"ided inlO four ""''''
partS
1. hami""hon of 1h<"p<lloCllt
2. Mooe of Ihin],.ing and pl.lnning
3. Tre.llmenllcchniques
4. AS5C5Smenl
Otmthng tilo<" 'mode of thmking' [MIl al lhts st<lge ....f
di,;cllssion. lhe fil"5t fe.lture of the 'C0I1Cll'l' rej"les to
understandiflg Ihe fI.·IM;\"(' ImpClrlancc th.,t Ihe parlsol
m.,nipulat;ve tfl.'-.1tmenl he,,, It1 � � � � � other. Though
skill io ..ach ""'" is ;"'p'''.t,ml, Ihe � � � � � � � � � of Ih" skill
fI."llHO'd for e.-><;h is nul l"'lul\·.llenl, E\'ery manipul,,·
liw � � � � � � � � � .. r"pist must always renK'ffibt>r tho,1 the
/><'sr treatm('nt c;,onOI be gll'en ""thout p<:rkctly p',r-
formed 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. � � � a Iotalty wrong ide.t of � � � � � � � � � � � �
m.almenl, and � � � � � � � � � � � � � � � � � � � � � COUf':iCS thai consl5I
lI\iIinl} of l<rlmiqtJe5"hook/ bt � � � � � � � � � � � � � � � �
'Thesoe four parts, along wtth years of oonscious
""pericnce and Iearrnng bo,5t.'If on ItIe mode of think.-
iog and � � � � <11mb",.. to provide effect" to "nd
mlormabve troeJtmenl
n..,. four m.lio afl!<1S are depictl..::l in figurt' 1.4 to
dcrnonslrate their retan,,, 'rnpor!i>occ> 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;"" � � � � � � � � � is nol � � � � � �
Ass"ssmenl irlvolves e,·"luntm); lhe chang"" in Ihc
pal;"nl'ssymrlums "tid mo,emenl signs lh.Jt occur ,IS
a result oj lhoc � � � � � � � � � � � � � � � � � � � � � � � � � � ,md it IS this
a>O>eSsmenl that IS Ill<! key.wt\e of inf"rrnnti,'c t...."t-
m..nl. Assessmcnl (dis<:us.se<! in filII On pp. 5J-8J) is
nol an NSy skill to m",t.:r, and il is In.,. area wh..",
mo"t manip"lntorslo>c thdr ,·ffl"<:I""nes.s in Irc"lnwnl
"nd thciT ",,1"10 ,n m"kJnf\ pt"ll!;nn,;.,,;.
ASSESSlilOO
T_Toclwuq.....
� � � � � � � � � � � � � � � � �
� � � � � � �__lOknoorlloor
� � � � � � � � � � � �
"!lurr � � � Jhe � � � � � � � imp<><tant(. of � � � � � � � � � � � � � � � � �
<..minatiotl of m. p.n.. nt••",,,,,mwl Irnl the ",0* of th;nki"'l
TECHNIQUES
� � � � � � � � � tlXhniqueo; are � � UI rcldlion 10 their
� � � � � � � � � � MId l<.> tho;> fa<1 Ina' <;(>Ill(' poopJe aft'
� � � � � � � � looking 1m ne'" It'Chniques ralm than undeo'-
sl;mdinK Ilc:w.. and "'hen thl'\ should be modifit...d and
USoL.... f',,>:"fI' I," d""""""tr.lle lno, ...� � � � � � of tech-
ni<Juc'> In n!'IallQlllo tho;> lotill con<:q)I of treatment.
� � � � � � � � � � � ...s they ..pply to the oont:ll'1 � �
in thisbook,..m' m.'H'I'cndmgand � � � � � � roc' .... "'ill h,a,."
an "nding So Ioog as palit11ts � � � � � � ""ltIl dllfen'llt
� � � � � � � � � � :\nd � � � � � i""tion � � � � � � th..'rt' "'ill h.Jw tobe
� � � � � � � � m l«hniqlk'S to fR.'t' lho'! p.. tients or mUSt'
,}mpl"ms.
Cyriax (1"78.,) � � � that Ihe � � � � � � � � � � � � � � � � Ic'Chniques
inciudtd in lh" \l.'xt of this book W"I'\.' fi .....t pracHsro in
� � � � � � � � � � � � � � � � � � � � 1&'18j,and it � � � � � � � � � � thatlhe 'bone-
seIK'1'S' of !X'nturie; ago (Cl'ri.. " 1Y7Si» 11.1> (',,!so prae-
li-....t t....,,,. \\'(' mu,1 al",,,}"!; � � � � � � � � � � � � � � � � � � � is
no ",""" � � � � undl'rthe ,un' � � � � � � � � � � � � � � 1:9), and thai
all "'" do IS ',",'uk ,he ro.od mao.. b)' <toot""'" CChill<'se
pron'rlo).
If rt'Cottb of all lhe d,lfm.'fll tlXhmqu05 thaI ha,e
M.'f\ de>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
� � � � � � � � � � Th\"I'l'h; an 'ffiIIlo<'aSUI'ablcnumbo>r of d,ffur-
I!fll t«hnoqu<'5. and each Of\(' 005 un ,nc.>.I"'u.>bble
numbt.'f vi '-,In,,lions
'I � � � !iUt\>o."i;n,,-,,> been SOlId during � demonstration
1"'.. ln...."1 ....f a f'l'hent, 'You dldn', � � � � U5 Ihill IlXh·
"'que 1<I"t � � � � � � � ..,ply � � � � "'Omctimes "'-",n, '1
couldn't, I've ncH'r don" il like Ih,. jx,fotl,'_ This � �
b<'(.llJse Ihl: � � � � � � � � � � � � h.1S be\)n (<lnd must � � � � � � � be)
adapted Iv "nil Ih" � � � � � � � � � � � findlllH-'_
� � � � � � � � t......'" <lre basic techniques that
mu.t I.... l"ohht. the � � � � � � � is Ih..1l mampuJalin-
� � � � � � � � � � � � 5
phb>U'lhcrapi'>lJ>' lJUIlds mu:.t bo.' 50 ope!' thai Ihl.')'
� � � � tht...r I......hrnq...... until � � � � � ocm.,,-e !h<.-ir int......
1101\. ll>ebasK:trealmo.'f\ll"'Chnoque mll>ol indudcC"ery
mo<l''Inl.,,1 01 "him a !budu", is caJ"'ble. the 1'1,,"-110-
\oj;Jco1l mO\:tments ...-.d the � n\O\·............"'. plus
;ill poosoible cumbmatiorb. When it CDIIk"S 10 st'I.',:tin);
the lO.'dIruqu<' for b'l""tmcnt. IllS first � � � � Iu 1o.ncM-
the F""",,-e � � � � � Or f'OS'llOnS th.>l pmvokt' or
� � � � � ... e th<' patient's � � � � � � � � � Whft, lhe symptoms
"n' "a.,ll "1'roducoo. the � � � � � � � � � � chos<:-n '""y be
",thel the mO,,"-'fTler\1 Ihal � � � � � � � the symptoms or me
rrK)\'emt"t that 1'00\'0...... th.' s}'mplnm,>- 1 his ch",i,,.
� � � � � � � � on � � � 'nalu",' of lhe di-.on.!<'r. the '''''''Nit}'' nf
lhe .ymptoms and Ih" 'i,rit<lbilil}'" <\f th" dIsorder!
A technique is the brainchild � inC','"',"'C"'---__
Th("I'l' .. re no """ or imari.,bl.' tlXhniques; sIdlements
� � � � 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 � � � � � � � 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 � � � � � � � � � or II><' lo.'dmique to the
examination findings..
1lolc.1\l5elh..>st} I" or mo,emt"llhal can boo osed � � a
Ire.umenl � � � � � � � � � � C<lll be 01 dllf""""l � � � � � � � � � ..
.lOd in � � � � � � � � � � p<lrts ui I.... a' aila"le ,angc. GRADl'S
OF MOVEME:'.'T be<:omc � � � � � � � � 10 the � � � � � � � � �
The)' � � """"nti,,] fo, three I'\.'a!".>n';'
I. n",y form Ihe be-l b",i.l"r � � � � � � � � � � � � � � �
c"mmu",,,,hon
2, 111,,) fon:c the m"",pulalor 10 think in much liner
detail about lhe � � � � � � � � � � � � � � � � � � � performed
3. Thev form an e:!;......"ri.allflC'lhod of at!bll!'.-iation
"h\.:" AXordmg lr'NtnwnL � � � � � 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"
� � � of m""tII'tnt � � =not al
� a � � � fu' � � � � � � � � � Ir>d commun,calron
For � � � � � � � � � � � � � � � � � � � � lhe IrctlOlqur 3ad fo,
� � � � � � � � � � � �
In rrrordirg � � � � � � � � �
THE RH'l'THl\1 OF THE TECHNIQUE i, ,onotlx-r loc-
lor to be C0T\5rdere<t on ...·L";on 1(\" p"ssi,-e mo.-em"nl
6 MAITLAND'S V£RTfBRAt MANIPULATION
I",alment lechnique. rv. lhe palient who � � � 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.
This � � � � � us to lhe nl'XI f""'lm" l<> be cort5lden-d in
l"IILlhon to a trdmique Whrl"ll >hou1d the � � � � � � 5mOOIh
te;:hniqu... be performed? If w(' roru"dcr IIv:- "cry
pamful di50rd('f, II should unlJ.illh be p<!Tfol'1Tll"l:l � � � �
� � � � � � � a Tan!;" of mon:rrw:nt a, is possible \\"thout lhe
pali"nl bdng abl... I" � � � � � any � � � � � � � � � � � � � � � � � � � � � � � �
� � � � � � � � � � � � � � � of l!>e «all', if Ihe ralienl h;>sachrooic
di:,t)n.Jc." hkh is ani!, pron,ked b, mO\crTI"nl at the
� � � � � � � � � � � � � � � � � � � � � po>oition. il "ill probably � � � � � � � �
siretdung. <'Od-(lf-rang;>. small � � � � � � � � � � men""",,,l,
I"l""fnnne<l. � � � � � � � � � � as a ,Iacc.lto rl>ylhm. The mm',.''''
ml"t would bf: ronsider.'lbly fasle. lhiln Ihe smooth"
slo\\' lechnique � � � � � � � � � abm .... This ml....ns that Ihe
Il-cllniqu", ("I",tIlL..- a p.,lpaton' t\"pc of � � � � � � � � � � � � � � �
niqut! 0. an ioo""",,1 Ilocalized]teehmq",,) would aim
10 b!.' fast enough to ...u.. It\l'" ;.piN! SIlwno-"'t bl..ng
In...tl'd reach its end--of·range paslhoo bcfOf'l! the ad,""
O'flt � � � � � � bogin thl:lr mlr.-cml."fll.
Tht rhythm in � � � � � Iht � � � � � � � � � � � � ""rto,mtd 1$
� � � � � � � � 10. tI't qu;llily of � � � Icc/lnlll.x· It may ....'Y
fnIm 'gentlt-smaoltl' to )trddo � � � � � � � � � � �
� � � � � � � � � I)!'l t!'.c d ,"alCOftd!lOtl 0' t'le � � � � �
� � � � perfollrllng .1I'y � � � � � � � � � � � � manipul"t,,·(, ph}'si"..
tht:.api5ts � � � � t>t:ronl(' ," inlimatelr � � � � � � � � wilh
"hal lhey' are doing as do w!0i5ts pl'"rfonning with an
� � � � and � � � � � � � � � � � � � � � 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 � � � � � � � � � � � � � � � � � � a"oJ diagnO!l'
lie lilk'S a", difficult problems wIth which 10 come to
I"'tn!>. I,xen within medIcine. many diagnostic lIlies
� � � � � � � � � � � � madequale, inrnrrt'Ct.OI' may br ""'rei,·
linUd with palterns of symptom.>t<dogy; they mav
,-"'en be b,,'lC'd on � � � � � � � � � � � � � � � � In Il'latiun 10 � � � � � �
� � � � � � many m,\lJml Ill'alments are mitially adminis-
ten."I:I empiri(allr; � � � � L1!<'T. as tht!scienn:oi me.licu'"
ulCho "'1" dOl", lho>lheory be«Irnt' known.
\\1t1un mt.odiolW todolV Itv.rc � � much tNt ... ck:...ly
I<no\o.·n and undef5l00d T1ten' � abo much thaI jo;
being disco>t:I'(od dar 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 � � � � be rorlSidl'rl'tl then'
;s much we n n:-:K we know; "1'1 i>'> me<hral � � � � � � � � � �
progres.;.es. the thought ......!' t>e'pru"ed "rQltg. A pet-
ft:.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'>
� � � � � � � � � � � �
tlu'rld"ilc,' ,,,,,·I,,,,,i0 "''''''''y j"Ji"id,,,,j j,,;J1/S .>flll
1tlJ.",,1 III",,,.
lb."",' facl5.aklni.' dt-'INtnd thaI,..' -.hould nol be dOS'
mal>cor riSId � � � � � � � � � � th,nking when e.;"mimnj;,. tn.... t
ing, or making ,udgl'fTlL"flts aboul palimts.ln addlllOn
to the � � � � � � � 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 � � � � � � � � � � � � � �
1 1lIt:'re is much we do know
2. There is much � � � � � � � � 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, � � � � � � � � � � � � � biomechanics
and pathology. In all of these, sclenllf", invI'S!lgalion
conl"'''I'-'' Il' milka' disco\·cr;cs. AU vf th"' fo". � � � � � of
medical knowil'dge coIlI,';n dements uf knowns and
unlnowns, � � � � � � � � � � � � � 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 � � � � � � � � � � difficull 10 n.'L11C a � � � � � � � � � � � 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 � � ...... found
dunng Sill'gl(all''q)lorahon to lome <1i>cs lhal were not
abnormal in Ihe way anticipated. A•• ..,..,,!l of Ihis
Sl:r;l'" of � � � � � � � � � fi,'1-' T\:,'sons other 11I"n disc hl"''';,''
lion we... � � � � � � � � � � � � � for lhese p<1tK:nts' s!'mptom>.
TIt", � � � � � � � � me""" ......t a paho,tt who on. clinical
f'x.tnu....tion preo.ents with a .5l1 of � � � � � � � � and
IntrodlKtlon 7
bble 1.\ Asrtlgk cl,mcal � � � � � � � � � r=f have
Stvtriill diagnostic ttle->
\j! � � � � � � �
II:
in H"tory+SymjlWt"S
"iSign,
Known
Thoognt
� � �""-Sprotiltion
HypntOds
� � � � � � � � � �"'",-� � � � � � � � � � �•.-
Table 1.3 Division of IhJnklng in � � � � � � � � � and tht
clinical � � � � � � � � to tilt � � � � � � � � � � � � �
� � � � � � � � � � � � � � � � � � � � � � � � � � �
IJiSIO<y(HI
� � � � � � � � � (S)
and Signs lS))
Ont·,M< h..niallon
Macnab two
W.cnablh"t
I.'I.."bfou'
lI.l1ml1blivt
""'"""
Table 1.2 Asingle diagnostic tItle may me..n � � � � �
chn,cal � � � � � � � � � � �
signs indic:ahng nt........ mot Imullen ma), ha... a db...
order with on<.' of at least six � � � � � � � � � � � � � � � htles
(T4b1t'111_
The probl..m also occurs in It", 1'\" ....... order. � � � �
� � d patient who has a disorder th.l1 is � � � � � � � � � � 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 � � � � ...
meanIngful. So, "'hat can the ph. <;iothcrapbt 1\'1\ on?
It IS � � � � � � � pos:oible to detennjo,:
th.,t no r/i",,,><, pnxL";:; IS lI1\'Qln-d, and
..... hetl"', Ihe is a � � � � � � � � !\elll'(lmusculo-)kclet;ll
l",>blem rn � � � Ihal m.l)' bo,> � � � � � � � � ior tJt:"lment
by .. physiotlw,.apist � � � � p/lSoSke � � � � � � � � �
Within du, (ontt-d ,he manlpulati' e ph,·siotheraplSt.
ulld('rstand,ns lhe patholog,c.-l MId biomo.,<:hamGlI
change; that IN)' be � � � � � � � to base m"illm('nt
IlXtUlI'lU<'S••nd subseq"..!!lt dwtgt.'S 10 lhccI, on a"...
11'1;01"1 � � � � � of chanS'" In I..... � � � � � � � � � symp-
tom:. 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 � � � � � � � � � � � und('r the general � � � � � � � � ·Il>\!..
orctiClll aad speculati,,,', and t..... other under the gen-
eral he<>ding � � � � � � � � � and c1ink.1 presenbtion'.
Thi::n> are � imporLmI rt"awT!, tor employmg
Ihis reat"re of l',,,...;:ompartmcnl thinking:
1. It cnabll'S manip\lI.ltj"c lreatn",,,ll,, b.. ""od, ev,,,,
illhe di,lgno,is i, nl,t prI'Cisc, pn" Idt'd it is ktl<1wn
thaI thesymptnm,> Me ansing In)lll a neuromU5<;U-
lu.kell"toll dN)rUl.'T ..ad not from SCllO\b patholOJS}
2. II males r<-ibl., the use of nwupulanon and ana-
� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �
3. II enables till' ref....ring doctors and !he � � � � � � � � � � � � � ..
..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
� � � � � � 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 � � � � � � � � � � � � � � � � � � � � � � � � � � � �
The I,;oil<)ll ","tween the 1"'0 � � � � � � � � � � � � � � � lhe
chniC41 comp.ortmml and Ihfo lheordic;o/ comp;ort..
rnent IS .itIJ fOf thl.' growth or � � � � � � � � � � � � � �
ClImc""", IIW)' ;r«ul"te and h)'flOlhesize, while
lheon!tical practitioners Me often too f.u remo...� �
frum the clinical situ.ltion to assist thL'l1l.1tGln ..1-.0
be h.lrmful "hen clinicians helre--e theIr hrpolh-
egelI dogmarkaU}.
There is � � � � � � � � � � � � � 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 � � � � � � � � � � � lack of kilL Seldom do examination
findmgs behe thepatlC!l"s true � � � � � � � � condibon. For
a � � � � � � � � � � 10 be corTOCt ,t mu"" fit til(>
clinical SlIuation- II it doI5 not til .t IS the lheofttical
� � � � � � � � 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
� � � � � � � � � � � � � � � � � � is wmmonly rdl_,",-'\:i to
mctaphoricall: � � the 'symbolic semi'p"rme-able � � � � �
l\",'il' Tht" dividing hne be!>..."" the � � � � � � � � � � � � � � � � � � � � � � � �
ulati"e' compartment ind thoe 'c1inic.I' (omp.,rtrneflt
., the 'brid. wal1'. It is not a solid ,,·all; it has rna"y
",,,""",.� � he,n,ation with nt"'"root irritation'
� � � � � � � � � VERTEBRAL MA=O""---
Table 1.4 The 'pcfmCiiblc brid wall'
op;."fWl9 kI aJk"..,·lhough15 to tim,- from ...... (ompart-
mentto � � (T;;LW I.':).
THEORY
� � � � � � � Ilh,I"lrate< ,he relationship bctwem t/lelh.-
"-"hear kOO\<olcdgc and tht'dinic.al' � � � � � � � � � � � � � Tho>
� � � � � feature of me � � � � � � � 01 this � � � � Il'!>t!i "'Ilh lilt>
� � � � ..'1n..."t, 'V.c must not gel di\erted by the � � � � � � �
aSfX'Ct5 of .. patient's dISOrder such thai it is to th..
dctrinK,U of the clinic.l1 aspect', ThffI';< � � � � � an ..nor·
mous amount ..cdo not know, and till' fhcoory � � � � � � be
� � � � � � 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-
lory of a \\'on"'''', symptoms (6 wwks). The SC'Cond
eX,lInpl" dcmom;t",tL'S how the theoretinl Implica-
� � � � � � of a c<',vic.11 radiogr.lph may not fit Illc dinkal
siluJli"n
He 'svmbolic � � � � � � � � � � � � � bfick walr 11 a model
thai � � � � � phy"':lIhr'i1pisls ill tM· ",od( of � � � � � � � � �
In � � � � ",ay � � � � all � � � � � tt!(" � � � � � � � � � � r((\cd,()I'lS
� � � � � � � � � � � � � � � � � � � � Imowlnl'l" ill two � � � � �
bllt '''dtpendml � � � � � � � � � � � � At tt!e SiI'ftt ti..,(
info,...... ti()l'l � � � � ff(l' to 1Io.....om 0"" l.oCl( to 1M
otIln 0.,., COII'jIaf'!ll'ffit � � � ttlf'tain 3 ' lhco-ctiarl
illfor...:lttOn" � � � � � .nll spttal>ltiw:. 'no:/ud"'S
tM ptU3ulions iIIld � � � � ronlratnclJcalJOm for
llNt'l"Oe'l Olr orllft � � � � � � � � � � � � � � � � � � � COIIta'n a'
� � � d'NCllI � [hr.tory. """' nd � � � � � � � � � �
� .asscwd ...... rvalualr<l The oJdVar'ta!fe of 1"'.....S
in!h'S � � � that � � � � � � � � � � � � � � � doe root
� 10 � � � � I or bus cbnat � � � � � � � �
Elample A - shouldel
A 7-1-H>,u-old � � � � � � � woman, bcGlU>e ()f � � � � � � � � �
� � � � � � � � � � and dJ...;coI;,fort'. had be"" ul\olble either to
tt>rnb � � � hair or Il'ach fa, eI1OUj;h behind her b.1ck to
do up he, brn»iere for 6 wl."'ks, She � � � � h;>ld dUlIlhe
only � � � � � � � � � � � vpcn to her were 'm"jor surgery' or to
'put up with if, She � � � � � � � � � S,nter}'. � � � � � � � � 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 � � � � � � � � � � "'liS
'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 � � � � � � p"in on Sllrtch,nl/- and considerable
rainless d".. CI'll"tus dunng .tel;'"" mo'"emenls. Whenmo, 00 passnely with the j;!mohulTM'....1joinl � � � � � � �
c«npres5ed, cnepituS w'"" � � � � and dlSa)mfur1
(not "",in).,.as plO\"okd. mar to t"" � � � of l>} mp-
loms 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
� � � � � � � � � � It would be unroiIli:<tk to lhink 1....1
these radiok.g;cai chanj;f:S could � � oca,Tn'd o,-er
the6-weck period, "nil In fact lho;oy It' more h1<l'I.y 10
be 'eI)' long-standinl( although her spnptoms "-ere
retati"ely n'«'llt On cJiniCIII eJ<aminal;{\(\, her problem
was an ·end..,f ranr,.,· pmbk'm ralherthan a "throu,,'"h·
range' (gr....., 05tCQo1rmri!isj problt-m Her shoulder
responded qUJIt' Sdtisfactoril)' to mobilintion, rej:;ai""
j"b 'Is � � � � � � � � � � � � � � � � � � � � � � ,.talc
Examplt B - ctrvical spine
F'gul"(' � � � � � � � � � � th" radiograph nf lhe cer"kal spine of
a woman aged 73, l'ilrs. who hlld neck symptoms fol-
1m, ing a Ian 3 " .."'\Q; pre' '''u>ly. Sh" hod not h.,d an)'
ll<:'O:k symplom,.......t 0'....."11 � � day of ....'Ck stiffflO'S».
prior to this incidl."I1t. She alro l\."<f'OT'ded ,et}.
favour"bh' to � � � ",,_,ern,,',,1 tre'<ltrnent. 'I'hll.must
nwan 1....1 a IJCr.lQIl <:.m d<.... dup gm;.s rad'ological
chang..., and ho"e ro... potn. C""'·l'1Wly, il can also be
said that a pt"r"OIl C.1l "-In> S{'''',,' symptoms ",Ihout
.... � � � � any rad'<.>!ogic"l ch.J,'S'-....
AptfYlfl <:.n have 9'0\6 laddogN;;ll cha"9l" but h;m,
� � � � � � � � � � � � � � � � � � � � � � � � �
Tho> <:eIYical splI\i! "'-'pllrt wos ",. folio... '"
TlIt' � � !!1m... i!. ttm"f'll 011"....-10 I/r r<gl"_
Thtrt i:; "",It" IrUlrl.Nfllrl....orarrgtrl.lllioll a' C4-5
:rill! .;J'g/,I Qulmor $JI/!I'l)aI;c>tJ t1{Cl 0" C5. WIUI
j10:iOll/!J(" it; � � � � � � IVilerNrwbl,,;mIw.1 alC)Q"
C4. Tilt'" is "nrmrl'mg of111/ II... ;l1lmnlrol1l1 dISC
SjJ<lc/'S 1",1ln<1 C1, bm IlIis is IIII"t I'mlwllIlCl'dQt
C5----6 111.1 C6-i. � � � � � � � � � � � � � � � � � � � � � � � � /I,.,' ",..irln,1 i"
tI", 'j"CQ('i'Tlrbrnl � � � � � Irdm,' Uri' Inri c(Cl/J/!"lrrolly
TlI<'rc is i'IICI"OrKhmCIII,m Ilw il1lmwtcbml forQwi,w
0" II,,, lefl $jd" III Cl-J. CJ-lllIIJ 0-5. C5----6
Till''''' is 5<'1111 Ilsyml""I'¥ of Ille � � � � � � � � � � fiu"'1
cfCl: l!lis is porliwlarly "<elllll/ltdfor by roM/wn
Introduction 9
figu,,", 1.5 RadI09'" 0'
=-iC3 � � � � � � itl Exo...
� B..
CcnO<uI.,:tm:
� � � rl... curl..I",,, � � � � � � � � � � � � � � � � � � � � lmp$<jort
Xn-rr th).vtlrnrtrrlt' � � � � � ...>e; in rlr � � � � � � � � � � � � � Il!'
� � � � � � � � � \\",7< r/!,rrIl'Il/ prtrivu; in'''1)/1
APPROPRIATE WORDING
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;; � � � � � � � � � � � and � � � � � � plnces
"""ther dem"ird on the manipulati,,, pll)";;;olh",.'p;;;t.
who mu;;1 employ a � � � � � � � � pattern of IhinkinK � � � � �
""lu,l"\"5 "cry can>iul oeleoction of the \\(1rds aoo
phras.s ",,--.I "hoen "''''.:lking o. "-"COrdmg in wriling.
Tht> phraseolog:.· on(' uses sIlo,,-, dean) lhoe way one is
thm)..mg.. and Iherd,,", If, for e=mpJr.>. !he :>polen
phra:>e:<; aao wHaled � � � � � � � � the lhinkins behind
IIwm Must ...Iso be wrong.
It is tumtial to � � � � � � � apP"lI'riale wo,d'rl!I.
as t!1IS will ir,f1l,1tnct tilt t!1 nkirg � � of ttlt
pnysiotherapi'l
A ""'rle .'>.ampl" rna" help to make mi. point c1eu.
� � � � � � � � a physiothcTilpi.>! pre5<!nling a I"'ht'fll, Mr X.,
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 � � � � of � � � � � 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
� � � � � � � � � � � � � � � � � � � � � � � � � � dnd ',Ii"ical � � � � � � � � � � � � � � � �
comp.1rtmeJlt,;-s,,", should So'}' 'p.1in in tllis/"m'" hill'
� � � � � � � � � � � � � � � � � ..... ""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 � � � � � 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 � � � of the 5ilCfOiliIK joint.
And this is the imporu.nt el<!:rnent,.and.ln essenli.ll OIW
of Ille COIlClV'-
f.1..1ny reackTS IN)' bodie"e NI alll:f\tion 10 thi§
kind 01 do!tail is qUIte unnecess,a'J QuIl1l! the opposite
is lnJe' if theCOf'T'l"Cl chota:! oj ",'i\fd,.,; m.>de \\,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 � � � � � � � � � � � � � � � � � � � � � � � �
p<m'ol<.>d by \cfllateral � � � � � � � � 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 � � � � � lest
,'n." normal••",d tllene ,'n." nn � � � � � � � � � dlangiS.
(A",lI" PA pn.."",ure on bolh l.-t and L5 pro"ok" det'p
<n>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' � � � � ink"",td,.,.11 di"<C" bulglllgposter-
iOTI)' on Ihe left .,d". � � � � � � � � ,mt"t",n of the
fifth hl1nb"r "en'e root.
� � � � demimSlr,1tL"l II very linl,h'd ,lppro.,ch. Thl' nl',t
question rnif;ht b,,; '\\,11,11 would you du in "n � � � � � � �
� � � � � � him beller?'
A2. Iwpuld � � � � � � � � � � � � � � � � � � to try to � � � � � � � � � � � � � � 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 � � � � � � � 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
A2. I would inil..ny u"" � � � � � pas6I\'1! mD>1!-
menl � � � � � in an rifort I(> hnpro-.e h,s
..rc on flexion, and impftwc rangcs of I('ft 1::11-
eral /le>;iQn and rotation At IhI! ,,'me lime I
"ouki hope Kx a l\.'d1lCrion in the ",,'enty of
Llw rclcrred pain. ConlinUilI � � 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.<rt, I will ptUbabl}
finish up with mcwement ll:'dmi<fu<.'" ...-hich
lIlo·.-e mw poun,luns d,n."Chon,.
LISTENING
It '" exlraonhnary how oI'ten doctur5 and pll)'SKMhcr.
aplSls {in fact aD � "-00 dea.I with peorItl do not
listen, nor listen � � � � � � � � � � � � � � � � nor \;,;"", "''I>Sltl\'dy
enough. nor listen al sufflOl!fll depth. 10 thell pabents.
u;/rni"K ii..,,;,//. of � � � � � � � � � � � 111111 is rllrl'f! il
.:tftr's � � � � � � � � ""'""'Il' HIVrillS Iii pawt't';
lis/millS islJdirr.lkan,,'Il' IS "rro/lllll"ry; lislt1l/1'S
dnrUl'W; .lfnl!;"". HrIlrm!: is .Ullund; � � � � � � � � is
"" tJO{l,irrrJ Jisd,,,,,,,,. (The- Ag«, 21 Aug.... 19S2.)
11IeIe 's;;o much 10 \e.lm about l)'lt,enl:<' � � � � � � � � � ,f
onl)' we ",ill hstt.'J1 11"s is � � � � � � � rete',l11t when ,I
is belie\'ed thai I.... � � � � � � � � � � bodies (an tell them
Ihlllgs lhal we can onl}' dl5Co"er by � � � � � � � � � � � to their
COIlHT\("I.tS. Our nllnds h.....• to be fn..'I:' nowlIlg. able to
be dinxted. n'directl'd or innuenad by sublle com-
� � � � � lhal I"" patient may � � � � as a pa"lIl!; remark
We must be good � � � � � � � � � � � ,,"d "'" must bdin.,.
patienl" subtle comments o..... � � � � � � Also. � � � �
such a remark has OC'L'J1 made, which innUenCl'S our
!lul\k'O\g, the � � � � � � � � � � 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 � � � � � � � � � 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
lind, picking up 'kC)' ....ords· and kno,vmg how 10
.".tabllSto good rapport. This subfect i5 � � � � � � "''1th in
dclail in Chap«'1" .3.
� � and underslAnding � � � � � � � � � � � � � b!, a!il<.
ing que<tio:lns based on bcl>l.... mg that Iheu body a.n
inform patH!nts aboul aspocts of their disorder that
caru..>! � fuund by "uminabon. � � � � � � � �
1. 'b II � � � � thlllg that is � � � � � � "hl(h i5 sore, or '" il
Just � from my treatmen,r
'1\.<>, it's nol a silly ql1C'oti"n to � � � � � � � � � � your
b.1(k problem could hal'e any CONll'Clion wilfl
� � � � � � � � � � IVhat ha"" y...u nOlked Ih,,1 g"'('S you
lhi, r"cling?'
3, 'We both a"....", 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 � � � � � 'I doesn't � �
� � � � � � � � � or on "hat "ay il ,sn'l better?'
lnIorm.lllon gained b> such qllC!>I1OJ'un" can "",·e..1
'n'i1h.....ble mfonnalion.. � � '''list I,,,,,,,, . .,... m..<l ,....7rl>.
.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..> � � � � � � � � of
c1u>iclans ,,"" familiar Fo< e>:ample, in the � � � � � � � � � � �
li,r of aspt'Cts imporlanllo e""mHl.ltion. t....o