Orthopedic Manual Therapy—An Overview Part I: The Extremities
Part 1 of an introductory overview of orthopedic manual therapy is presented, covering evaluation and treatment of the extremities. The first section defines introductory concepts about passive movement, including types of movement, limitations of movement, and types of treatment movements. The remaining four sections cover general concepts, evaluation schemes, and treatment procedures of four practitioners belonging to different schools of thought in orthopedic manual therapy: James Cyriax, MD, MRCP; Freddy Kaltenborn, DO, RPT; Geof frey Maitland, MAPA, FCSP; and John McM Mennell, MD. The conclusion stresses the importance of developing skills in evaluation, as well as treatment, prior to practicing orthopedic manual therapy. Key Words: Examination, Orthopedics, Physical therapy, Rehabilitation.
The age of specialization is upon physical therapy, as evidenced by the many special interest groups. One special interest is orthopedic manual therapy, which is "the study of anatomy, mechanics and pathology as well as the application of evaluative and treatment techniques of the neuromusculoskeletal system." 1 Functionally speaking, orthopedic manual therapy refers to the evaluation and treatment of joints and their surrounding structures to relieve pain, increase or decrease mobility, and prevent recurrence of pain." The treatment techniques include various forms of active and passive exercise and techniques for treating soft tissues, such as friction massage. Physical therapists obtain instruction in orthopedic manual therapy in the United States primarily by attending short courses offered by various practition ers of the subject. This system has its disadvantages. First, no short course covers the richness of material
Mrs. Cookson was a candidate for the degree of Master of Arts in Physical Therapy from Stanford University, Stanford, CA 94305. at the time this paper was written. Her current address is 5919 Moon Dance, San Antonio, TX 78238. Ms. Kent is an Adjunct Professor and Clinical Coordinator at Stanford University. This manuscript was submitted November 8, 1977, and accepted May 25, 1978.
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available in the field; consequently, participants may be left with a piecemeal view of orthopedic manual therapy. Differences in vocabulary exist between the main schools of thought, and while established prac titioners may transpose their thoughts between sys tems, beginners may remain hopelessly confused. To our knowledge, no educational system has combined the various schools of thought into a single integrated system. Second, orthopedic manual therapy is in danger of becoming a technical skill in the procedures used by the physical therapist. Because of the lack of inte grated course work, a therapist may attend a course on technique prior to taking one on evaluation skills. The beginner, then, may know how to perform a particular technique, but not when to use it. Ignorant application of technical manual skills is a detriment to physical therapy as a profession and threatens the safety of the patient. The purpose of this article is to define and clarify the basic concepts of orthopedic manual therapy by comparing the general concepts, evaluation schemes, and treatment procedures of James Cyriax, MD, MRCP; Freddy Kaltenborn, DO, RPT; Geoffrey Maitland, MAPA, FCSP; and John McM Mennell, MD. The material presented is introductory and the
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JANET C. COOKSON, MA, and BARBARA E. KENT, MA
PHYSICAL THERAPY
specifics can be found in the publications and courses of these men.2"7 INTRODUCTORY CONCEPTS
Graded
\J IV
(v)
Mobilization
Fig. 1. Joint movement (physiological or accessory) during three types of mobilization through range of motion. [Adapted with permission from Paris SV: Joint Manipulation: The Spine and Extremities (course notes). Staten Island, Institute of Orthopedic Physical Therapy, 1974, p 288.J
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Before considering the concepts of the specific prac titioners, knowledge of several concepts in orthopedic manual therapy is necessary. Orthopedic manual therapy includes the evaluation and treatment of both joints and soft tissues: muscles, tendons, bursae, and ligaments. The term lesion refers to a pathological or traumatic discontinuity in these tissues.4'8 In examination or treatment, movement of a joint may be a physiological movement: movement of the joint in a direction in which the patient can voluntar ily move. The movement can also be an accessory movement: a normally occurring joint movement that cannot be reproduced by the patient and must be performed by the therapist.5 An example of a physi ological movement at the glenohumeral joint is shoul der flexion; an example of an accessory movement at the glenohumeral joint is the lateral distraction of the head of the humerus from the glenoid fossa. The accessory or physiological movement available may be normal, hypermobile (having more range available than normal), or hypomobile (having less range available than normal). The anatomical limit of joint range of motion is the cessation of normal motion because of the shape of the articular surfaces,
the influence of ligaments and Muscles, and the con tact or tension produced by extra-articular structures.9 A hypomobile joint demonstrates a pathological limit of range of motion.5 Such a joint has the capacity, but decreased capability, to reach its anatomical limit because of pain or tissue resistance occurring after the pathological limit has been reached. Passive movement performed by a physical thera pist to a joint needing treatment is termed mobiliza tion. A physiological or accessory movement can be performed within the pathological limit of motion, or it can be performed beyond the pathological limit, but it cannot exceed the anatomical limit of motion. Any passive movement performed within the patho logical limit of motion can be prevented by the vol untary muscular contraction of the patient.10 The movement may be a sustained stretch approaching the pathological limit.2'4 The distance the joint is moved into its total range of motion may be graded— divided into steps of increasing movement. The mo tion may be oscillatory: the therapist rhyth mically working the joint up to and away from the pathological limit of motion. Alternately, the thera pist may progressively push toward the pathological limit in a series of steps (Fig. I).10 Prevention of all these movements can occur by the muscular contrac tion of the patient. Mobilization beyond the pathological limit of mo tion consists of a small amplitude movement of rapid velocity that moves the joint to the anatomical limit
EXERCISE
PASSIVE / Traditional
/ l \
\ Mobilization
To Pat h o I o i \ z
/ \
Oscillation
T o ^ W ^a t o m i c
Assisted
Free
Isotonic
Is oto
Isometric
Resisted |
I s o t onic IsoK inemat ic
Limit
/ \
General
Specific
Fig. 2. Mobilization within the scheme of exercise. [Adapted with permission from Paris SV: Joint Manipulation: The Spine and Extremities (course notes). Staten Island, Institute of Orthopedic Physical Therapy, 1974, p 291.]
of motion so fast that the patient cannot prevent the movement from taking place.10 Such a movement may be specific or general. A specific mobilization of this type produces motion in only one joint, while movement in a general mobilization to the anatomical limit occurs in several joints. 10 Mobilization is a cat egory in the broad spectrum of exercise (Fig. 2). JAMES CYRIAX, MD, MRCP
Dr. Cyriax is a British physician in private practice whose courses are offered in the United States on announcement by the sponsoring institution.
There are many specific lesions in joints and soft tissues that are responsive to physical treatment. Joints are subject to arthritis caused by immobiliza tion, trauma, or disease; to pain and locking through internal derangement, such as a meniscus tear; and to fusion of parts of the joint's capsule, causing a cap sular adhesion. Pain in soft tissues is caused by in flammatory changes leading to abnormal scar tissue from minor muscle tears and tendon tears (tendinitis); by the irritation of a tendon within its sheath (teno synovitis); or by an acute ligamentous sprain, which may become chronic and have the ligament adhere to the joint and surrounding structures, preventing normal motion. 1
General Concepts General Scheme of Evaluation
In Dr. Cyriax's system of orthopedic medicine, making the correct diagnosis is essential to ensure that the proper tissue is treated. His work is based on three principles: 1. All pain arises from a lesion. 2. All treatment must reach the lesion. 3. All treatment must exert a beneficial effect on the lesion.4 He states that the chief obstacle in evaluating and treating musculoskeletal disorders is that the area of referred pain felt distal to the injury is treated rather than the tissue producing the pain. Referred pain is perceived distant from the actual site of the injury either along a predictable, segmental (dermatomal) reference pattern or along a nonpredictable, nonsegmental pattern. Pain from injuries to nerve roots and soft tissue is referred segmentally. Pain from compres sion of the spinal cord or the dura mater is referred nonsegmentally. Evaluation identifies the specific tis sue injured and ignores the confusing referred pain. 3 138
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Limit
Stretch
ACTIVE
After the history is taken, an "evaluation by selec tive tension" is performed. During this evaluation, the patient's affected extremity is moved through an exacting group of active, passive, and resistive physi ological motions. 11 The purpose is to determine whether a contractile or an inert structure is respon sible for the pain. Contractile structures include the muscle, tendons, and their attachments to the bone. Inert structures include joint capsules, ligaments, bursae, fascia, dura mater, and nerves. ! Subjective Evaluation
The subjective history informs the examiner about the onset of the pain and enables him to begin to locate the source. The therapist uses the history to determine the past and present behavior of the pain, any previous treatment and the results, and to help plan the examination.'* PHYSICAL THERAPY
Objective Evaluation
Interpretation of Evaluation
The interpretation of results of the passive motion determines whether joint capsule irritation (arthritis) is present. In arthritis, characteristic limitations in joint range of motion occur in predictable propor tions. For example, in arthritis at the elbow, there is usually more limitation of passive flexion than of extension. These predictable proportions are known as capsular patterns. Each joint under voluntary con trol has its own capsular pattern when arthritis is present (Tab. 2). Limitations of motion in proportions other than the listed capsular patterns indicate that arthritis is not the source of the pain, and suggest ligamentous or capsular adhesions, bursitis, or inter nal derangement in the joint.
TABLE 1 End Feel"
Description
End Feel Bone-to-bone
Spasm
Elastic stretch (Capsular feel)
Springy block Tissue approximation
Empty
The abrupt halt to movement when two hard surfaces meet A hardish feel imparted as muscles immediately and reflexly stop the motion A hardish arrest of move ment with some give, like a piece of thick leather being stretched A rebound felt at the end of the movement A soft arrest of movement as muscles contact one an other Considerable pain at some distance from the anatom ical limit with no feel of mechanical blocking
Example in a Normal Joint
Significance in Evaluation
Extreme of passive elbow ex tension
Anatomical limit of joint has been reached
None in normal
Acute or subacute arthritis, bony fracture
Extreme of passive hip and shoulder rotations
Arthritis
None in normal
Internal derangement of the joint No mechanical block present in the joint
Extreme of knee and elbow flexion None in normal
Suspect acute bursitis, extra-ar ticular abcess, neoplasm, hys teria, neurogenic hypertonus
Adapted from J. Cyriax.
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Objective inspection of the painful part and related structures is used to determine the presence of de formity, atrophy, swelling, and changes in skin color. The stationary part is palpated for temperature and swelling, and the moving joint is palpated for crepitus and clicking. Palpation of tissues specifically for pain production is avoided initially, as the referred nature of the pain may mislead the examiner. 3 During the evaluation movements, positive and negative signs are noted as well as the presence or absence of pain during movement. The same steps are performed during every evaluation to avoid com ing to a premature conclusion about the cause of pain. Testing active motion provides a general idea of the available range of motion and muscular power. This motion, however, will not allow the determina tion if an inert or contractile structure is causing the pain, because the joint motion involves both contrac tile tissues and inert surrounding structures. Passive movement of all physiological motions in dicates the state of the inert tissues, as no contractile tissues are brought into play aside from occasional stretching. Movements are performed by the exam iner, and the patient is encouraged to relax. Particular care is taken to move the joint as close to its anatom ical limit as possible. Slight additional stress, or over pressure, is applied to the joint at the end of its available range of motion. The end feel, or sensation imparted to the examiner's hand during this over pressure, is noted to be bone-to-bone, spasm, elastic
stretch, springy block, tissue approximation, or empty (Tab. 1). The relative ranges of physiological motion are compared with normal range of motion. Testing resisted motion gives information about contractile structures around the joint tested. A max imal contraction is performed against equal resistance so that no movement occurs. The joint is held near midrange, so that the other structures in the area are not stressed or pinched. Careful hand placement en sures that only one group of muscles is tested at a time. The presence of pain and weakness is sought. No accessory motions are tested aside from special passive tests to put tension on ligaments or to deter mine if tendons are being pinched. !
TABLE 2 Capsular Patterns of Selected Jointsa Pattern of Limitation
Sternoclavicular and acromioclavicular Shoulder
Pain at the extremes of range Given a limitation of abduc tion, there will be a greater percentage loss of external rotation and a lesser percentage loss of internal rotation More limitation of flexion than extension Equal limitation of flexion and extension More limitation of flexion than extension Gross limitation of flexion, abduction, and internal rotation; slight limitation of extension; and little or no limitation of external rotation Gross limitation of flexion; slight limitation of exten sion
Elbow Wrist Thumb and fingers Hip
Knee
a
Condensed from J. Cyriax.3
Four main findings are possible in examining re sisted movement; 1. Strong and painful: This suggests minor damage to a muscle or tendon. Passive movement in the opposite direction may also cause pain by stretch ing the contractile structure. 2. Painful and weak: This suggests a gross lesion, such as a bone fracture, or a partial tear in a muscle or tendon. 3. Painless and weak: This suggests either a complete rupture of a tendon or muscle, or a nervous system disorder such as a compressed nerve root or en trapment of a nerve. 4. Strong and painless: This suggests that either there is no detrimental lesion, or that it lies outside the musculoskeletal system.3 Treatment of Joint Pain
Treatment of the joint depends upon the diagnosis of the lesion and the acuteness of the pain. The aim of all treatment is to restore normal, pain-free move ment. The treatment of arthritis in a joint under voluntary control is to increase the mobility of the joint. An acutely painful limitation with a hard end feel cannot be treated by mobilization. The joint requires a ste roid injection to decrease inflammation. A chronic, less painful joint limitation is passively stretched, using a physiological motion sustained in the direc 140
Treatment of Soft Tissue Pain
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Joint
tion of the limitation. Arthritis at a joint not under voluntary control is immobilized to prevent laxity from developing.4 Various maneuvers are used when a noncapsular pattern is present, depending on the lesion. Accessory tests found in Cyriax's publications3'4 help to identify the lesion. Manual treatment is not used when bursitis is present; instead, the bursa is injected with steroids. A ligamentous adhesion limiting joint motion is first massaged deeply (deep friction massage) transverse to its length, and then the joint is mobilized by a phys iological movement to break the adhesion. A joint containing a loose piece of cartilage that can cause it to lock or give way is mobilized. The mobilization uses physiological and accessory movements com bined with joint distraction. Chronic joint laxity is treated by immobilization either by physical means or by the artificial production of adhesions by inject ing a sclerosing agent.4
Pain on resisted movement distinguishes a muscle or tendon lesion. The treatment aim is to maintain or restore normal mobility. Tendinitis and tenosynovitis may respond to an injection of a steroid or to the application of deep friction massage. The massage is delivered transverse to the tendon for 10 to 20 minutes at variable intervals during the week, depending upon the irritability of the tissue. Different tendons respond better to one treatment (steroid injection or deep friction massage) than to the other. Friction massage at the site of a chronic muscle strain mobilizes the adherent muscle fibers. Active isometric exercise with the muscle in the fully shortened position should follow. This isometric exercise is also done by the patient throughout the day and helps to maintain the increased mobility without further damaging the mus cle.4 FREDDY KALTENBORN, DO, RPT
Freddy Kaltenborn is a Norwegian physical ther apist belonging to a Scandinavian movement in or thopedic manual therapy. General Concepts
In treating peripheral joint and soft tissue lesions, many Scandinavians have adopted the etiological philosophy of Dr. Cyriax, treating the specific lesions found by evaluation. Successful trial treatment of the involved tissue assists in determining the final diag nosis.2 PHYSICAL THERAPY
Subjective Evaluation
During the case history (the subjective evaluation), the patient describes his pain: its location, its charac ter, when it started, any accompanying symptoms, and what influences it. Secondly, a "previous history" is taken, which notes the following: the prior treat ment given for the problem, the actions relieving the pain, the patient's general health, and the presence of any similar or related symptoms.
The objective tests are included under the title of "present status" and include: inspection, function (movement tests), palpation, neurological tests, and additional examinations if warranted. Inspection in cludes observation of general movements, posture, body shape, skin condition, and the use of aids such as a cane or corset. General movement tests, including active, passive, and resisted motions, are performed and are analyzed as described by Cyriax.3 Specific accessory movements of traction, compression, and gliding at the joint are also inspected. A correlation between the test findings and the patient's complaints is sought. Neurological tests will be described in Part 2 of this article. Additional examinations are reviewed when indicated, including results of radiography, lab oratory tests, electrodiagnosis, and other tests done by appropriate medical personnel.2 Interpretation of Evaluation
The examiner summarizes his findings, noting the signs and symptoms found. Analysis of the tests of general movement determines whether the lesion is in the joint, muscles, or nerves, or whether it is related to the circulatory system, the autonomic nervous system, or the patient's psychological state. Analysis of the specific accessory movement tests determines the biomechanical diagnosis of a pathological joint. If a treatable lesion is present, a preliminary diagnosis is made and a gentle trial treatment is given.2
Treatment of Joint Pain
A joint may be found to be hypermobile or hypomobile. The treatment of the hypermobile, lax joint, is to stabilize it; treatment of the hypomobile, stiff joint, is to mobilize it. As a joint moves and the joint surfaces slip over one another, a certain amount of gliding (another accessory motion) takes place. A joint with limited range of motion caused by capsular tightness has lost Volume 59 / Number 2, February 1979
Position
Upper Extremity Joints Glenohumeral Humeroulnar Humeroradial Radioulnar Radiocarpal Intercarpal First carpometacarpal Metacarpo phalangeal Interphalangeal
Combined abduction and exter nal rotation Full extension Halfway between pronation and supination Halfway between pronation and supination Full extension Full extension Full opposition of thumb Full flexion Full extension Position
Lower Extremity Joints
Full extension with internal ro tation Full extension with the tibia ex ternally rotated on the femur Full dorsiflexion Combined dorsiflexion and in version
Hip Knee Talocrural Talar
"Adapted from M.A. MacConaill. 14
this glide, and mobilization consists of restoring the normal glide between joint surfaces. The therapist must know which joints are ovoid and which are sellar to evaluate joint limitation and to determine the direction of the mobilization. He must know the location of each joint's close-packed and open-packed positions to determine the position of mobilization (Tab. 3). These arthrokinematic terms have been defined by M.A. MacConaill. According to MacConaill, there are two basic types of joints: TABLE 4 Classification of Selected Jointsa'h Ovoid Joints Glenohumeral Humeroradial Proximal radioulnar Distal radioulnar Metacarpophalangeal Hip Proximal tibiofibular Metatarsophalangeal Interphalangeal (lower extremity)
Sellar Joints Sternoclavicular Humeroulnar First carpometacarpal Interphalangeal (upper extrem ity) Talocrural
a The acromioclavicular, intercarpal, and knee joints are structurally classified as sellar joints, but functionally behave as ovoid joints. h Condensed from F. Kaltenborn 2 and Warwick and Wil liams."
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Objective Evaluation
TABLE 3 Common Close-packed Positions of Selected Joints'1
* t F I X . f n MOBIL.
CONVEX
RULE-
Mobilize in direction opposite restricted motion
T
Restricted notion
^
Direction
J
of
i1 1 d i ni
mobiiizatii Gliding
motion
in
joint
CONCAVE
T
RULE-
Mobilize in same direction as restricted motion Fig. 3. The convex/concave rule. (Permission to adapt and reprint from FM Kaltenborn. 1 )
ovoid, where one joint surface is concave and the other surface convex, and sellar, where each joint surface is both concave and convex (Tab. 4). There are two basic articular positions: close-packed and open-packed. The close-packed position is the unique position of the joint where the joint's surfaces are completely congruous, the capsule and ligaments are maximally taut, and the two bones cannot be sepa rated by traction. The open or loose-packed position is any other position of the joint where the joint surfaces are not congruent and the ligaments are loose. The maximum loose-packed position is the resting position, which is the optimal position for obtaining distraction and movement during tests and treatment procedures. 12,13 Familiarity with the moving bone's articular shape (in an ovoid joint) enables the therapist to use the convex/concave rule to mobilize in the proper direc tion (Fig. 3). For example, if there is limitation in shoulder abduction, mobilization would depress the humerus in the opposite direction to the limitation, since the humerus is convex (convex rule). If there is limitation in knee flexion, mobilization would glide the tibia in the same direction as the limitation, since the tibia is concave (concave rule). 13,14 Longitudinal traction is an integral part of joint mobilization. There are three stages of traction. Stage One traction (also termed "piccolo") neutralizes the pressure within the joint without separating the joint surfaces. This stage of traction may be applied in conjunction with many mobilization movements to avoid trauma to the joint being mobilized. Applied alone, Stage One traction is used for pain relief. Stage
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Treatment of Soft Tissue Pain
Treatment of many soft tissue lesions follows Dr. Cyriax's treatment methods. Deep friction massage may be applied to muscles and tendons. The propri oceptive neuromuscular facilitative method of holdand contract-relax is used, sometimes in conjunction with passive stretching, to reduce the tension in the muscles and other connective tissue in preparation for mobilization. Passive stretching is also used for muscular contracture. Patients are taught pertinent exercises to maintain their mobility. 2 GEOFFREY MAITLAND, MAPA, FCSP
Mr. Maitland is an Australian physical therapist whose approach is currently being taught in the United States and Australia. General Concepts
Mr. Maitland has a nonpathological orientation to the treatment of all joints, basing the treatment on the signs and the symptoms of the patient. To quote Mr. Maitland: Such a plan avoids both the confusion caused by diagnostic titles calling to mind different symptoms to different people, and the controversy over pathology.10
Except in rare instances, no specific lesions in joints or soft tissues are described, although Mr. Maitland has illustrated the use of the system for some of the PHYSICAL THERAPY
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FIX. DyMOBIL.
Two traction separates the joint surfaces, taking up the slack in the joint as allowed by the soft tissues, and relieves pain. Stage Three traction is stronger and consists of a distraction that stretches the soft tissues about the joint. Joint mobilization to the pathological limit is pri marily specific; however, mobilization to the anatom ical limit is used. Stretching techniques were devised to localize the stretch to the tightened portion of the joint capsule and the surrounding soft tissues. The movements consist of either sustained stretching of accessory movements being applied under some trac tion or distraction of the joint surfaces. Straps may be used to stabilize the joint so the therapist can use both hands to apply the stretch. After treatment by mobi lization, exercises to maintain the mobility are given to the patient. 2 Hypermobile joints are treated by supportive splints and strapping, often in conjunction with injec tions for sclerosing the tissue. Patients are taught exercises to improve joint stability.
more commonly agreed-upon diagnoses. 15 The changeable signs and symptoms of the patient guide the therapist in varying the treatment technique.
PAIN Initial questions before asking the more direct q u e s t i o n s Is I I c o n s t a n t ? (qualify)
General Scheme of Evaluation YES Does it vary in intensity?
1. When do you g e t i t ? 2. Do you have some every day? 3. 4.
What brings it on? A s s e s s how s e v e r e i t i s ; n u i s a n c e value or limiting.
5 . How long d o e s it l a s t ? 6 . What helps to e a s e i t 9
Subjective Evaluation
YES What makes it worse? How long d o e s it l a s t ?
During the subjective examination the specific area of pain, its quality, and any paresthesia or anesthesia are recorded on the body chart (Fig. 4). The patient is asked how the pain behaves throughout the day (Fig. 5). Functional activities that are limited are marked with an asterisk. Subjective improvement is followed by objectively comparing the progress of these asterisk signs from one treatment to the next. One such activity is explored in detail to determine both the severity of the pain produced by the activity and the length of time after the activity during which the increased symptoms persist. Other special ques tions are included to determine treatment precautions. A detailed past and present history is also taken (Fig. 6).
Fig. 4. Body chart.
Volume 59 / Number 2, February 1979
F requency?
NO
7 . How long can you be free? Do you mean nothing makes it worse no matter what you do?
Fig. 5. Pain flow chart. (Reproduced with permission of the author and publisher?)
Objective Evaluation
The therapist plans the objective examination, us ing the subjective information. The novice is encour aged to record his plan for the objective examination to avoid omitting pertinent tests. Criteria determining the vigor of the objective evaluation include the ther apist's own subjective assessment of the severity and irritability of the pain, derived in part from details about the functional activities, and the nature of the pain (such as signs of osteoporosis or imminent nerve compression, and the frequency of recurrent epi sodes). The objective examination includes examina tion of: 1. Joints that lie under the painful area, 2. Joints that refer pain into the area, and 3. Muscles that lie under the painful area. 6 The presence of pain, spasm, and resistance throughout joint range of motion is noted during the objective examination. After observing the patient's willingness to move, the therapist asks the patient to perform active (physiological) and static resisted tests. Other joints that can refer pain into the area in question are examined to determine if the pain is being referred from other areas. Passive physiological movements are performed, noting the behavior of pain, spasm, and resistance during the motion. Ac cessory movements of the joint are performed. The 143
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A meticulous examination is essential to this method, because the examination provides the guide lines to treatment. Correlation of pain, stiffness, and spasm during active and passive physiological mo tions and during accessory motions will determine how gentle or vigorous the evaluation need be. The main elements of the evaluation are the subjective examination and the objective examination. 6
HISTORY PRESENT HISTORY When did it s t a r t
to another, requiring a change in the treatment pro cedure. 5 Treatment of Joint Pain
Dividing Mr. Maitland's procedures into those di rected to joints and those directed to soft tissue is difficult because of his nonpathological orientation to evaluation and treatment. In practice, all treatment is directed to joints. what happened what noticed f i r s t (injuring movement) (pain, stiffness) Oscillatory movements constituting mobilization are divided into four grades: d e g r e e of immediate pain predisposing f a c t o r s I: Small amplitude movement in the beginning of the I I progress s i n c e progress since range of motion, II: Large amplitude movement within the range of (1) R e l a t e s e v e r i t y of i n c i d e n t to d e g r e e of d i s a b i l i t y for motion, comparability ( s e r i o u s pathology). III: Large amplitude movement up to the end of the (2) History of l o c a l pain compared with history of referred p a i n . range of motion, and (3) P r o g r e s s over i n i t i a l period t i l l " l e v e l l i n g o f f " of symptoms. IV: Small amplitude movement up to the end of the range of motion (Fig. 1). Fig. 6. Present history flow chart. (Reproduced with Grade I and II movements are used for the reduction permission of the author and publisher. ) of pain, and Grade III and IV movements are used to increase range of motion. Mobilization movements include both physiological and accessory movements. area is palpated for temperature, swelling or wasting, Mobilization to the anatomical limit of joint range is relevant tenderness, and altered sensation and posi used infrequently, because most peripheral mobili tion. During the active movements a minimum of one zation takes place within and up to the pathological comparable sign is sought and noted with an asterisk. limit of the joint. Accessory movements and physio A comparable sign is a motion, or a combination of logical movements of Grades I and II are used to motions, that reproduces "the" pain or "the" stiffness. treat the painful joint. Physiological movements of Combined motions that maximally stress joints are Grades III and IV are used to treat the stiff, painless described and are labeled quadrant positions. If the joint. Combined (quadrant) movements are used to joint is highly irritable after one comparable sign has treat the joint with intermittent pain. After each movement, the patient is asked to per been found, the examination may stop. The treatment can begin using changes in this sign for assessing form the movement that produced the comparable treatment progress. Normally, several comparable sign. Mr. Maitland emphasizes the importance of using only one technique per treatment, especially signs are found. 5 ' 6 while the physical therapist is learning. The therapist then knows the exact reaction of the patient to the Interpretation of Evaluation treatment maneuver. If two separate maneuvers are The patient is placed into one of five groups, which used, the therapist doesn't know which maneuver had which effect on the patient. 5 aids in the choice of treatment technique: Group 1: Pain is the main consideration, and the limitation of movement is caused entirely by pain. Treatment of Soft Tissue Pain Group 2: Pain and joint stiffness are concurrent, and the intensity of pain increases in proportion to the Soft tissue lesions are treated by mobilization only increase in strength of resistance. to the extent that a comparable sign can be found. Group 3: Loss of movement is the main disability, The position of the patient in the grouping determines and pain is of little consequence. the treatment procedure. Group 4: Pain is intermittent and momentary, and movements appear to be full range. JOHN McM. MENNELL, MD Group 5: A diagnosis of internal derangement can be made. Dr. Mennell is an American physician whose Group position is not stationary. During the course courses on joint mobilization are offered by special of treatment the patient will change from one group request. How did it s t a r t
PHYSICAL THERAPY
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General Concepts
General Scheme of Evaluation
The purpose of the evaluation is mainly to rule out contraindications to treating the joint with passive movement. The evaluation correlates pain and stiff ness during active and accessory movements to deter mine the presence of treatable joint dysfunction.
Subjective Evaluation
During the subjective evaluation the patient is asked about the onset of the pain. Was it sudden? Gradual? Accompanied by trauma? The patient de scribes the nature or quality of the pain and how it behaves with activity and rest. As the patient locates the pain, patterns of referred pain are considered.'
Objective Evaluation
A traditional review of body systems is performed by a physician. Further objective tests include inspec tion of the body part in pain, palpation, observation of active physiological movements, evaluation of lab oratory and x-ray findings, and examination of joint play or accessory movements. Dr. Mennell describes nine rules for examining accessory movement. Care less breaking of these rules leads to damage of the joint. These rules are abbreviated as follows: 1. The patient must be relaxed and each aspect of the joint ... must be supported and protected from unguarded painful movement.... 2. The examiner must be relaxed ... the grasp that he uses must be firm and protective, but not restric tive. Volume 59 / Number 2, February 1979
Interpretation of Evaluation
Interpretation is based on the results of the subjec tive evaluation combined with the limitation of joint range determined by the objective evaluation. Joint dysfunction is present when the onset of pain was sudden and traumatic. Joint dysfunction is not pres ent if the joint is swollen and the onset was sudden and without trauma or if the onset was gradual. If many joints are affected at once, unless they have all been immobilized or traumatized together, joint dys function is not present. 7
Treatment of Joint Pain
If Dr. Mennell finds a particular motion limited because of joint dysfunction, he performs a "frac tional therapeutic" movement to restore the normal range of motion. In a therapeutic movement, the examiner uses a quick thrust that moves the joint rapidly just beyond the physiological limit of range but within the normal anatomical limit of motion of the joint. The noticeable increase of range of motion during treatment is an accumulation of the minute increases caused by the fractional movements. The mobilization is followed by muscular reeducation procedures to maintain the newly gained motion. Rules 1 through 7 for therapeutic movements are the same as those for examination. In addition: 8. The ... movement used is a sharp springing thrust... and must be differentiated from a force ful movement .... 9. The springing movement is imparted to the joint only after taking up the slack in the joint to the point of pain .... 10. In the presence of... clinical signs of... inflam mation no therapeutic movements ... should be undertaken. 7 145
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Dr. Mennell treats by diagnosis of joint dysfunc tion. Although his evaluation determines the amount of pain and limitation present in a joint, it does not assess muscle pain. Soft tissue pain is diagnosed by traditional medical examination and is not treated by mobilization. Dr. Mennell maintains that the joint pathology for which one mobilizes is joint dysfunction. This is "a loss of one or more movements of an involuntary nature which occur at any synovial joint." 7 These involuntary movements are labeled joint play and are accessory movements. Causes of joint dysfunction include: disuse, aging, immobilization, intrinsic trauma, and the resolution of a more serious injury or disease. 7,16
3. One joint must be examined at a time .... 4. One movement at each joint is examined at a time. 5. ... One facet of the joint being examined is moved upon the other facet of the joint, which is stabilized. 6. The extent of normal joint play can usually be ascertained by examining the same joint in the unaffected limb. 7. No forceful movement must ever be used, and no abnormal movement must ever be used. 8. An examining movement must be stopped at any point at which pain is elicited. 9. In the presence of obvious clinical signs of joint (or bone) inflammation or disease, no examining movements ... should be undertaken. 7
Treatment of Soft Tissue Pain
CONCLUSION
The general concepts, evaluation schemes, and treatment procedures of four schools of thought in orthopedic manual therapy have been presented. All practitioners include the same basic elements in their evaluation schemes (subjective/historical information and objective/movement information) arranged into different orders. The treatment techniques may vary.
Acknowledgement. The authors express sincere ap preciation to Robert Simpson, Linda Van Hoesen, and Eileen Vollowitz for their constructive editorial suggestions.
REFERENCES 1. Paris SV: The scope and future of orthopaedic physical therapy. Section of Orthopaedic Physical Therapy Newsletter 2(2):3-8, 1975 2. Kaltenborn FM: Manual Therapy for the Extremity Joints, ed 2. Oslo, Olaf Norlis Bokhandel, 1976, pp 2, 3, 13-16, 20-24 3. Cyriax J: Textbook of Orthopaedic Medicine: Diagnosis of Soft Tissue Lesions, ed 6. Baltimore, Williams & Wilkins Co, 1975, vol 1, pp 28-48, 61-91 4. Cyriax J: Textbook of Orthopaedic Medicine: Treatment by Manipulation, Massage and Injection, ed 8. Baltimore, Williams & Wilkins Co, 1971, vol 2, pp 1, 50-53 5. Maitland GD: Peripheral Manipulation. Woburn, MA, Butterworth (Publishers) Inc, 1970, pp 4, 22-25, 155-169 6. Maitland GD: The Peripheral Joints: Examination and Record ing Guide, ed 3. Adelaide, Australia, Virgo Press, 1976, pp 1-8 7. Mennell JMcM: Joint Pain: Diagnosis and Treatment Using Manipulative Techniques. Boston, Little, Brown and Co, 1964, pp 1-30, 134, 142, 151-153, 169-170 8. Dorland's Illustrated Medical Dictionary, ed 25. Philadelphia, W.B. Saunders Co, 1974, p 851 9. Barnett CH, Davies DV, MacConaill MA: Synovial Joints: Their Structure and Mechanics. London, Longmans, Green and Co Ltd, 1961, pp 208-218 10. Maitland GD: Vertebral Manipulation, ed 3. Wobum, MA, Butterworth (Publishers) Inc, 1973, pp ix, 67-71, 165-168
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Several therapeutic maneuvers are described for such soft tissue injuries as a torn common extensor tendon in the elbow or a displaced medial meniscus at the knee. For the temporary relief of myofascial pain and muscle spasm during muscular stretching, Dr. Mennell advocates the use of a vapocoolant spray. It is applied to the entire muscle, from origin to insertion, prior to stretching. After stretching, the patient is taught exercises to maintain the increased range.17 All other soft tissue techniques are the traditional treatments used in physical therapy such as heat, muscle reeducation, massage, and postural reeduca tion.7
Various techniques may bring similar results if the evaluation has been carefully undertaken and inter preted. These evaluations performed prior to treat ment keep orthopedic manual therapy from becoming a technical skill.4 No single school contains all of the possible treatment techniques. Variation in technique is acceptable from a therapeutic viewpoint. Omission of evaluation is not. We hope we have reduced the beginner's confusion that results from lack of information about orthopedic manual therapy and the experienced practitioner's confusion arising from differences in vocabulary among the schools of thought. Further clarification can only come from further education. The organized educational system for orthopedic manual therapy in the United States is still in its infancy. These systems of therapy must be further coordinated by developing long-term, clinically oriented postgraduate courses, in addition to orthopedics specialty areas in the master's degree programs.18"20
11. Cyriax J: Examination of the spinal column. Physiotherapy (London) 56:3-7, 1970 12. MacConaill MA: Joint movement. Physiotherapy (London) 50: 363-365, 1964 13. MacConaill MA, cited in Warwick R, Williams PL (ed): Gray's Anatomy: 35th British edition. Philadelphia, W.B. Saunders Co, 1973, pp 403-405 14. MacConaill MA, Basmajian JV: Muscles and Movements: A Basis for Human Kinesiology, ed 2. Huntington, NY, R. E. Krieger Pub Co, Inc, 1977, pp 34-38 15. Maitland GD: Relating passive movement to some diagnoses. Australian Journal of Physiotherapy 20:129-135, 1974 16. Mennell JMcM: Back Pain: Diagnosis and Treatment Using Manipulative Techniques. Boston, Little, Brown and Co, 1960, pp 23-29 17. Spray-Stretch for Pain and Muscle Spasm [Film]. Featuring Travell JG, Mennell JM. Distributor: Richard Lambert, 254 Cleveland, Mill Valley, CA 94941 18. Grieve GP: The post-graduate teaching of manipulation. Physi otherapy (London) 56:21-28, 1970 19. Paris SV: Letters to the editor: Crisis in clinical physical therapy. Phys Ther 52:1086-87, 1972 20. Stephens EB: Manipulative therapy in physical therapy curricula. Phys Ther 53:40-50, 1973
PHYSICAL THERAPY
Part 1 of an introductory overview of orthopedic manual therapy is presented, covering evaluation and treatment of the extremities. The first section defines introductory concepts about passive movement, including types of movement, limitations of movement, and types of treatment movements. The remaining four sections cover general concepts, evaluation schemes, and treatment procedures of four practitioners belonging to different schools of thought in orthopedic manual therapy: James Cyriax, MD, MRCP; Freddy Kaltenborn, DO, RPT; Geof frey Maitland, MAPA, FCSP; and John McM Mennell, MD. The conclusion stresses the importance of developing skills in evaluation, as well as treatment, prior to practicing orthopedic manual therapy. Key Words: Examination, Orthopedics, Physical therapy, Rehabilitation.
The age of specialization is upon physical therapy, as evidenced by the many special interest groups. One special interest is orthopedic manual therapy, which is "the study of anatomy, mechanics and pathology as well as the application of evaluative and treatment techniques of the neuromusculoskeletal system." 1 Functionally speaking, orthopedic manual therapy refers to the evaluation and treatment of joints and their surrounding structures to relieve pain, increase or decrease mobility, and prevent recurrence of pain." The treatment techniques include various forms of active and passive exercise and techniques for treating soft tissues, such as friction massage. Physical therapists obtain instruction in orthopedic manual therapy in the United States primarily by attending short courses offered by various practition ers of the subject. This system has its disadvantages. First, no short course covers the richness of material
Mrs. Cookson was a candidate for the degree of Master of Arts in Physical Therapy from Stanford University, Stanford, CA 94305. at the time this paper was written. Her current address is 5919 Moon Dance, San Antonio, TX 78238. Ms. Kent is an Adjunct Professor and Clinical Coordinator at Stanford University. This manuscript was submitted November 8, 1977, and accepted May 25, 1978.
136
available in the field; consequently, participants may be left with a piecemeal view of orthopedic manual therapy. Differences in vocabulary exist between the main schools of thought, and while established prac titioners may transpose their thoughts between sys tems, beginners may remain hopelessly confused. To our knowledge, no educational system has combined the various schools of thought into a single integrated system. Second, orthopedic manual therapy is in danger of becoming a technical skill in the procedures used by the physical therapist. Because of the lack of inte grated course work, a therapist may attend a course on technique prior to taking one on evaluation skills. The beginner, then, may know how to perform a particular technique, but not when to use it. Ignorant application of technical manual skills is a detriment to physical therapy as a profession and threatens the safety of the patient. The purpose of this article is to define and clarify the basic concepts of orthopedic manual therapy by comparing the general concepts, evaluation schemes, and treatment procedures of James Cyriax, MD, MRCP; Freddy Kaltenborn, DO, RPT; Geoffrey Maitland, MAPA, FCSP; and John McM Mennell, MD. The material presented is introductory and the
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JANET C. COOKSON, MA, and BARBARA E. KENT, MA
PHYSICAL THERAPY
specifics can be found in the publications and courses of these men.2"7 INTRODUCTORY CONCEPTS
Graded
\J IV
(v)
Mobilization
Fig. 1. Joint movement (physiological or accessory) during three types of mobilization through range of motion. [Adapted with permission from Paris SV: Joint Manipulation: The Spine and Extremities (course notes). Staten Island, Institute of Orthopedic Physical Therapy, 1974, p 288.J
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Before considering the concepts of the specific prac titioners, knowledge of several concepts in orthopedic manual therapy is necessary. Orthopedic manual therapy includes the evaluation and treatment of both joints and soft tissues: muscles, tendons, bursae, and ligaments. The term lesion refers to a pathological or traumatic discontinuity in these tissues.4'8 In examination or treatment, movement of a joint may be a physiological movement: movement of the joint in a direction in which the patient can voluntar ily move. The movement can also be an accessory movement: a normally occurring joint movement that cannot be reproduced by the patient and must be performed by the therapist.5 An example of a physi ological movement at the glenohumeral joint is shoul der flexion; an example of an accessory movement at the glenohumeral joint is the lateral distraction of the head of the humerus from the glenoid fossa. The accessory or physiological movement available may be normal, hypermobile (having more range available than normal), or hypomobile (having less range available than normal). The anatomical limit of joint range of motion is the cessation of normal motion because of the shape of the articular surfaces,
the influence of ligaments and Muscles, and the con tact or tension produced by extra-articular structures.9 A hypomobile joint demonstrates a pathological limit of range of motion.5 Such a joint has the capacity, but decreased capability, to reach its anatomical limit because of pain or tissue resistance occurring after the pathological limit has been reached. Passive movement performed by a physical thera pist to a joint needing treatment is termed mobiliza tion. A physiological or accessory movement can be performed within the pathological limit of motion, or it can be performed beyond the pathological limit, but it cannot exceed the anatomical limit of motion. Any passive movement performed within the patho logical limit of motion can be prevented by the vol untary muscular contraction of the patient.10 The movement may be a sustained stretch approaching the pathological limit.2'4 The distance the joint is moved into its total range of motion may be graded— divided into steps of increasing movement. The mo tion may be oscillatory: the therapist rhyth mically working the joint up to and away from the pathological limit of motion. Alternately, the thera pist may progressively push toward the pathological limit in a series of steps (Fig. I).10 Prevention of all these movements can occur by the muscular contrac tion of the patient. Mobilization beyond the pathological limit of mo tion consists of a small amplitude movement of rapid velocity that moves the joint to the anatomical limit
EXERCISE
PASSIVE / Traditional
/ l \
\ Mobilization
To Pat h o I o i \ z
/ \
Oscillation
T o ^ W ^a t o m i c
Assisted
Free
Isotonic
Is oto
Isometric
Resisted |
I s o t onic IsoK inemat ic
Limit
/ \
General
Specific
Fig. 2. Mobilization within the scheme of exercise. [Adapted with permission from Paris SV: Joint Manipulation: The Spine and Extremities (course notes). Staten Island, Institute of Orthopedic Physical Therapy, 1974, p 291.]
of motion so fast that the patient cannot prevent the movement from taking place.10 Such a movement may be specific or general. A specific mobilization of this type produces motion in only one joint, while movement in a general mobilization to the anatomical limit occurs in several joints. 10 Mobilization is a cat egory in the broad spectrum of exercise (Fig. 2). JAMES CYRIAX, MD, MRCP
Dr. Cyriax is a British physician in private practice whose courses are offered in the United States on announcement by the sponsoring institution.
There are many specific lesions in joints and soft tissues that are responsive to physical treatment. Joints are subject to arthritis caused by immobiliza tion, trauma, or disease; to pain and locking through internal derangement, such as a meniscus tear; and to fusion of parts of the joint's capsule, causing a cap sular adhesion. Pain in soft tissues is caused by in flammatory changes leading to abnormal scar tissue from minor muscle tears and tendon tears (tendinitis); by the irritation of a tendon within its sheath (teno synovitis); or by an acute ligamentous sprain, which may become chronic and have the ligament adhere to the joint and surrounding structures, preventing normal motion. 1
General Concepts General Scheme of Evaluation
In Dr. Cyriax's system of orthopedic medicine, making the correct diagnosis is essential to ensure that the proper tissue is treated. His work is based on three principles: 1. All pain arises from a lesion. 2. All treatment must reach the lesion. 3. All treatment must exert a beneficial effect on the lesion.4 He states that the chief obstacle in evaluating and treating musculoskeletal disorders is that the area of referred pain felt distal to the injury is treated rather than the tissue producing the pain. Referred pain is perceived distant from the actual site of the injury either along a predictable, segmental (dermatomal) reference pattern or along a nonpredictable, nonsegmental pattern. Pain from injuries to nerve roots and soft tissue is referred segmentally. Pain from compres sion of the spinal cord or the dura mater is referred nonsegmentally. Evaluation identifies the specific tis sue injured and ignores the confusing referred pain. 3 138
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Limit
Stretch
ACTIVE
After the history is taken, an "evaluation by selec tive tension" is performed. During this evaluation, the patient's affected extremity is moved through an exacting group of active, passive, and resistive physi ological motions. 11 The purpose is to determine whether a contractile or an inert structure is respon sible for the pain. Contractile structures include the muscle, tendons, and their attachments to the bone. Inert structures include joint capsules, ligaments, bursae, fascia, dura mater, and nerves. ! Subjective Evaluation
The subjective history informs the examiner about the onset of the pain and enables him to begin to locate the source. The therapist uses the history to determine the past and present behavior of the pain, any previous treatment and the results, and to help plan the examination.'* PHYSICAL THERAPY
Objective Evaluation
Interpretation of Evaluation
The interpretation of results of the passive motion determines whether joint capsule irritation (arthritis) is present. In arthritis, characteristic limitations in joint range of motion occur in predictable propor tions. For example, in arthritis at the elbow, there is usually more limitation of passive flexion than of extension. These predictable proportions are known as capsular patterns. Each joint under voluntary con trol has its own capsular pattern when arthritis is present (Tab. 2). Limitations of motion in proportions other than the listed capsular patterns indicate that arthritis is not the source of the pain, and suggest ligamentous or capsular adhesions, bursitis, or inter nal derangement in the joint.
TABLE 1 End Feel"
Description
End Feel Bone-to-bone
Spasm
Elastic stretch (Capsular feel)
Springy block Tissue approximation
Empty
The abrupt halt to movement when two hard surfaces meet A hardish feel imparted as muscles immediately and reflexly stop the motion A hardish arrest of move ment with some give, like a piece of thick leather being stretched A rebound felt at the end of the movement A soft arrest of movement as muscles contact one an other Considerable pain at some distance from the anatom ical limit with no feel of mechanical blocking
Example in a Normal Joint
Significance in Evaluation
Extreme of passive elbow ex tension
Anatomical limit of joint has been reached
None in normal
Acute or subacute arthritis, bony fracture
Extreme of passive hip and shoulder rotations
Arthritis
None in normal
Internal derangement of the joint No mechanical block present in the joint
Extreme of knee and elbow flexion None in normal
Suspect acute bursitis, extra-ar ticular abcess, neoplasm, hys teria, neurogenic hypertonus
Adapted from J. Cyriax.
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Objective inspection of the painful part and related structures is used to determine the presence of de formity, atrophy, swelling, and changes in skin color. The stationary part is palpated for temperature and swelling, and the moving joint is palpated for crepitus and clicking. Palpation of tissues specifically for pain production is avoided initially, as the referred nature of the pain may mislead the examiner. 3 During the evaluation movements, positive and negative signs are noted as well as the presence or absence of pain during movement. The same steps are performed during every evaluation to avoid com ing to a premature conclusion about the cause of pain. Testing active motion provides a general idea of the available range of motion and muscular power. This motion, however, will not allow the determina tion if an inert or contractile structure is causing the pain, because the joint motion involves both contrac tile tissues and inert surrounding structures. Passive movement of all physiological motions in dicates the state of the inert tissues, as no contractile tissues are brought into play aside from occasional stretching. Movements are performed by the exam iner, and the patient is encouraged to relax. Particular care is taken to move the joint as close to its anatom ical limit as possible. Slight additional stress, or over pressure, is applied to the joint at the end of its available range of motion. The end feel, or sensation imparted to the examiner's hand during this over pressure, is noted to be bone-to-bone, spasm, elastic
stretch, springy block, tissue approximation, or empty (Tab. 1). The relative ranges of physiological motion are compared with normal range of motion. Testing resisted motion gives information about contractile structures around the joint tested. A max imal contraction is performed against equal resistance so that no movement occurs. The joint is held near midrange, so that the other structures in the area are not stressed or pinched. Careful hand placement en sures that only one group of muscles is tested at a time. The presence of pain and weakness is sought. No accessory motions are tested aside from special passive tests to put tension on ligaments or to deter mine if tendons are being pinched. !
TABLE 2 Capsular Patterns of Selected Jointsa Pattern of Limitation
Sternoclavicular and acromioclavicular Shoulder
Pain at the extremes of range Given a limitation of abduc tion, there will be a greater percentage loss of external rotation and a lesser percentage loss of internal rotation More limitation of flexion than extension Equal limitation of flexion and extension More limitation of flexion than extension Gross limitation of flexion, abduction, and internal rotation; slight limitation of extension; and little or no limitation of external rotation Gross limitation of flexion; slight limitation of exten sion
Elbow Wrist Thumb and fingers Hip
Knee
a
Condensed from J. Cyriax.3
Four main findings are possible in examining re sisted movement; 1. Strong and painful: This suggests minor damage to a muscle or tendon. Passive movement in the opposite direction may also cause pain by stretch ing the contractile structure. 2. Painful and weak: This suggests a gross lesion, such as a bone fracture, or a partial tear in a muscle or tendon. 3. Painless and weak: This suggests either a complete rupture of a tendon or muscle, or a nervous system disorder such as a compressed nerve root or en trapment of a nerve. 4. Strong and painless: This suggests that either there is no detrimental lesion, or that it lies outside the musculoskeletal system.3 Treatment of Joint Pain
Treatment of the joint depends upon the diagnosis of the lesion and the acuteness of the pain. The aim of all treatment is to restore normal, pain-free move ment. The treatment of arthritis in a joint under voluntary control is to increase the mobility of the joint. An acutely painful limitation with a hard end feel cannot be treated by mobilization. The joint requires a ste roid injection to decrease inflammation. A chronic, less painful joint limitation is passively stretched, using a physiological motion sustained in the direc 140
Treatment of Soft Tissue Pain
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Joint
tion of the limitation. Arthritis at a joint not under voluntary control is immobilized to prevent laxity from developing.4 Various maneuvers are used when a noncapsular pattern is present, depending on the lesion. Accessory tests found in Cyriax's publications3'4 help to identify the lesion. Manual treatment is not used when bursitis is present; instead, the bursa is injected with steroids. A ligamentous adhesion limiting joint motion is first massaged deeply (deep friction massage) transverse to its length, and then the joint is mobilized by a phys iological movement to break the adhesion. A joint containing a loose piece of cartilage that can cause it to lock or give way is mobilized. The mobilization uses physiological and accessory movements com bined with joint distraction. Chronic joint laxity is treated by immobilization either by physical means or by the artificial production of adhesions by inject ing a sclerosing agent.4
Pain on resisted movement distinguishes a muscle or tendon lesion. The treatment aim is to maintain or restore normal mobility. Tendinitis and tenosynovitis may respond to an injection of a steroid or to the application of deep friction massage. The massage is delivered transverse to the tendon for 10 to 20 minutes at variable intervals during the week, depending upon the irritability of the tissue. Different tendons respond better to one treatment (steroid injection or deep friction massage) than to the other. Friction massage at the site of a chronic muscle strain mobilizes the adherent muscle fibers. Active isometric exercise with the muscle in the fully shortened position should follow. This isometric exercise is also done by the patient throughout the day and helps to maintain the increased mobility without further damaging the mus cle.4 FREDDY KALTENBORN, DO, RPT
Freddy Kaltenborn is a Norwegian physical ther apist belonging to a Scandinavian movement in or thopedic manual therapy. General Concepts
In treating peripheral joint and soft tissue lesions, many Scandinavians have adopted the etiological philosophy of Dr. Cyriax, treating the specific lesions found by evaluation. Successful trial treatment of the involved tissue assists in determining the final diag nosis.2 PHYSICAL THERAPY
Subjective Evaluation
During the case history (the subjective evaluation), the patient describes his pain: its location, its charac ter, when it started, any accompanying symptoms, and what influences it. Secondly, a "previous history" is taken, which notes the following: the prior treat ment given for the problem, the actions relieving the pain, the patient's general health, and the presence of any similar or related symptoms.
The objective tests are included under the title of "present status" and include: inspection, function (movement tests), palpation, neurological tests, and additional examinations if warranted. Inspection in cludes observation of general movements, posture, body shape, skin condition, and the use of aids such as a cane or corset. General movement tests, including active, passive, and resisted motions, are performed and are analyzed as described by Cyriax.3 Specific accessory movements of traction, compression, and gliding at the joint are also inspected. A correlation between the test findings and the patient's complaints is sought. Neurological tests will be described in Part 2 of this article. Additional examinations are reviewed when indicated, including results of radiography, lab oratory tests, electrodiagnosis, and other tests done by appropriate medical personnel.2 Interpretation of Evaluation
The examiner summarizes his findings, noting the signs and symptoms found. Analysis of the tests of general movement determines whether the lesion is in the joint, muscles, or nerves, or whether it is related to the circulatory system, the autonomic nervous system, or the patient's psychological state. Analysis of the specific accessory movement tests determines the biomechanical diagnosis of a pathological joint. If a treatable lesion is present, a preliminary diagnosis is made and a gentle trial treatment is given.2
Treatment of Joint Pain
A joint may be found to be hypermobile or hypomobile. The treatment of the hypermobile, lax joint, is to stabilize it; treatment of the hypomobile, stiff joint, is to mobilize it. As a joint moves and the joint surfaces slip over one another, a certain amount of gliding (another accessory motion) takes place. A joint with limited range of motion caused by capsular tightness has lost Volume 59 / Number 2, February 1979
Position
Upper Extremity Joints Glenohumeral Humeroulnar Humeroradial Radioulnar Radiocarpal Intercarpal First carpometacarpal Metacarpo phalangeal Interphalangeal
Combined abduction and exter nal rotation Full extension Halfway between pronation and supination Halfway between pronation and supination Full extension Full extension Full opposition of thumb Full flexion Full extension Position
Lower Extremity Joints
Full extension with internal ro tation Full extension with the tibia ex ternally rotated on the femur Full dorsiflexion Combined dorsiflexion and in version
Hip Knee Talocrural Talar
"Adapted from M.A. MacConaill. 14
this glide, and mobilization consists of restoring the normal glide between joint surfaces. The therapist must know which joints are ovoid and which are sellar to evaluate joint limitation and to determine the direction of the mobilization. He must know the location of each joint's close-packed and open-packed positions to determine the position of mobilization (Tab. 3). These arthrokinematic terms have been defined by M.A. MacConaill. According to MacConaill, there are two basic types of joints: TABLE 4 Classification of Selected Jointsa'h Ovoid Joints Glenohumeral Humeroradial Proximal radioulnar Distal radioulnar Metacarpophalangeal Hip Proximal tibiofibular Metatarsophalangeal Interphalangeal (lower extremity)
Sellar Joints Sternoclavicular Humeroulnar First carpometacarpal Interphalangeal (upper extrem ity) Talocrural
a The acromioclavicular, intercarpal, and knee joints are structurally classified as sellar joints, but functionally behave as ovoid joints. h Condensed from F. Kaltenborn 2 and Warwick and Wil liams."
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Objective Evaluation
TABLE 3 Common Close-packed Positions of Selected Joints'1
* t F I X . f n MOBIL.
CONVEX
RULE-
Mobilize in direction opposite restricted motion
T
Restricted notion
^
Direction
J
of
i1 1 d i ni
mobiiizatii Gliding
motion
in
joint
CONCAVE
T
RULE-
Mobilize in same direction as restricted motion Fig. 3. The convex/concave rule. (Permission to adapt and reprint from FM Kaltenborn. 1 )
ovoid, where one joint surface is concave and the other surface convex, and sellar, where each joint surface is both concave and convex (Tab. 4). There are two basic articular positions: close-packed and open-packed. The close-packed position is the unique position of the joint where the joint's surfaces are completely congruous, the capsule and ligaments are maximally taut, and the two bones cannot be sepa rated by traction. The open or loose-packed position is any other position of the joint where the joint surfaces are not congruent and the ligaments are loose. The maximum loose-packed position is the resting position, which is the optimal position for obtaining distraction and movement during tests and treatment procedures. 12,13 Familiarity with the moving bone's articular shape (in an ovoid joint) enables the therapist to use the convex/concave rule to mobilize in the proper direc tion (Fig. 3). For example, if there is limitation in shoulder abduction, mobilization would depress the humerus in the opposite direction to the limitation, since the humerus is convex (convex rule). If there is limitation in knee flexion, mobilization would glide the tibia in the same direction as the limitation, since the tibia is concave (concave rule). 13,14 Longitudinal traction is an integral part of joint mobilization. There are three stages of traction. Stage One traction (also termed "piccolo") neutralizes the pressure within the joint without separating the joint surfaces. This stage of traction may be applied in conjunction with many mobilization movements to avoid trauma to the joint being mobilized. Applied alone, Stage One traction is used for pain relief. Stage
142
Treatment of Soft Tissue Pain
Treatment of many soft tissue lesions follows Dr. Cyriax's treatment methods. Deep friction massage may be applied to muscles and tendons. The propri oceptive neuromuscular facilitative method of holdand contract-relax is used, sometimes in conjunction with passive stretching, to reduce the tension in the muscles and other connective tissue in preparation for mobilization. Passive stretching is also used for muscular contracture. Patients are taught pertinent exercises to maintain their mobility. 2 GEOFFREY MAITLAND, MAPA, FCSP
Mr. Maitland is an Australian physical therapist whose approach is currently being taught in the United States and Australia. General Concepts
Mr. Maitland has a nonpathological orientation to the treatment of all joints, basing the treatment on the signs and the symptoms of the patient. To quote Mr. Maitland: Such a plan avoids both the confusion caused by diagnostic titles calling to mind different symptoms to different people, and the controversy over pathology.10
Except in rare instances, no specific lesions in joints or soft tissues are described, although Mr. Maitland has illustrated the use of the system for some of the PHYSICAL THERAPY
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FIX. DyMOBIL.
Two traction separates the joint surfaces, taking up the slack in the joint as allowed by the soft tissues, and relieves pain. Stage Three traction is stronger and consists of a distraction that stretches the soft tissues about the joint. Joint mobilization to the pathological limit is pri marily specific; however, mobilization to the anatom ical limit is used. Stretching techniques were devised to localize the stretch to the tightened portion of the joint capsule and the surrounding soft tissues. The movements consist of either sustained stretching of accessory movements being applied under some trac tion or distraction of the joint surfaces. Straps may be used to stabilize the joint so the therapist can use both hands to apply the stretch. After treatment by mobi lization, exercises to maintain the mobility are given to the patient. 2 Hypermobile joints are treated by supportive splints and strapping, often in conjunction with injec tions for sclerosing the tissue. Patients are taught exercises to improve joint stability.
more commonly agreed-upon diagnoses. 15 The changeable signs and symptoms of the patient guide the therapist in varying the treatment technique.
PAIN Initial questions before asking the more direct q u e s t i o n s Is I I c o n s t a n t ? (qualify)
General Scheme of Evaluation YES Does it vary in intensity?
1. When do you g e t i t ? 2. Do you have some every day? 3. 4.
What brings it on? A s s e s s how s e v e r e i t i s ; n u i s a n c e value or limiting.
5 . How long d o e s it l a s t ? 6 . What helps to e a s e i t 9
Subjective Evaluation
YES What makes it worse? How long d o e s it l a s t ?
During the subjective examination the specific area of pain, its quality, and any paresthesia or anesthesia are recorded on the body chart (Fig. 4). The patient is asked how the pain behaves throughout the day (Fig. 5). Functional activities that are limited are marked with an asterisk. Subjective improvement is followed by objectively comparing the progress of these asterisk signs from one treatment to the next. One such activity is explored in detail to determine both the severity of the pain produced by the activity and the length of time after the activity during which the increased symptoms persist. Other special ques tions are included to determine treatment precautions. A detailed past and present history is also taken (Fig. 6).
Fig. 4. Body chart.
Volume 59 / Number 2, February 1979
F requency?
NO
7 . How long can you be free? Do you mean nothing makes it worse no matter what you do?
Fig. 5. Pain flow chart. (Reproduced with permission of the author and publisher?)
Objective Evaluation
The therapist plans the objective examination, us ing the subjective information. The novice is encour aged to record his plan for the objective examination to avoid omitting pertinent tests. Criteria determining the vigor of the objective evaluation include the ther apist's own subjective assessment of the severity and irritability of the pain, derived in part from details about the functional activities, and the nature of the pain (such as signs of osteoporosis or imminent nerve compression, and the frequency of recurrent epi sodes). The objective examination includes examina tion of: 1. Joints that lie under the painful area, 2. Joints that refer pain into the area, and 3. Muscles that lie under the painful area. 6 The presence of pain, spasm, and resistance throughout joint range of motion is noted during the objective examination. After observing the patient's willingness to move, the therapist asks the patient to perform active (physiological) and static resisted tests. Other joints that can refer pain into the area in question are examined to determine if the pain is being referred from other areas. Passive physiological movements are performed, noting the behavior of pain, spasm, and resistance during the motion. Ac cessory movements of the joint are performed. The 143
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A meticulous examination is essential to this method, because the examination provides the guide lines to treatment. Correlation of pain, stiffness, and spasm during active and passive physiological mo tions and during accessory motions will determine how gentle or vigorous the evaluation need be. The main elements of the evaluation are the subjective examination and the objective examination. 6
HISTORY PRESENT HISTORY When did it s t a r t
to another, requiring a change in the treatment pro cedure. 5 Treatment of Joint Pain
Dividing Mr. Maitland's procedures into those di rected to joints and those directed to soft tissue is difficult because of his nonpathological orientation to evaluation and treatment. In practice, all treatment is directed to joints. what happened what noticed f i r s t (injuring movement) (pain, stiffness) Oscillatory movements constituting mobilization are divided into four grades: d e g r e e of immediate pain predisposing f a c t o r s I: Small amplitude movement in the beginning of the I I progress s i n c e progress since range of motion, II: Large amplitude movement within the range of (1) R e l a t e s e v e r i t y of i n c i d e n t to d e g r e e of d i s a b i l i t y for motion, comparability ( s e r i o u s pathology). III: Large amplitude movement up to the end of the (2) History of l o c a l pain compared with history of referred p a i n . range of motion, and (3) P r o g r e s s over i n i t i a l period t i l l " l e v e l l i n g o f f " of symptoms. IV: Small amplitude movement up to the end of the range of motion (Fig. 1). Fig. 6. Present history flow chart. (Reproduced with Grade I and II movements are used for the reduction permission of the author and publisher. ) of pain, and Grade III and IV movements are used to increase range of motion. Mobilization movements include both physiological and accessory movements. area is palpated for temperature, swelling or wasting, Mobilization to the anatomical limit of joint range is relevant tenderness, and altered sensation and posi used infrequently, because most peripheral mobili tion. During the active movements a minimum of one zation takes place within and up to the pathological comparable sign is sought and noted with an asterisk. limit of the joint. Accessory movements and physio A comparable sign is a motion, or a combination of logical movements of Grades I and II are used to motions, that reproduces "the" pain or "the" stiffness. treat the painful joint. Physiological movements of Combined motions that maximally stress joints are Grades III and IV are used to treat the stiff, painless described and are labeled quadrant positions. If the joint. Combined (quadrant) movements are used to joint is highly irritable after one comparable sign has treat the joint with intermittent pain. After each movement, the patient is asked to per been found, the examination may stop. The treatment can begin using changes in this sign for assessing form the movement that produced the comparable treatment progress. Normally, several comparable sign. Mr. Maitland emphasizes the importance of using only one technique per treatment, especially signs are found. 5 ' 6 while the physical therapist is learning. The therapist then knows the exact reaction of the patient to the Interpretation of Evaluation treatment maneuver. If two separate maneuvers are The patient is placed into one of five groups, which used, the therapist doesn't know which maneuver had which effect on the patient. 5 aids in the choice of treatment technique: Group 1: Pain is the main consideration, and the limitation of movement is caused entirely by pain. Treatment of Soft Tissue Pain Group 2: Pain and joint stiffness are concurrent, and the intensity of pain increases in proportion to the Soft tissue lesions are treated by mobilization only increase in strength of resistance. to the extent that a comparable sign can be found. Group 3: Loss of movement is the main disability, The position of the patient in the grouping determines and pain is of little consequence. the treatment procedure. Group 4: Pain is intermittent and momentary, and movements appear to be full range. JOHN McM. MENNELL, MD Group 5: A diagnosis of internal derangement can be made. Dr. Mennell is an American physician whose Group position is not stationary. During the course courses on joint mobilization are offered by special of treatment the patient will change from one group request. How did it s t a r t
PHYSICAL THERAPY
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144
General Concepts
General Scheme of Evaluation
The purpose of the evaluation is mainly to rule out contraindications to treating the joint with passive movement. The evaluation correlates pain and stiff ness during active and accessory movements to deter mine the presence of treatable joint dysfunction.
Subjective Evaluation
During the subjective evaluation the patient is asked about the onset of the pain. Was it sudden? Gradual? Accompanied by trauma? The patient de scribes the nature or quality of the pain and how it behaves with activity and rest. As the patient locates the pain, patterns of referred pain are considered.'
Objective Evaluation
A traditional review of body systems is performed by a physician. Further objective tests include inspec tion of the body part in pain, palpation, observation of active physiological movements, evaluation of lab oratory and x-ray findings, and examination of joint play or accessory movements. Dr. Mennell describes nine rules for examining accessory movement. Care less breaking of these rules leads to damage of the joint. These rules are abbreviated as follows: 1. The patient must be relaxed and each aspect of the joint ... must be supported and protected from unguarded painful movement.... 2. The examiner must be relaxed ... the grasp that he uses must be firm and protective, but not restric tive. Volume 59 / Number 2, February 1979
Interpretation of Evaluation
Interpretation is based on the results of the subjec tive evaluation combined with the limitation of joint range determined by the objective evaluation. Joint dysfunction is present when the onset of pain was sudden and traumatic. Joint dysfunction is not pres ent if the joint is swollen and the onset was sudden and without trauma or if the onset was gradual. If many joints are affected at once, unless they have all been immobilized or traumatized together, joint dys function is not present. 7
Treatment of Joint Pain
If Dr. Mennell finds a particular motion limited because of joint dysfunction, he performs a "frac tional therapeutic" movement to restore the normal range of motion. In a therapeutic movement, the examiner uses a quick thrust that moves the joint rapidly just beyond the physiological limit of range but within the normal anatomical limit of motion of the joint. The noticeable increase of range of motion during treatment is an accumulation of the minute increases caused by the fractional movements. The mobilization is followed by muscular reeducation procedures to maintain the newly gained motion. Rules 1 through 7 for therapeutic movements are the same as those for examination. In addition: 8. The ... movement used is a sharp springing thrust... and must be differentiated from a force ful movement .... 9. The springing movement is imparted to the joint only after taking up the slack in the joint to the point of pain .... 10. In the presence of... clinical signs of... inflam mation no therapeutic movements ... should be undertaken. 7 145
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Dr. Mennell treats by diagnosis of joint dysfunc tion. Although his evaluation determines the amount of pain and limitation present in a joint, it does not assess muscle pain. Soft tissue pain is diagnosed by traditional medical examination and is not treated by mobilization. Dr. Mennell maintains that the joint pathology for which one mobilizes is joint dysfunction. This is "a loss of one or more movements of an involuntary nature which occur at any synovial joint." 7 These involuntary movements are labeled joint play and are accessory movements. Causes of joint dysfunction include: disuse, aging, immobilization, intrinsic trauma, and the resolution of a more serious injury or disease. 7,16
3. One joint must be examined at a time .... 4. One movement at each joint is examined at a time. 5. ... One facet of the joint being examined is moved upon the other facet of the joint, which is stabilized. 6. The extent of normal joint play can usually be ascertained by examining the same joint in the unaffected limb. 7. No forceful movement must ever be used, and no abnormal movement must ever be used. 8. An examining movement must be stopped at any point at which pain is elicited. 9. In the presence of obvious clinical signs of joint (or bone) inflammation or disease, no examining movements ... should be undertaken. 7
Treatment of Soft Tissue Pain
CONCLUSION
The general concepts, evaluation schemes, and treatment procedures of four schools of thought in orthopedic manual therapy have been presented. All practitioners include the same basic elements in their evaluation schemes (subjective/historical information and objective/movement information) arranged into different orders. The treatment techniques may vary.
Acknowledgement. The authors express sincere ap preciation to Robert Simpson, Linda Van Hoesen, and Eileen Vollowitz for their constructive editorial suggestions.
REFERENCES 1. Paris SV: The scope and future of orthopaedic physical therapy. Section of Orthopaedic Physical Therapy Newsletter 2(2):3-8, 1975 2. Kaltenborn FM: Manual Therapy for the Extremity Joints, ed 2. Oslo, Olaf Norlis Bokhandel, 1976, pp 2, 3, 13-16, 20-24 3. Cyriax J: Textbook of Orthopaedic Medicine: Diagnosis of Soft Tissue Lesions, ed 6. Baltimore, Williams & Wilkins Co, 1975, vol 1, pp 28-48, 61-91 4. Cyriax J: Textbook of Orthopaedic Medicine: Treatment by Manipulation, Massage and Injection, ed 8. Baltimore, Williams & Wilkins Co, 1971, vol 2, pp 1, 50-53 5. Maitland GD: Peripheral Manipulation. Woburn, MA, Butterworth (Publishers) Inc, 1970, pp 4, 22-25, 155-169 6. Maitland GD: The Peripheral Joints: Examination and Record ing Guide, ed 3. Adelaide, Australia, Virgo Press, 1976, pp 1-8 7. Mennell JMcM: Joint Pain: Diagnosis and Treatment Using Manipulative Techniques. Boston, Little, Brown and Co, 1964, pp 1-30, 134, 142, 151-153, 169-170 8. Dorland's Illustrated Medical Dictionary, ed 25. Philadelphia, W.B. Saunders Co, 1974, p 851 9. Barnett CH, Davies DV, MacConaill MA: Synovial Joints: Their Structure and Mechanics. London, Longmans, Green and Co Ltd, 1961, pp 208-218 10. Maitland GD: Vertebral Manipulation, ed 3. Wobum, MA, Butterworth (Publishers) Inc, 1973, pp ix, 67-71, 165-168
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Several therapeutic maneuvers are described for such soft tissue injuries as a torn common extensor tendon in the elbow or a displaced medial meniscus at the knee. For the temporary relief of myofascial pain and muscle spasm during muscular stretching, Dr. Mennell advocates the use of a vapocoolant spray. It is applied to the entire muscle, from origin to insertion, prior to stretching. After stretching, the patient is taught exercises to maintain the increased range.17 All other soft tissue techniques are the traditional treatments used in physical therapy such as heat, muscle reeducation, massage, and postural reeduca tion.7
Various techniques may bring similar results if the evaluation has been carefully undertaken and inter preted. These evaluations performed prior to treat ment keep orthopedic manual therapy from becoming a technical skill.4 No single school contains all of the possible treatment techniques. Variation in technique is acceptable from a therapeutic viewpoint. Omission of evaluation is not. We hope we have reduced the beginner's confusion that results from lack of information about orthopedic manual therapy and the experienced practitioner's confusion arising from differences in vocabulary among the schools of thought. Further clarification can only come from further education. The organized educational system for orthopedic manual therapy in the United States is still in its infancy. These systems of therapy must be further coordinated by developing long-term, clinically oriented postgraduate courses, in addition to orthopedics specialty areas in the master's degree programs.18"20
11. Cyriax J: Examination of the spinal column. Physiotherapy (London) 56:3-7, 1970 12. MacConaill MA: Joint movement. Physiotherapy (London) 50: 363-365, 1964 13. MacConaill MA, cited in Warwick R, Williams PL (ed): Gray's Anatomy: 35th British edition. Philadelphia, W.B. Saunders Co, 1973, pp 403-405 14. MacConaill MA, Basmajian JV: Muscles and Movements: A Basis for Human Kinesiology, ed 2. Huntington, NY, R. E. Krieger Pub Co, Inc, 1977, pp 34-38 15. Maitland GD: Relating passive movement to some diagnoses. Australian Journal of Physiotherapy 20:129-135, 1974 16. Mennell JMcM: Back Pain: Diagnosis and Treatment Using Manipulative Techniques. Boston, Little, Brown and Co, 1960, pp 23-29 17. Spray-Stretch for Pain and Muscle Spasm [Film]. Featuring Travell JG, Mennell JM. Distributor: Richard Lambert, 254 Cleveland, Mill Valley, CA 94941 18. Grieve GP: The post-graduate teaching of manipulation. Physi otherapy (London) 56:21-28, 1970 19. Paris SV: Letters to the editor: Crisis in clinical physical therapy. Phys Ther 52:1086-87, 1972 20. Stephens EB: Manipulative therapy in physical therapy curricula. Phys Ther 53:40-50, 1973
PHYSICAL THERAPY
