September, 1964 P H Y S I O T H E R A P Y Page 3 Passive Movement and Manipulation B y J E N N I F E R H I C K L I N G , M .C .S .P . P assive m o v em e n t is a n e sta b lish e d p a r t o f p h y sio th e ra p y a n d has alw ays b een in clu d e d in o u r tra in in g . M a n ip u la tio n o c cu p ies a m o re n e b u lo u s p o s itio n . I t is no w w idely h e ld to b e a tre a tm e n t w h ic h th e p a tie n t sh o u ld be a b le to h a v e a t a n y h o sp ita l, a n d t h a t it fo rm s a n a tu r a l ex te n sio n o f th e p h y s io th e ra p is t’s jo b . P h y s io th e ra p is ts do, in fa ct, m a k e g o o d m a n ip u la to rs , since th e y h a v e th e re ­ q u isite kno w le d g e o f a n a to m y a n d j o in t m o v e m e n t a n d a lso p re serv e a n e th ic a l s ta n d a rd . H o w ev e r, as w e a ll k n o w , m a n ip u la tio n is so m e tim es co n sid ere d to lie o u ts id e o u r p ro v in ce . I t is c u rio u s t h a t th is should b e so, fo r m a n ip u la tio n is p a ssiv e m o v e m e n t; t h a t is, a m o v e m e n t o f a jo in t c a rrie d o u t b y a n o p e r a to r w ith o u t aid o f th e p a tie n t’s m u sc le s. T h o u g h a ll m a n ip u la tio n is passive m o v em e n t, how ever, n o t a ll p a ssiv e m o v e m e n t is m a n ip u la tio n , a n d c o n fu sio n o fte n a rises h e re, as it does over o th e r fa c to rs su c h a s d e fin itio n , in d ic a tio n s a n d effects. G e n u in e d isa g re e m e n t exists o n a ll th e s e p o in ts . I n a d d i­ tio n , o n e ten d s n a tu ra lly to view th e su b je c t o u t o f o n e ’s ow n exp erien c e a n d p ra c tic e , w h ic h m ay re s u lt in a n o p in io n based o n c e rta in a sp e cts ra th e r th a n o n th e w h o le o f th e m atter. M isu n d e rsta n d in g a ls o a rises b e ca u se p e o p le a re a t cross p u rp o se s o v e r term s. I have trie d to give a g e n era l view sh o w in g w h e re th e m ain differences lie a n d h o w th ey c a n b e re so lv ed o r, if th is is n o t yet possible, h o w w e c a n n e v erth ele ss w o rk w ith th e m . T h e subject d oes n o t d ivide e asily u n d e r s e p a ra te h e ad in g s, fo r each p o in t b e a rs c losely o n o th e rs . I suggest th e re fo re th a t those in te re s te d first re a d th e p a p e r th ro u g h fo r ge n era l arg u m e n t, a n d th e n re -re a d fo r p a rtic u la r d e ta il. D IF F E R E N C E S O V E R D E F I N I T I O N L ack o f d e fin itio n o v e r te rm s o fte n leads to d isa g ree m e n ts w hich a re a p p a re n t ra th e r th a n re a l, a n d w o rd s o ften obscure facts. S everal w ays in w h ic h th is o c c u rs a re listed below. 1. M a n ip u la tio n is so m e tim es h eld t o b e sy n o n y m o u s w ith c h iro p ra c tic o r o s te o p a th y b e ca u se th ese p r o ­ fessions h a v e specialized in m a n ip u la tio n w ith o u t a n ae sth esia a n d d id so lo n g b e fo re th e m ed ic al p r o ­ fession. A n y o n e w ishing t o m a n ip u la te sh o u ld c ertain ly stu d y th e ir tec h n iq u e s, fro m w h ic h th e re is m u ch to b e le a rn t. T h e re is, h ow ever, a p a rtic u la r re c u rrin g s itu a tio n w hich len d s m o re a u th o r ity to th e c h ir o p r a c to r ’s tea ch in g th a n it n e cessarily m e rits. T h is o c c u rs w h e n a p a tie n t has, say, a p a in in th e n e ck th a t is b o th s u it­ ab le fo r m a n ip u la tio n a n d q u ick ly c u ra b le by it, b u t the fa ct is n o t re co g n ize d b y th e m ed ic al p ro fessio n . A fte r w eeks o r m o n th s o f tre a tm e n t, th e p a tie n t de sp a irs, “ goes ro u n d th e c o rn e r” to th e c h iro p ra c to r a n d is c u red in o n e o r tw o tre a tm e n ts . Such a n e v en t h a s tw o effects. F irstly , to t h a t p a tie n t th e c h iro p ra c to r is 100 p e r c e n t successful, if n o t a d o w n rig h t m ag ic ia n . A s a la y m a n h e c a n n o t be expected to recognise t h a t, th o u g h th is is a c o m m o n result o f m a n ip u la tio n , it is by n o m ea n s a n in v a ria b le one, a n d th a t m an y o f th e p a tie n ts b e fo re h im w ith sim ilar sy m p to m s m ig h t h a v e b een n o b e tte r. U n ­ fo rtu n a te ly it is n o t o n ly th e la y m a n w h o is o v e r­ p e rsu ad e d in this w ay, a n d m a n ip u la tio n so m e tim es gets a se n sa tio n a l o v e rto n e even in th e m ed ic al w orld, re m a rk a b le re su lts b e ing alw ays e xpected. T h is does n o th in g b u to h a rm to its p ro p e r a sse ssm e n t as a tre a tm e n t. T h e second re su lt o f th is s to ry is th a t, b e ca u se th e p a tie n t gets q u ick ly b e tte r in th e te e th o f c o n v e n tio n a l trea tm e n t, th e c h iro p ra c to r’s view o f w h a t h e h a s d o n e is believed to be c o rre c t, w h ic h d o e s n o t n e cessarily fo llo w . I f a m a n p u ts o u t a fire w ith a g a llo n o f m ilk d e c la rin g th a t o n ly th e a n im a l sp irit c a n c o n q u e r th e fire sp irit, th e fa c t t h a t it h a s h a d th e d e sired effect do e s n o t m e a n t h a t h is th e o rie s a re rig h t. T h is , o f c o u rse , d o e s n o t re fe r specifically to c h iro p ra c to rs , fo r th e p o in t a p p lie s u n iv e rs a lly , a n d p a rtic u la rly in a field su c h as th is w h e re so m u c h is in d isp u te . I t is v e ry im p o r ta n t in d ee d t o b e a b le to see w h e n a s ta te ­ m e n t h a s re a lly b e en p ro v e d . 2. T h e p h y s io th e ra p is t o fte n defines m a n ip u la tio n as b e in g a p a ssiv e m o v e m e n t d o n e u n d e r a n a e sth e sia , w h e rea s a p a ssiv e m o v e m e n t d o n e w ith o u t a n a e sth e s ia is c alled fo rce d o r re la x ed p a ssiv e m o v em e n t. T h is will n o t d o , since m a n y e x p e rts in m a n ip u la tio n d o n o t use a n a e sth e s ia . 3. T h e w o rd is so m e tim e s re serv e d fo r m o b ilisin g a m o v e m e n t n o t n o rm a lly u n d e r v o lu n ta ry c o n tro l, su c h a s th e g lid in g m o v em e n ts a t th e w rist. T h is a g a in is a d e fin itio n t h a t is n o t u sed b y m a n y experts. 4. I t is n o t sa tis fa c to ry t o re serv e th e w o rd fo r m o v em e n t c a rrie d o u t in a p a in fu l, b u t n o t a p a in le ss, ra n g e, fo r m a n ip u la tio n o f a j o in t o fte n involves d o in g b o th . 5. A c o m m o n view is th a t “ m a n ip u la tio n ” is a s h o rt q u ic k m o v e m e n t, w h ile “ p a ssiv e m o v e m e n t” is slo w e r a n d m o re g entle. T h is d is tin c tio n c a n n o t be p re sse d to o f a r; fo r in sta n c e , w h e n tre a tin g a cervical d isc lesio n , esp e cially w ith g ro ss p a in fu l lim ita tio n o f m o v em e n t, o n e o fte n b eg in s w ith very g e n tle d e lic ate m o v em e n ts w hile try in g to e s ta b lish w h ic h m a n o e u v re w ill b e h elpful. O n c e th is h a s b e e n d e te rm in e d a n d th e p a tie n t h a s b e g u n to im p ro v e , th e sa m e m a n o e u v re m a y w ell b e c a rrie d o u t m u c h m o re firm ly, q u ick ly , o r w ith m o re force. I t w o u ld g e n e ra lly be a g re e d th a t th e first m a n o e u v re s w ere p a ssiv e m o v e m e n t a n d th e last o n e s m a n ip u la tio n , b u t e x a c tly w h e re o n e m erges in to th e o th e r is h a rd to define a n d th e e ffo rt m a k e s fo r so m e v e ry u n re a l d istin c tio n s . 6. D r . C y riax , in his a rtic le in th is jo u r n a l , defines m a n ip u la tio n as p a ssiv e m o v e m e n t d o n e fo r o n e o f tw o p u rp o s e s : to r u p tu r e a n a d h e s io n o r to reduce in te rn a l d e ra n g e m e n t. T h a t is, it is defined b y th e d is o rd e r a n d n o t by m e th o d . T h is so m e tim es leads to difficulty fo r th e p h y s io th e ra p is t, since th e m edical p ro fe s sio n is n o t a g ree d a b o u t d ia g n o s is a n d th e sa m e sig n s a n d sy m p to m s m a y be a sc rib e d by different d o c to rs to d iffere n t c o n d itio n s . T h e w a y o u t o f th is difficulty is d isc u sse d below . 7. I t m u s t a ls o b e re m e m b e re d t h a t th e re a re several te rm s, su c h as m o b ilis a tio n , fo rc in g , stre tc h in g , as w ell as p a ssiv e m o v e m e n t a n d m a n ip u la tio n , a ll o f w h ic h m a y be used b y d iffere n t p e o p le to m e a n v ir tu ­ a lly th e sa m e th in g ; th is so m e tim e s gives rise to w h a t s o u n d s lik e d isa g re e m e n t w h e n in fa ct th e re is n o n e . T h e p h y s io th e ra p is t w ishing to stu d y o r c o n trib u te to th is field h a s to p ic k h e r w ay th ro u g h th e a b o v e p o in ts a n d m u s t alw ay s m a k e a m etic u lo u s e ffo rt to define te rm s a n d e sta b lish w h a t a re th e b a sic fa c ts u n d e r d isc u ssio n . O n e d e fin itio n o f m a n ip u la tio n is “ th e h a n d lin g o f o b jects fo r a p a rtic u la r p u r p o s e ” , a n d if “j o in t s ” is su b s titu te d fo r “ o b je c ts” it gives a v e ry fa ir p ic tu re o f th e p ro c e d u re : a p a ssiv e m o v e m e n t d o n e w ith a n y th in g fro m g re a t d e licacy to c o n sid e ra b le fo rce , a n d w ith v a ry in g ra n g e, speed a n d p u rp o s e . I t h in k m y se lf th a t re se a rc h in to th e su b je ct is o n ly h a rm e d by d ra w in g a h a rd lin e b etw een p a ssiv e m o v em e n t a n d m a n ip u la tio n , fo r th e y c a n o n ly be u se fu lly stu d ied to g e th e r; it w o u ld , in fa c t, be h e lp fu l to d ro p th e te rm m a n ip u la tio n a lto g e th e r, w e re th is n o t c e rta in to b e c o n ­ R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Page 4 P H Y S I O T H E R A P Y September, 1964 s tru e d a s im p ly in g t h a t it la y o u ts id e th e sp h e re o f p h y s io ­ th e ra p y . T h e y a re c o n sid e re d h e re a s p a r t o f o n e su b je ct. E ith e r te rm is u sed a s it p o ssesse s m o st n e a rly th e re q u ire d m ea n in g . D IF F E R E N C E S O V E R D IA G N O S IS T h e re a re th re e m a in c a te g o rie s o f d is o rd e r w h ic h a re a g ree d , b y o n e e x p e rt o r a n o th e r, to re s p o n d a t tim e s to p a ssiv e m o v e m e n t. T h e s e a r e : a r th ritis , a d h e s io n , in te rn a l d e ra n g e m e n t. H o w ev e r, th e m ed ic al p ro fe s sio n d o e s n o t a g ree , e specially a t th e spine, o n w hich signs a n d s y m p to m s in d ic a te a p a r ­ tic u la r d is o rd e r n o r u p o n w hen p a ssiv e m o v e m e n t sh o u ld be u se d . T h e p h y s io th e ra p is t, k n o w in g t h a t m a n ip u la tio n has d a n g e rs a n d t h a t d o c to rs disa g ree , m a y w ell sa y o u t o f a sense o f re sp o n sib ility to th e p a tie n t “ th is te c h n iq u e sh o u ld n o t b e used by us u n til th e m ed ic al w o rld is a greed a b o u t it ” . T h is is a p ity fo r tw o re a so n s . F irs tly , m a n y p a tie n ts a re d e p riv e d o f effective tre a tm e n t, a n d th o u g h th is w o u ld be ju stifia b le if su c h tre a tm e n t m e a n t su b je ctin g th e p a tie n t to d a n g e r, I d o n o t th in k th is need b e so, as I h o p e to show . Secondly, it is th e c ritic a l use o f th e tec h n iq u e s th e m ­ selves t h a t c a n d o so m u c h to c la rify th e d is p u te d p o in ts . T h e se a rc h fo r a n a g ree d , d e finitive d ia g n o s is sh o u ld , o f c o u rse , go o n , b u t if th e p h y s io th e ra p y p ro fe s sio n w a its fo r it, w e a re lik e ly t o w a it a lo n g tim e . W e c a n , in th e m e a n tim e , u se th e tec h n iq u e s, s tu d y m e th o d s a n d effects, a n d c o n ­ tr ib u te a m ass o f ev id e n ce to th e c e n tra l disc u ssio n . D a n g e r in th is s itu a tio n is a v o id e d b y fo llo w in g th e p re c e p t th a t m anipulation is c o ntrolled n o t b y th e diagnosis b u t b y the p a tie n t’s signs a n d sy m p to m s. T h e s e a re n o t in d is p u te ; th e y a re verifiable a n d re-verifiable, a n d it is t o th e m th a t tre a tm e n t is p in n e d a n d b y th e m th a t it is re g u la te d . T h is p o in t is e n la rg ed u p o n u n d e r “ D a n g e r a n d its a v o id a n c e ” below . A R T IC U L A R P A T T E R N S T h e re is n o a tte m p t in th is p a p e r t o disc u ss e x a m in a tio n in d e ta il o r d e sc rib e in d iv id u a l le sio n s in p a rtic u la r. T h e difference o f o p in io n a b o u t th e s e d iso rd e rs, how ever, m e a n s th a t d isc u ssio n o f m a n ip u la tio n c an u su a lly b e k e p t c le a r o n ly b y re fe re n ce to th e p h y sic a l findings ra th e r th a n th e d iag n o sis. A rtic u la r signs a re th e re fo re d iscussed h e re briefly b o th t o h e lp define th e c o n d itio n s in q u e stio n , a n d b e c a u se p a in fu l lim ita tio n o f m o v e m e n t is o n e o f th e m a in p ro b le m s w ith w hich p a ssiv e m o v e m e n t h o p e s to d e al. ( F u rth e r d isc u ssio n o f signs a n d sy m p to m s , in so fa r as th e y c o n tr o l tre a tm e n t a n d a re u sed in re a sse ssm e n t, ta k e s p la c e u n d e r “ T r e a tm e n t” b e lo w .) Selective T ension D r . C y ria x ’s m e th o d o f e x a m in in g th e m o v in g p a r ts by selective te n s io n m u s t b e re fe rre d to h e re, to se ttle te rm s o f refe re n ce . A n y o n e w ishing to stu d y it fu rth e r is re fe rre d to h is te x tb o o k o n th e su b je c t1. T e n s io n is p u t o n e a c h o f th e tissu e s in t u r n t o see w hich te s t p ro v o k e s p a in , o r is o th e rw ise a b n o rm a l. F o r th is p u r ­ p o s e th e tissu e s a re d ivided in to th e c o n tra c tile a n d in e rt g ro u p s. T h e contractile g ro u p ; c o m p rise s m u sc le s, te n d o n s , a n d th e ir a tta c h m e n ts , a n d is so -c alled b e ca u se te n s io n c a n be p u t u p o n th e m b y m a k in g th e m c o n tra c t. T h e te s t fo r th em is a s tro n g sta tic c o n tra c tio n . T h e e x a m in e r h o ld s th e jo in t in a n e u tr a l p o s itio n so as to av o id te n s io n u p o n th e in e rt tissu e s as fa r as p o ss ib le a n d to p re v e n t m o v em e n t. T h e m u sc le g ro u p is th e n teste d in is o la tio n b y a sk in g th e p a tie n t to c o n tra c t. R e fe rre d (a n d in d ee d q u ite n o rm a l) te n d e rn e s s is very c o m m o n a n d m isle a d in g . T e n d e rn e s s in a m u sc le is o n ly acc ep te d a s a ris in g fr o m th a t m u sc le i f it is fo u n d to be p a in fu l w h e n te ste d in th e a b o v e w ay. T h is p rin c ip le is a p p lie d to o th e r tissu e s a s w e ll; th e tis su e a t f a u lt is iso late d b y selective te n s io n a n d o n ly w h e n it h a s b e e n n a m e d d o e s p a lp a tio n fo r te n d e rn e s s, c onfined to t h a t tissu e , p la y a p a r t in lo c a liz a tio n , a n d th e n o n ly if th e s tru c tu re is fa irly superficial. T h e inert group c o m p rise s a ll o th e r tissu e s, a n d is tested b y b e in g stre tc h e d o r p in c h e d : th a t is, b y p assive m o v em e n t d o n e th ro u g h th e fu ll p o ss ib le ra n g e. A c tiv e m o v em e n ts c a n a lso b e u sed t o te s t th e in e rt tissues a n d a re o fte n m o re c o n v en ien t, b u t a sm a ll p a ssiv e p u sh sh o u ld b e a d d e d a t th e e n d o f m o v em e n t to see w h a t th e ex tre m e o f p o ss ib le ra n g e feels like, to see if p a in is p r o ­ vo k e d , a n d to ju d g e m u sc le spasm . A n active m o v em e n t d o e s, o f c o u rse , involve m uscles as w ell, b u t w hile it is a g o o d g u id e to th e sta te o f th e inert tissu e s a b o u t a jo in t,, it is a v e ry p o o r g u id e to th e c o n tra c tile tissues. F o r in stan c e, if a p a tie n t c a n lift his a rm e asily to fu ll e le v a tio n o n e c a n b e fa irly su re t h a t th e re is n o th in g w ro n g w ith th e j o in t b u t n o t a t a ll su re th a t th e re is n o th in g w ro n g w ith th e te n d o n s a b o u t it. P a in fu l lim ita tio n o f an a c tiv e m o v em e n t, th e re fo re , m a y ge n era lly b e ta k e n as in d ic a tin g tr o u b le w ith th e in e rt tis su e s; if th e re is a ny d o u b t, th e tis su e g ro u p s c a n b e teste d se p a ra te ly b y passive a n d re siste d m o v em e n ts a n d th e findings w eighed a g ain st e a c h o th e r. A rtic u la r P a tte rn s E x a m p le s o f th e th re e b a sic c o n d itio n s u n d e r discussion w h ich m a y re q u ire tre a tm e n t b y p a ssiv e m o v em e n t a re as fo llo w s : (a) A rth ritis or capsulitis. (T h e te rm “ c a p s u litis” m ay be used h e re to d e sc rib e t h a t a sp e c t o f th e c o n d itio n w hich re s p o n d s to p a ssiv e m o v em e n t.) T h e p a inful lim ita tio n o f m o v em e n t a t a j o in t fo llo w in g im m o b ili­ sa tio n o r t r a u m a ; p a in fu l c o n tra c tu re acc o m p a n y in g o ste o -a rth ritis a t th e c ervical sp in e o r h ip jo in ts. (b) A dhesion. P o s t-tra u m a tic a d h e s io n giving rise to p e r­ siste n t d isc o m fo rt w ith m in o r lim ita tio n o f m ovem ent, a n d p re v e n tin g fu ll re tu r n o f fu n c tio n a fte r athletic in ju ry , fra c tu re , o r o p e ra tio n . (c) In tern a l derangem ent. D is c lesio n s a t th e spine, or d e ra n g e m e n t, o r n ip p in g o f th e sy n o v ia l fringe, o f the fa c e t jo in ts . (T h is is w h e re o n e o f th e m a in arg u m en ts a b o u t d iag n o sis o c cu rs.) L o o s e b o d y in th e e lbow or knee. I f a n y o f th e a b o v e c o n d itio n s a re p re se n t th e re w ill be, in g e n era l, p a in fu l lim ita tio n o f p a ssiv e a n d a ctiv e m ove­ m e n ts, a n d th e s ta tic re sisted m o v em e n ts w ill b e painless. T h is p a in fu l lim ita tio n o f m o v em e n t w ill fa ll in to e ith e r the c a p s u la r o r th e n o n -c a p s u la r p a tte rn . 1. C apsular p a tte rn . T h is is fo u n d in, a n d is d ia g n o stic of, a rth r itis o r c a p s u litis1. A L L m o v em e n ts a re p a in fu l and lim ite d in th e c a p s u la r p a tte rn p e c u lia r to th a t jo in t. T h e c a p s u la r p a tte rn is c o n s ta n t fo r a n y o n e jo in t, in th at th e lo ss o f ra n g e in o n e d ire c tio n is p r o p o rtio n a l to th e loss o f ra n g e in th e o th e rs ; th e se verity v a rie s, b u t th e all-over p a tte rn d o e s n o t. F o r in stan c e, a t th e k n e e th e p a tte rn is a little lo ss o f ex te n sio n , a gro ss lo ss o f flexion a n d a b o u t equal lo ss o f r o ta tio n s ; if th e a rth r itis b e co m es w orse, m ovem ent is lo s t in a ll ra n g e s p ro p o rtio n a te ly to e ac h o th e r a n d the a ll-o v er p a tte rn is pre serv e d . T h is is, o f c o u rse , q u ite differ­ e n t fro m th e p a tte rn o f a rth ritis a t th e h ip o r c ervical spine, b u t is sim ila r fo r a ll o th e r a rth rite s a t th e knee. 2. N on-capsular p a tte rn . T h is is p re s e n t b o th w ith adhesion a n d w ith in te rn a l d e ra n g e m e n t (w hich c a n m im ic e ac h other closely), a n d c o n sists ge n era lly in so m e m o v em e n ts being lim ite d a n d p a in fu l a n d o th e rs n o t ; i.e. n o t th e w hole o f the jo in t. W ith a n a d h e s io n , th o se m o v em e n ts w hich m ove or stre tc h th e le s io n w ill h u r t w hile th o se t h a t re la x it will be fu ll a n d p a in le ss. W ith in te rn a l d e ra n g e m e n t th e p a tte rn is e n tire ly variable a n d a rb ita r y a n d m a y in v o lv e g ro ss p a in fu l lim ita tio n of m o v e m e n t in se veral d ire c tio n s o r m ere ly a little p a in a t the e x tre m e o f o n e ra n g e . A ll th a t c a n be said is th a t th e pattern w ill n o t b e th e c a p s u la r one. X -ra y A n X -ra y m a y b e e sse n tia l to e xclude se rio u s disease or in ju ry . X -ra y a p p e a ra n c e s o f o ste o -a rth ritis o r diminished jo in t space, how ev er, a re o n ly acc ep te d a s re le v a n t to the R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) September, 1964 P H Y S I O T H E R A P Y Page 5 (a) P o s itio n in g . (b) E xec u tio n . Fig. 1 C lo se -u p o f ro ta tio n at the cervical spine. p a tie n t's pain if they a re b o rn e o u t by clinical e x a m in a tio n . F o r in stance, it is q u ite p o ssib le fo r a p a tie n t to have m arked cervical o s te o -a rth ritis on th e X -ra y , b ut on clinical e x am in atio n to have a n o n -c a p su la r p a tte rn o f su d d e n o n se t; i.e. it is n o t his a r th ritis as such w hich is c au sin g the pain. M a n ip u la tio n o f such a neck sh o u ld be fo r the n on- cap su la r p a tte rn a n d o f th e “ n o t s e t” v a rie ty (discussed below ); to reg ard th e c o n d itio n as a rth ritis and m a n ip u la te it as such is likely to be ineffective, if n ot h a rm fu l. T h e decision to m a n ip u la te , th e re fo re a n d the n a tu re o f the lesion being tre a te d is based p rim a rily u p o n clinical findings. T R E A T M E N T B Y P A S S IV E M O V E M E N T O R M A N IP U L A T IO N “ S e t” o r “ N o t S e t ” ? T h is is o n e o f the c ru cial d istin c tio n s th a t has to be d ra w n in m a n ip u la tio n . W here th ere is a r th ritis o r a d h e sio n , the p ro c e d u re is “ set” , in th a t th e o p e r a to r kn o w s in a d v a n c e w hich range o f m ovem ent w ill be p ushed d u rin g tre a tm e n t. C e rta in m ove- I m ents a re found on e x a m in a tio n to be lim ited and p a in fu l; once it has been decided to try passive m ov em e n t, it will be in those d irec tio n s th a t the jo in t m ust be m oved to stre tc h o r ru p tu re th e c o n tra c te d o r a d h e re n t fibrous tissue. T h e re are still o th e r d ecisio n s to be m ade, a b o u t range a n d force and speed o f m o v em e n t, b u t the direction is p re d eterm in ed . In te rn a l d e ran g e m e n t p re sen ts a different p ro b lem . H ere one c a n n o t p redict th e effective m an o e u v re w ith c e rta in ty , fo r one is trying to shift a m echanical b lock a nd it is not possible alw ays to k n o w w h a t will achieve this. It m ay be m ovem ent in to a p a in fu l range, o r a p a in le ss range, o r b o th . It m ay be m ovem ent in o n e d irec tio n o nly, o r several. It m ay be possible to m ak e the c o n d itio n b e tte r w ith one m anoeuvre a n d w orse w ith a n o th e r. T h e c o rre c t d ire c tio n o f th ru st has th ere fo re to be d iscovered, as well as ra n g e and force and speed. T h e m a n ip u la tio n is th e re fo re c alled “ n o t- set” , and the p ro c e d u re is as follow s. F irstly the jo in t is e x am ined to d e te rm in e th e re levant signs and sy m p to m s. A m a n o e u v re is th e n trie d , and the jo in t is re-exam ined to see w hat c h an g e s have o c c u rre d . I f there is a good re su lt, it is re p e a te d ; if th e re is no change, a n o th e r m an o e u v re is a tte m p te d . T h e jo in t is th en once m ore exam ined to see the re su lts o f the second m an o e u v re, and the selection o f th e next o n e is based u p o n th a t e x a m in a ­ tion. I f th ere is a ny su g g e stio n o f w orsening, a n o th e r d irec ­ tio n m ay be tried w ith c a u tio n o r it m ay be decided to a b a n d o n m a n ip u la tio n . T h e m a n ip u la to r th u s feels his w ay th ro u g h o u t the tre a tm e n t, re g u la tin g it by a n y c h anges th a t o c cu r. In no sense d o e s th e m a n ip u la tio n have to be sym ­ m etrica l a nd m ay c o n sist in o n e m a n o e u v re rep eated m any tim es. A d h e sio n a n d in te rn a l d e ra n g e m e n t b o th give rise to the n o n -c a p su la r p a tte rn a n d it is o ften difficult to tell them a p a rt. Indeed a t th e sp in e m ed ical o p in io n m ay be far from a greed o v e r th e m ea n in g o f a sy n d ro m e . F o r e x am p le a u n ila te ra l p ain in th e b a ck , giving rise to p ain in som e d ire c tio n s a nd n o t in o th e rs and w ith no o th e r physical signs m ay be a ttrib u te d to in te rn a l d e ra n g e m e n t o r to an a d ­ hesion. T h e h isto ry m ay give a c lue (for exam p le, if the pain c am e o n su d d e n ly it is n o t likely to be a n ad h esio n ), b u t so m e tim es the p h y s io th e ra p is t has no c le a r directive, th o u g h it w ould c o m m o n ly be agreed th a t th is is the s o rt o f p a tte rn w hich re sp o n d s to m a n ip u la tio n . T h e p ro p e r m a n ip u la tio n fo r an a d h e s io n is a sh o rt q u ic k m o v em e n t o f sufficient fo rce to ru p tu re th e lim iting fib ro u s tissue, b u t su c h a p ro c e d u re sh o u ld n o t be used u nless th e p h y sio th e ra p ist has a c le a r d iag n o sis a nd the d o c to r’s b a cking. I f th ere is a p o ssib ility o f in te rn a l d e ra n g e ­ m en t it is alw ays best to be o n the safe side, a n d a d o p t the p ro c e d u re for “ n o t s e t” m a n ip u la tio n as a b o v e. T h is is, in essence, to feel o n e ’s w ay fo r d ire c tio n as well as for range and force, a n d to o b se rv e re su lts a t re -e x a m in a tio n before a tte m p tin g m ore. A naesthesia I t is n o t p o ssib le to fo llo w the a b o v e p ro c e d u re on the a n ae sth etise d p a tie n t, a n d in D r. C y ria x ’s view a n a e sth e s ia is s tro n g ly c o n tra -in d ic a te d in “ not se t” m a n ip u la tio n w here it is im p o ssib le to p re d ic t w ith c e rta in ty the effective m a n o ­ e u v re a nd a lso p o ssib le to m a k e th e p a tie n t w orse by d o in g the w ro n g one. It is claim ed th a t th e to ta l re la x a tio n re su lts in m a n ip u la tio n being m o re effective; th is is indeed tru e and w hereas useful if th e rig h t m o v em e n t is d o n e , if th e w rong o n e is c hosen real h a rm c a n re su lt. It is alw ay s p o ssib le to get sufficient re la x a tio n on the c o n sc io u s p a tie n t, a nd th is is discussed fu rth e r below . O n the o th e r h a n d a n a e sth e s ia is n ot alw ays c o n tr a ­ indicated in “ se t” m a n ip u la tio n , and m ay be necessary if p ain a n d m uscle sp a sm o th erw ise p re v en t a d e q u a te jo in t m o v em e n t. E ven so, it is n ot alw ays useful. I f gross lim ita ­ R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) tio n o f m o v em e n t is fo rce d , th e jo in t so m e tim es re sp o n d s w ith a m ark e d after-flare. T h e p h y s io th e ra p is t’s stru g g le to m a in ta in ra n g e w hile th is is su b sid isin g m a y a m o u n t to m u c h th e sa m e th in g as try in g to achieve it m o re slow ly o n th e c o n sc io u s p a tie n t. I f m a n ip u la tio n u n d e r a n a e sth e s ia is c arried o u t, in tra -a rtic u la r h y d ro c o rtiso n given 24 h o u rs b e fo re h a n d d oes m u c h to a b a te th is re ac tio n . Note-keeping and Co-operation with the Doctor G o o d n o te-k e ep in g c o n trib u te s e n o rm o u s ly to w a rd s th e p ro p e r use o f p assive m o v em e n t a n d is v ita l fo r its safety a n d fo r p ro p e r re sea rc h . T h e tre a tm e n t c a rd m u st have sufficient sp a c e t o w rite a n a d e q u a te h isto ry a n d all signs a n d sy m p to m s re le v a n t to tre a tm e n t, so th a t it gives a c le ar p ic tu re o f th e p ro b le m w ith w hich p h y sio th e ra p y is try in g to d eal. I f th e s e d etails a re n o t ta k e n d ow n a t th e clinic, tim e m u s t b e m ad e a t th e first v isit fo r such a n e x a m in a tio n . If, a s is u s u a l, th e re is n o tim e, th e n it is n o t o n ly ju stifia b le , b u t is in th e b e st in te rests o f th e p a tie n t, fo r th e w hole o f th e first tre a tm e n t to be given u p to this p u rp o se . T h e re m u st a lso be ro o m o n the c ard fo r changes in p h y sic al signs to b e n o ted a t re g u la r re assessm en t. Such n o te s m a y be b rie f in “ se t” m a n ip u la tio n w here th e tr e a t­ m e n t is o fte n a r o u tin e o n e a n d follow s fro m th e o rig in a l e x a m in a tio n . I n “ n o t s e t” m a n ip u la tio n , o n th e o th e r h a n d , p a rtic u la rly a t th e spine, n o te s have to b e k e p t m u c h m o re fully, since in d iv id u a l m an o e u v res, a n d th e c h an g e s re su ltin g fro m th e m , o fte n have t o be w ritte n in detail. C lo se c o -o p e ra tio n w ith th e d o c to r is esse n tia l a n d th e tre a tm e n t card w ill o fte n help here. I n th e first in stan c e, th e p h y sio th e ra p ist sh o u ld b e careful n o t to m a n ip u la te e x cept a t th e ex p ress w ish o f th e d o c to r in c h arg e ; “ p h y sio , p le a se ” is n o t sufficient. T h is is p a rtly b ecause n o t a ll d o c to rs agree to p h y sio th e ra p ists m a n i­ p u la tin g , a n d p a rtly b ecause th ere a re d a n g ers w hich have to be excluded b e fo re m a n ip u la tio n is used. T h is re tu rn s us to the p ro b le m o f w h e re p assive m o v em e n t b eco m es m a n i­ p u la tio n , since th e first is a n u n q u e stio n e d p a r t o f o u r te c h n iq u e s a n d th e l a tte r is n o t. M a n y d o c to rs w o uld n o t he sita te to let us u se th e fo rm e r o n o u r o w n ju d g m e n t, while feeling stro n g ly th a t th is is n o t sufficient fo r th e la tte r. T h is im p a sse c a n be resolved by the re sp o n sib ility o f th e p h y sio ­ th e ra p is t to w a rd s th e d o c to r’s w ishes a n d d isc u ssio n w ith h im so th a t he a p p re c ia te s the p ro b le m a n d c a n give g u id ­ ance. T h e re sh o u ld a ls o b e close c o -o p e ra tio n w ith the d o c to r w hile tre a tm e n t is g o ing o n , so th a t its effects, successes a nd fa ilu re s a re alw ays u n d e r review . H e re v a rio u s a c tio n s will h elp. I t is useful if a 'physio­ th e ra p is t c a n b e a t th e clinic w hen th e p a tie n t is p u t o n to tre a tm e n t, so th a t its aim s a nd p o ssib ilities c a n b e discussed. T h e tre a tin g p h y sio th e ra p ist sh o u ld a lso have re a d y access to th e d o c to r fo r gu id an c e a n d d isc u ssio n if difficulties arise d u rin g tre a tm e n t. F in a lly it is useful if th e p a tie n t sees th e sam e d o c to r a t fo llo w -u p visits. I k n o w th a t m a n y o th e r fa c to rs have a b e a rin g u p o n w h e th er th is is e ith e r p o ssib le o r a d visable. N e v erth e le ss, w here th is is n o t th e p ra ctic e th e d o c to r so m e tim es h as little id ea o f the re a l effects o f p h y sio th e ra p y , a n d a n im p o rta n t corre c tiv e to ineffective tre a tm e n t is lo st. I f th e sam e d o c to r o r p h y sio th e ra p ist c a n n o t b e p re se n t a t th e fo llo w -u p visit th en a t least th e tre a tm e n t card sh o u ld be th ere . I t sh o u ld b e c le a rly u n d e r­ sta n d a b le b y th e d o c to r (a n im p o rta n t p o in t) a n d a c c o m ­ p a n ie d b y a n o te fro m th e p h y s io th e ra p is t giving h e r view o n p ro g ress. I n this w ay a real e ffo rt can b e m a d e to sto p tre a tm e n t if it d oes n o t help, w hich is o n e o f th e b e st th in g s th a t c a n be d o n e fo r p h y sio th e ra p y . S h ould a p a tie n t b e c ured q u ick ly by m a n ip u la tio n , he is o fte n discharged cle ric a lly fro m th e p h y sio th e ra p y d e p a rt­ m e n t w ith o u t re fe re n ce b a c k to th e d o c to r; th is is d o n e to save tim e in cro w d ed clinics. H o w ev e r, th e fu n d a m e n ta l im p o rta n t tim e-save is th a t tre a tm e n t is a p p lie d w here it w o rk s a nd a b a n d o n e d w here it d o e s n o t. I f a tre a tm e n t is q u ick ly successful, th is sh o u ld a t lea st be b ro u g h t to the P a g e 6 d o c to r’s a tte n tio n . T h e p a tie n t need n o t nece ssa rily re tu rn to the c lin ic; th e p h y sio th e ra p ist c a n m e re ly h ave a w ord w ith th e d o c to r, sho w in g him a tre a tm e n t c ard w hich gives th e re le v an t signs a n d sy m p to m s. H is m e m o ry is th u s refreshed a b o u t th e sy n d ro m e th a t w as tre a te d a n d he c a n b u ild u p a c le a r p ic tu re o f w hen a tre a tm e n t w orks. Signs and Symptoms, and Assessment of Progress T re a tm e n t b y p assive m o v em e n t, p a rtic u la rly m a n ip u la ­ tio n , u su a lly re su lts in ste a d y p ro g re s s fro m th e beginning. I f this does n o t o c c u r, th e p o s itio n sh o u ld be re co n sid e red . T h e c o n d itio n s u n d e r d isc u ssio n give rise to c e rta in signs a nd sy m p to m s w hich a re re le v an t in a ssessing p ro g ress. T h e y a re n o w discussed u n d e r th ree h e adings a n d th e w ay in w hich th e y c an be used fo r th is p u rp o s e is discussed. 1. P ain T h e m o re severe th e lesio n th e m o re d ista l a n d extensive w ill be th e reference o f p a in and vice v e rsa 1. T h e position o f th e p a in is th ere fo re v e ry im p o rta n t, a n d is p e rh a p s th e m o s t v a lu a b le single fa c to r in g u iding tre a tm e n t a n d a v o id ­ ing d a n g er, e specially a t th e spine. I f a m a n o e u v re sh o rte n s th e p a in o r m oves it p ro x im a lly , th is is a n e n co u ra g em e n t to c o n tin u e . C onversely, if a m a n o e u v re m oves th e p a in m o re d istally, t h a t p a rtic u la r m a n o e u v re is lik e ly to be h a rm fu l, a n d if th e sa m e effect is m e t in several d irec tio n s, m a n ip u la tio n sh o u ld n o t b e co n tin u e d . T h e p h y sio th e ra p ist m u st a sk the p a tie n t to sa y if th e p a in c h anges in th is w ay while the jo in t is being m o v ed into position, a n d if th e c h an g e is a n a d v e rse one, th a t m a n o e u v re is n o t pressed h o m e (i.e. th e re is p o sitio n in g b u t n o t exe­ cu tio n ). R e sp o n se is th u s assessed b e fo re the final th ru s t an d guides w h e th er it is given o r n o t. In th is way, th e w orst th a t o c c u rs is a little te m p o ra ry a c h in g ; su c h c o n tro l c a n n o t, o f c o u rse, b e m a in ta in e d u n d e r a n ae sth esia . O th e r asp e cts o f p a in , su c h as its severity, d u r a tio n o r ease o f p ro v o c a tio n w ill a lso o ften help in assessing p rogress. 2. A rtic u la r P attern F irstly , th e re is p a in a n d lim ita tio n o f m o v em e n t in the c a p s u la r o r n o n -c a p s u la r p a tte rn . Secondly, th e re m a y b e d e fo rm ity , a n d th ird ly th e re m ay b e signs o f in fla m m a tio n . T h e last tw o can b e d e a lt w ith fa irly briefly here. M a rk ed d e fo rm ity o f th is k in d o fte n a cc o m p a n ies in te rn a l d e ran g e ­ m e n t a t th e spine, a nd m ay call fo r c e rta in p re c a u tio n s. I t is n o t a c o n tra in d ic a tio n to passive m o v em e n t, b u t o ften cau ses difficulty in h a n d lin g th e jo in t. T h e a im o f tre a tm e n t is o f c o u rse to a b o lish it, a n d a m a n o e u v re th a t te n d s to do th is is a useful one. Signs o f in fla m m a tio n (such as h eat, fluid in the jo in t, e tc.) a re a g ain n o t in them selves c o n tra ­ in d ic a tio n s to tre a tm e n t, th o u g h in c o n ju n c tio n w ith o th e r findings th e y m a y be so, o r m ay c all fo r a c au tio u s a p p ro a c h . T h e ir d im in u tio n fro m o n e tre a tm e n t to th e n e x t, e.g. w ith a lo o se b o d y in th e k nee, m ay' b e a h e lp fu l guide. P a in a n d lim ita tio n o f m o v em e n t a t th e jo in t re q u ire ra th e r m o re to be said a b o u t th em here. W ith adhesion or internal derangem ent, th e a im o f passive m o v em e n t is u su a lly to achieve a full a n d p a in le ss ra n g e o f m o v em e n t b y b re a k in g th e a d h e s io n o r re d u cin g th e dis­ p lac em e n t. R e su lts a re q u ic k if th e y a re a ch ie v a b le ; the p a tie n t is well in 1-5 tre a tm e n ts . A n increase in p a in le ss ra n g e o b v io u sly in d ic a te s im p ro v e m e n t; assessm ent is fro m o n e tre a tm e n t t o th e n e x t w ith a n a d h e s io n , a n d o c c u rs m a n y tim e s in o n e tre a tm e n t fo r in te rn a l d e ra n g e m e n t, fo r re a s o n a lre a d y discussed. T h e re is n o good a n d m ay b e h a rm in c o n tin u in g m a n i­ p u la tio n a fte r a full a n d p a in le ss ra n g e o f m o v em e n t has b e en achieved (a view n o t held b y so m e c h iro p ra c to rs). F o r in sta n c e , w h en d e ra n g e m e n t h a s b een re d u ce d , c o n tin u e d jo in t m ov em e n t m erely cau ses u n w a n te d m o b ility a n d m ay cause re -d isp la ce m en t. I n c a p s u litis th e a im o f tre a tm e n t m ay a g a in b e th e r e s to ra tio n o f full p a in le ss m o v em e n t, w here th e c o n d itio n is su p e rim p o sed o n a n oth erw ise n o rm a l jo in t, su c h as in im m o b ilisa tio n o r tra u m a tic cap su litis. I n o ste o -a rth ritis, on th e o th e r h a n d , w here th e c ap su litis o c c u rs in a j o in t w ith irrev e rsib le deg en e rativ e changes, su c h a re s u lt is n o t September, 1964P H Y S I O T H E R A P Y R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) necessarily h o ped fo r. P ro lo n g e d , fa irly s tro n g stre tc h in g is o ften e xtrem ely successful in such jo in ts , b u t th e m a in hope is to get a good sy m p to m a tic re lie f lastin g m a n y m o n th s . I f m ovem ent a lso im p ro v e s, so m u ch the b e tte r, b u t th is is n o t th e c rite rio n o f successful tre a tm e n t. I t is q u ite p o ssib le , fo r in stance, fo r a p a tie n t to h ave th e p a in fro m her cervical o ste o -a rth ritis a lm o s t to ta lly relieved while still h a v in g gross lim ita tio n o f m ov em e n t. T h e p h y sio th e ra p ist h a s to ju d g e w hat is p o ssib le . O ne m u st n o t c o n tin u e to m a n ip u la te fo r a n in cre ased m o v em e n t o r a re lie f o f p a in w hich a re n o t a chievable. I t is n o good try in g to reassess to o o fte n a n d once a w eek is u su a lly a b o u t rig h t (tre a tm e n t b e in g tw o o r th re e tim es w eekly). T h e p a tie n t o ften finds it difficult to ju d g e p ro g re ss, b u t can generally m a k e a d e cision i f a sk e d to c o m p a re his p re se n t co m fo rt w ith th a t o f a w eek a g o . I t is w o rth c o n tin u in g tre a tm e n t if he say s con fid e n tly th a t he is m u c h b e tte r; if he is u n c e rta in , a n d th is b e a rs o u t o n e ’s o w n view , tre a tm e n t fo r o n e m o re w eek m a y b e trie d , b u t w ith th e sam e re su lt a gain it sh ould th e n b e sto p p e d . 3. E xtra-articular S ig n s a n d S y m p to m s T hese o c cu r w here th e d iso rd e r is o f su c h a n a tu re a s to involve tissues o u tsid e th e jo in t, su c h a s in a disc lesio n w hich is co m p re ssin g a n e rv e r o o t. T h e m o s t im p o rta n t is painful lim ita tio n o f stra ig h t-leg ra isin g , w hich p ro v id es a very exact guide to p ro g ress, a n d w here in cre ase in ra n g e can u su a lly be ta k e n as a n in d ic a tio n to re p e a t the m a n o e ­ uv re th a t p ro d u c e d it. O th e r findings in clu d e p a in fu l twinges, p a in o n co u g h in g o r sneezing, a nd so o n . O b v io u sly the a im o f tre a tm e n t is to a b o lish th em , a n d th e y c a n be useful in d e te rm in in g w h e th er to re p e a t o r c h an g e a m anoeuvre. T H E A V O ID A N C E O F D A N G E R T h ere a re d a n g e rs in m a n ip u la tio n as in a n y p o te n t trea tm e n t, and n o a tte m p t is m ad e here to d eal w ith th e special p re c a u tio n s w hich a p p ly to in d iv id u a l d iso rd e rs. N evertheless, I th in k so m e th in g useful c a n b e said in general term s a b o u t these h a za rd s, w hich n a tu ra lly cause m a n y people concern. T w o m a in ru les c a n be u se d , e ith e r to g e th e r o r singly, to govern th e safe use o f p a ssiv e m ov em e n t. T h ese a re ; R ule 1. O n ly go o n to the n e x t m an o e u v re w hen th e re su lts o f th e last o n e have b e co m e c lear. R ule 2. O n ly in cre ase fo rce w hen it is c le ar t h a t ra th e r less force in th a t d ire c tio n h as a lre a d y h ad g ood effect. T he first ru le su m m ariz es th e p ro c e d u re fo r “ n o t s e t” m a n ip u la tio n a lre a d y d e scribed. B o th ru le s a re referred to again below , in c o n sid erin g h ow d a n g e r is to b e a v oided. D a n g e r arises if th e re is e r ro r a t a n y o n e o f fo u r p o in ts : (1) Selection o f th e case. (2) Selection o f d ire c tio n o f force (“ n o t s e t” m a n ip u la ­ tio n ). (3) Selection o f a m o u n t o f force. (4) T h e w ay fo rce is used. T h e e rro rs th a t m a y o c c u r a t e a c h p o in t, a n d th e w ay in which they c a n be av o id e d , a re co n sid ere d in tu rn . A. U nsuitable C ase M edicine is n o t a n e xact science, a n d n o o n e w ould claim th a t it is p o ssib le to b e 100 p e r c en t c o rre c t in all diagnosis. A g a in , as a lre a d y discussed, th e m ed ical p ro fessio n is fa r fro m agreed o v e r d iag n o sis in th ese c o n d itio n s, a nd where there is d isa g ree m e n t som eone m u st be w rong. A rg u m e n t ov er d iag n o sis lies, o f c o u rse, larg e ly w ith in th e d o c to r’s pro v in ce , a n d th ere is n o a tte m p t h e re to e n te r it. H ow ever, as a re su lt o f th e a rg u m e n t it is so m e tim es held to be d a n g ero u s to m a n ip u la te u n til th e disa g ree m e n ts a re resolved. I t is this view w hich is discussed here, fo r it c o lo u rs the w hole su bject o f m a n ip u la tio n a n d p ro fo u n d ly influences its use. I w ould suggest th a t m a n ip u la tio n c a n nev erth ele ss be used if it is recognized th a t its c o n tro l is b y th e signs and sym ptom s o f th e d iso rd e r, ra th e r th a n b y the diagnosis. Septem ber, 1964 P H Y S I O H e re in lies safety. T h is p o in t w as m ad e e a rlie r a n d is no w d e a lt w ith in g re a te r d e ta il. I n a n y lesio n th e re a re c e rta in physical findings; these e sta b lish th e d ia g n o s is ; u p o n th e d iagnosis, th e d e cision to m a n ip u la te is based. T h e m a n ip u la to r, how ev er, gu id es his tre a tm e n t b y c o n s ta n t reference to the o rig in a l signs and sy m p to m s, as a lre a d y d escribed. I t is changes in the signs and sy m p to m s which determ ine w hether he stops, goes on or varies treatm ent. E ven w hen the d iag n o sis is u n q u e stio n e d , th is re m a in s tru e . T h e d iag n o sis a n d e x a m in a tio n o f in te rn a l d e ra n g e m e n t a t th e spine, fo r e xam ple, c a n d o n o m o re th a n say “ th is lo o k s a s if it is s u ita b le fo r m a n ip u la tio n ” . W h e th e r it is, a n d w h e th er m a n ip u la tio n w ill succeed, can o n ly be decided b y th e a tte m p t, th e guiding fa c to r b e in g th e p h ysical findings. I n a sense, th e re fo re , th e diag n o sis can be d ispensed with. O b v io u sly p re c isio n in diag n o sis m ak e s fo r p re cisio n in tre a tm e n t, b u t its a b se n ce o r e rro r n eed n o t m a k e fo r d a n g er o r c om pel in a c tio n . I t is q u ite p o ss ib le to m a n ip u la te a jo in t re sp o n sib ly a nd safely, a n d a t the sa m e tim e c o n sid er w hich o f several d iso rd e rs m ig h t give rise to the sy n d ro m e p re sen t, a n d w h ich is suggested m o st s tro n g ly by th e changes th a t o c cu r. I w o uld su b m it th a t th e w illingness to do th is can c o n trib u te a lo t o f u seful evidence to th e a rg u m e n t o ver diagnosis. B. W ro n g D irection T h e re is little d a n g e r o f e rro r h e re in “ se t” m a n ip u la tio n , since th o se m o v em e n ts w hich a re p a in fu l a n d lim ited a t e x a m in a tio n a re th o se w hich have to be p u sh e d . I n “ n o t se t” m a n ip u la tio n fo r in te rn a l d e ra n g e m e n t, on the o th e r h a n d , “ e r ro r ” c a n n o t alw ays be a v o id e d , f o r the m a n ip u la to r has to discover th e rig h t d ire c tio n . I t is o nly finding a m a n o e u v re ineffective o r e x a c e rb a tin g th a t e n ab les one to d iscard it in fa v o u r o f a n o th e r. S uch “ e r ro r ” how ever, w ill d o n o h a rm p ro v id ed it is su b je ct to th e tw o ru le s set ' o u t a b o v e ; th a t is, firstly, th a t it is c o n tro lle d b y the m eth o d o f re assse ssm e n t a lre a d y d escribed, and se condly, t h a t to o m u c h fo rce is n o t used to o soon, a p o in t n o w d e a lt with. C. T oo M u c h F orce T h is is w here re al d a n g e r lies; e r ro r in o th e r w ays o n ly becom es d a n g e ro u s if ad d ed to e r ro r here. “ T o o m u c h fo rc e ” m a y be a n y fo rce a t a ll o n th e w rong case o r in the w ro n g d irec tio n . I f case a nd d ire c tio n a re b o th su itab le , “ to o m u c h fo rc e ” is still p o ssib le , th o u g h it is lik e ly th en to re su lt n o t so m u ch in d a n g e r a s in severe, a v o id a b le tre a tm e n t soreness. “ T o o m u c h fo rc e ” c a n n o t be m easured b y a gauge, a n d re q u ire s ju d g e m e n t a n d a b a la n ce b etw een c o u rag e a n d re s tra in t in th e m a n ip u la to r. R u le 2 a b o v e sets o u t the p rin c ip le to be follow ed here, a n d th e m eth o d is n o w described in g re a te r d etail. A p re lim in a ry p u s h is a p plied a n d th e re su lts a re observed a t re -e x a m in a tio n . I f th e re is a g ood effect, m o re is done. I f th is re su lts in fu rth e r im p ro v e m en t, re a l firm n ess m ay th e n b e used. I f th e re is a n y su g gestion o f a d v erse effect, th a t m an o e u v re a n d p o ssib ly th e w h ole q u e s tio n o f passive m o v em e n t, m ay be re co n sid e red . T h e re su lt m a y b e assessed several tim es in o n e tre a tm e n t fo r in te rn a l d e ra n g e m e n t, o r fro m o n e tre a tm e n t to th e n ext, a s is m o re u s u a l in c ap su litis a n d ad h esio n . W here the c o n d itio n is a cu te o r o n e is u n s u re o f o n e ’s g ro u n d , th e first a tte m p t m ay well b e so g e n tle as to be a lm o s t useless. I t is o n ly the em ergence o f so m e slight im p ro v e m en t th a t en co u ra g es th e m a n ip u la to r to co n tin u e , a nd p ro b a b ly o n ly b y th e second o r third a tte m p t th a t he uses re q u is ite force. E x perience n a tu ra lly len d s speed here. P rovided the use o f fo r c e is alw ays subject to this rule, n o o n e need be a fra id o f it, a n d th e m a n ip u la to r m a y o fte n find h e rse lf using, a n d b e ing re q u ire d to use, c o n sid era b le stre n g th . T h e inexperienced a n d c a u tio u s p ro b a b ly b e gin b y u sin g insufficient th ru s t. I t is m u c h b e tte r fo r the p a tie n t a nd fo r the c o u rse o f m a n ip u la tio n to be o n th e safe side in th is w ay, b u t to a v oid d isa p p o in tm e n t th ey sh o u ld re m e m b e r th a t it is o n ly a fte r te n p a tie n ts a re n o w orse th a t th e ir tre a tm e n t T H E R A P Y page 7 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Page 8 P H Y S I O T H E R A P Y September, 1964 (a) P o s itio n in g (b) E x ec u tio n Fig. 2 R o ta tio n in E x te n sio n a t the lu m b a r sp in e . m ay becom e c o n fid e n t e n o u g h to m ak e the next p a tie n t be tte r. T h e re re m a in s a s itu a tio n , w hich o c c u rs o nly se ld o m b ut reg u larly fo r the m a n ip u la to r, w hen p re lim in a ry m an o e u v res p ro d u c e no change a t all. T h e p h ysical signs a n d sy m p to m s su g g e st the case to be su ita b le fo r m a n ip u la tio n , b u t clearly the o nly w ay o f a ch ieving a n y c h an g e is to use c o n sid e ra b le force, a n d th e n p e rh a p s find, to o late, th a t it is a n a d v erse one. W h e th e r this sh o u ld be d o n e is a m a tte r fo r ind iv id u a l o p in io n , a n d v a rio u s fa c to rs have to be co n sid ere d such as the g ravity o f the c o n d itio n a nd the p o ssib ility o f o th e r tre a tm e n t helping. C e rta in ly no o n e w ith o u t experience sh o u ld ta k e this ste p , a nd no p h y sio th e ra p ist sh o u ld d o so except a t the ex p ress wish o f the d o c to r a n d in c o n s u lta tio n w ith him. D . T ra u m a tic U se o f F orce E ven if th e case is s u ita b le and d ire c tio n and degree o f force c o rre c t, the m a n o e u v re can still be d o n e tra u m a tic a lly . M a n ip u la tio n th en becom es u n n e ce ssa rily p ainful a n d a la rm ­ ing fo r the p a tie n t a n d c au ses excessive tre a tm e n t soreness. I f th ere is a lso e rro r a t a n y o f the o th e r p o in ts, th e result will be p r o p o rtio n a te ly w orse. T h is su b je c t is in tim a te ly co n n ec te d w ith tec h n iq u e, and indeed is te c h n iq u e , a n d is th ere fo re discussed w ith o th e r m a tte rs u n d e r th is he ad in g . T E C H N I Q U E A good tec h n iq u e is c o m p o u n d e d o f m a n y fa c to rs b e arin g u p o n e ac h o th e r. It is im p o rta n t to a v oid “ ta k in g a ru n at th e j o i n t ” . T h is is so m e tim es d o n e to get a q u ick forceful m o v em e n t a n d is a c o m m o n cau se o f tre a tm e n t so re n ess. M o v e m en t becom es u n c o n tro lle d a t the e x tre m e o f ra n g e ; it th e re fo re becom es un n e ce ssa rily p a in fu l, h a rm fu l, frig h te n in g to th e p a tie n t, an d a sso c iated w ith in creased m uscle sp a sm . T h e sam e m ovem ent d o n e in a c o n tro lle d w ay h as n o n e o f these effects. T h is is p a rt o f the skill th a t the m a n ip u la to r m ust a c q u ire : th e a b ility to a p p ly a n e x a c t a m o u n t o f force a n e x ac t ra n g e o f m o v em e n t, w ith o u t u n c o n tro lle d “ ru n u p ” to the ra n g e o r “ ov er r u n ” b e yond it. Such skill is alw ay s im p o rta n t. I t is especially so w hen it is decided to m ove a jo in t in to a ra n g e o f m o v em e n t th a t is gro ssly lim ite d , since it is best to d o th is fra c tio n a lly ; th a t is, to m ove th ro u g h a few degrees first, o b se rv e re su lts, a n d th en m ove fu rth e r. I t is helpful here to th in k o f each m a n o e u v re as hav in g tw o p a rts : p o sitio n in g a n d exec u tio n . Positioning is m o ving the jo in t u p to the extrem e of po ssib le ra n g e w ith the p a tie n t tru stfu l, relaxed a nd as com ­ fo rta b le as possible, a nd o n e se lf in a goo d fu n c tio n a l p osi­ tio n . E xecution is the final effective o v e r-p re ssu re, once proper positioning has been achieved. ( N o t all m a n ip u a ltio n involves m o v em e n t in to a n e x tre m e o f range, b u t this p ic tu re can be used to ex p ress a n im p o rta n t prin cip le in tec h n iq u e.) Ju d g e ­ m en t in ex ec u tio n is very im p o rta n t, b u t the m ain a r t o f m a n ip u la tio n p ro b a b ly lies in p o sitio n in g , a n d it is this which is chiefly re sp o n sib le fo r re la x atio n . A t least th re e fa c to rs have a b e arin g here. F irstly , if the p a tie n t is frightened he will be u n a b le to relax, a n d a sim ple e x p la n a tio n o f w h a t o n e is a tte m p tin g will d o m u ch to set him a t ease. Secondly, if the p a tie n t is n o t used to full jo in t m o v em e n t (for one o f m an y re a so n s such as being u n a thletic, se d e n ta ry , aged, etc.) the se n sa tio n o f h a ving the jo in t taken to ex tre m e o f ra n g e m ay well be d istu rb in g , a t least, for him a n d he m ay ag ain be u n a b le to relax. F in a lly , a n acute c o n d itio n m ay well cause p ain n o t o n ly at the end o f possible ra n g e b u t o n m o v em e n t from one p o sitio n to a n o th e r; p o sitio n in g will have to be slow a n d d e lic ate to minimize b o th th is a n d the c o n se q u e n t tig h te n in g o f m uscles. F o rc e fu l a tte m p ts to ov e rco m e a n y o f these fa c to rs will p ro d u c e m ore p a in and m uscle sp a sm in a vicious circle th a t achieves n o th in g except the p a tie n t’s s tro n g disinclini- c a tio n to be m a n ip u la te d again. A jo in t c a n n o t be brow ­ b e aten in to c o -o p e ra tio n a ny m o re th a n a stra n g e ch ild or a w ild a n im a l. It is p a tie n ce a n d su b tle ty th a t c o u n t, a n d , if n ecessary, m o re tim e m ust be ta k e n o v e r p o sitio n in g . The second tre a tm e n t will o ften tak e a fra c tio n o f the tim e o f the first b ecause the c o n d itio n h as im proved and the p a tie n t is no lo n g er a p p reh e n siv e. It is alw ay s p o ssib le to get re la x a tio n sufficient to achieve w h a t one w a n ts, a n d m uscle sp a sm is v a lu a b le in indicating th e s ta te o f the jo in t a n d g u iding w h a t o n e does. W here it c a n n o t be ov e rco m e it m ay well be in ad v isa b le to try ; an a tte m p t to force su c h a m ovem ent sh o u ld be considered very c are fu lly indeed. T h is is a n o th e r w a rn in g th a t is re­ m oved by a n ae sth esia . S ta n ce and g rip m ust be eco n o m ic in effort fo r the physio­ th e ra p is t a n d c o m fo rta b le fo r the p a tie n t. A goo d technique stem s fro m first c o n sid e rin g w h a t s tra in o n e w ishes to apply to th e jo in t, th en stu d y in g how v a rio u s e x p erts h ave achieved this, a nd finally a d a p tin g these findings to o n e ’s own p h y siq u e and a p titu d e s . R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) September, 1964 P H Y S I O T H E R A P Y Page 9 T h e h a n d s h o u ld a t a ll tim e s b e a p e rfe c tly c o m fo rta b le in stru m e n t fo r tra n s m ittin g force. I t m o u ld s its e lf to th e p a tie n t a n d is b o th g e ntle a n d con fid e n t. O n e m u s t b e a b le to a p p ly c o n sid e ra b le fo rce w ith o u t p a ssin g o n a sense o f e ffort to th e p a tie n t b y u n n e c e ssa ry tig h te n in g o f th e fingers. T h e p a tie n t w ill sense a n y la c k o f a u th o r ity in h a n d s o r m a n n e r a n d find it difficult to re la x . T h e re is, u n fo rtu n a te ly , n o w ay o u t o f th e fa ct t h a t o n e p ra c tis e s o n o n e ’s first p a tie n t a n d indeed p ro b a b ly o n th e first h u n d re d . W h a t o n e p ra c tis e s how ever, m u s t b e h o w to re d u c e a disc lesio n a n d n o t how to d o a ro ta tio n . T h e m a n o e u v re s th em selves m u st a ll h a v e b een p ra c tis e d m an y tim e s o n m a n y m o d els, so t h a t o n e is fa m ilia r w ith th e w ide v a rie ty o f j o in t m o v e m e n t in different p h y siq u e s, a n d w h a t th e ex tre m e o f ra n g e feels like to o n e se lf a n d to th e m odel. T h e re is n o n eed fo r su c h p ra c tis e to b e fo rc e fu l; in fa ct it is b e tte r fo r it n o t to be. T h e a im is to stu d y grip, h a ndling, p o s itio n s a n d stance. T h u s w h e n first tre a tin g a p a tie n t o n e c a n a t le a s t h a n d le the jo in t a d ro itly a n d is th u s a b le to c o n c e n tra te o n th e lesion, e x p lo rin g ra n g e a n d m u sc le sp a sm a n d re su lts w ith han d s a n d o b se rv a tio n . P A I N A N D T R E A T M E N T S O R E N E S S P a in has to b e c o n sid ere d in tw o w ays. W e have a lre a d y seen ho w its b e h a v io u r can b e u sed as a g uide to assessing p rogress. Secondly, th e re is th e q u e stio n o f h o w m u c h p a in is in se p a ra b le fro m tre a tm e n t, a n d th is is n o w discussed. T o p u s h a p a in fu l ra n g e o f m o v e m e n t is so m e tim e s fo r ­ b idden as d a n g e ro u s, b u t I h o p e I have said e n o u g h to sh o w why th is need n o t b e so. P a ssiv e m o v e m e n t fo r c a p s u litis o r a d h e s io n m u s t a t le a st h u r t a little , since it involves pushing th e p a in fu l a n d lim ite d ra n g e. T h e effective m anoeuvre in in te rn a l d e ra n g e m e n t m a y b e in a p a in fu l o r a painless ra n g e a n d o n e has to d isc o v er w h ic h it is. T o forbid p a in fu l m o v em e n t a lto g e th e r is to p re v e n t tre a tm e n t where it c a n b e m o s t effective. O bviously, m o v em e n t in to a p a in fu l ra n g e m u s t be s u b ­ ject to w h a t th e p a tie n t c a n re a s o n a b ly to le ra te a n d it is unwise a n d in h u m a n e to exceed th is . T h a t h a v in g b e en said, however, it m u s t a ls o b e said th a t th e c rite rio n o f w h e th er o r n o t a m a n o e u v re sh o u ld b e u sed is n o t “ d o e s it h u r t ? ” b u t “ does it have th e rig h t e ffe c t? ” . T h e m e th o d o f re assess­ m ent th a t decides th is a n d th e ru les w hich p re v e n t e x a c e rb a ­ tion have a lre a d y b e e n discussed. M a n ip u la tio n is u n fo rtu n a te ly so m e tim es m a d e u n n e c e s­ sarily p a in fu l b y b a d te c h n iq u e . V a rio u s p o in ts t o b e avoided have a lre a d y b e en m e n tio n e d u n d e r “ T re a tm e n t” ; they c a n b e e lim in a ted b y skill a n d c are , a n d a m e n ta l p r o ­ jection o f o n e se lf in to th e j o in t o n e is tre a tin g . T re a tm e n t soreness d oes o c c u r, how ever, a n d m u s t b e re c k o n e d w ith. T rea tm e n t sh o u ld sto p b e fo re it b e co m es m a rk e d , b lu rrin g the p a tte rn o n re a sse ssm e n t w hich is th e m a n ip u la to r ’s guide. A p o in t to re m e m b e r here is th a t if, d u rin g m a n ip u la tio n , several m en o e u v res a re trie d w ith o u t effect, tre a tm e n t soreness can ra p id ly b e co m e se v e re ; th e o rig in a l c o n d itio n is as p ainful as ever a n d th e jo in t has no w b e en m o v ed a b o u t a good deal. O n c e a successful m a n o e u v re is fo u n d , the o rig in a l p a in fro m th e le s io n m a rk e d ly su b sid e s a n d trea tm e n t soreness is th e n sw allow ed u p in th e general im provem ent. T h e o nset a n d se verity o f tre a tm e n t so re n ess is in a n y case exceedingly diverse, v a ry in g w ith th e le s io n a n d th e sensitivity o f the p a tie n t’s p h y siq u e to j o in t m o v em e n t. T re a tm e n t a t one session c o n tin u e s u n til th e re q u ire d effect h a s b een p ro ­ duced, o r u n til e ith e r jo in t o r p a tie n t h a s h a d en o u g h . E X E R C IS E S (This p a p e r d eals w ith lesio n s o f th e in e rt tissu e s w here there is a n o rm a l n e u ro -m u s c u la r system . S om e o f w h a t is now said a p plies w h e n n e u ro -m u s c u la r d is o rd e r is p re se n t, b u t o th er fa c to rs m a y th e n ta k e preced en ce.) T here is som etim es a difference o f o p in io n a b o u t th e treatm ent o f these c o n d itio n s, a n d exercises m ay be used instead of, o r w ith, p assive m o v em e n t. T h is ra is e s v a rio u s p o in ts w h ich a re n o w disc u sse d . I f a le s io n re q u ire s tre a tm e n t by j o in t m o v e m e n t, it is o f c o u rse th e o re tic a lly p o ss ib le to m a k e th e m o v e m e n t an a c tiv e o n e (exercise) in stea d o f a p a ssiv e o n e (o r m a n ip u la ­ tio n ), th e p a tie n t’s m uscles b e in g used in stea d o f th e p h y s io ­ th e r a p is t’s. B o th p ro c e d u re s m ay h ave th e rig h t effect a n d . b o th o f th e m c a n th e re fo re b e fo u n d u se fu l in th e sa m e c o n d itio n . E x erc ises m ay th e re fo re b e u se d to p ro d u c e a j o in t m o v em e n t, th e m o v e m e n t its e lf b e in g th e effective m e a su re f o r th e in e rt tissu e s a n d th e m u sc le s m e re ly b e in g used to a tta in it. E xercises m a y a ls o b e u se d in th e s e c o n d itio n s b e c a u se it is c o n sid ere d t h a t th e m u sc le s th em se lv es re q u ire tre a tm e n t. F o r e x am p le, it m a y b e felt th a t s tre n g th e n in g o r tra in in g th e m u sc le s a b o u t a j o in t w h ich is d e g e n e ra te o r lia b le to d e ra n g e m e n t w ill re n d e r it less lia b le to stra in o r r e ­ d isp la c e m e n t. H e re th e exercise is d irec te d p rim a rily to th e m u sc le s, a n d th e jo in t m o v e m e n t is s u b o rd in a te to it. I t is n o t alw ay s k e p t c le a r, how ever, t h a t a m o v em e n t w h ic h is n icely c a lc u la te d fo r a p a r tic u la r effect o n th e m uscles m ay be excessive o r in a d e q u a te o r in th e w ro n g d ire c tio n fo r th e p rim a ry lesio n o f th e in e rt tissu e . F o r in stan c e, free a ctive exercises fo r the m uscles a b o u t a n a rth r itic j o in t m ay re su lt e ith e r in th e j o in t flaring o r b e c o m in g m o re a n d m o re stiff if th e m o v em e n t is to o d ra s tic o r insufficient fo r th e c a p ­ su litis itself. A g a in , o n c e re d u c tio n o f in te rn a l d e ra n g e m e n t is c o m p le te , e m p h a sis s h o u ld b e o n u sin g th e jo in t in g ood p o s itio n s o n ly a n d exercises fo r th e m u sc le s m u s t b e su bject to th is a n d av o id m o v e m e n t w hich m a y u p s e t th e lesion. I t is so m e tim e s held th a t exercises a re sa fer th a n passive m o v e m e n t b e ca u se th e p a tie n t w ill sto p s h o r t o f d o in g h im s e lf re a l h a rm a n d th u s e s ta b lis h a n a u to m a tic c o n tro l; th is is o fte n th e view o f-th o s e w h o fe a r t h a t if th e p h y s io ­ th e ra p is t is tu rn e d lo o se w ith p a ssiv e m o v em e n t, a n y th in g m a y h a p p e n . I t is p o ss ib le fo r fre e a ctiv e exercises to b e fa r m o re tra u m a tic th a n p ro p e r m a n ip u la tio n , how ever, e speci­ a lly if th e p a tie n t gets h old o f th e p e rn ic io u s (in in te rn a l d e ra n g e m e n t) id ea t h a t th e m o re it h u rts th e b e tte r it is. I t is a ls o difficult, in p ra c tic e , to u se th e m to p ro d u c e th e selective m o v e m e n t re q u ire d fo r in te rn a l d e ra n g e m e n t, w h e re d ire c ­ tio n o f th r u s t is b a se d u p o n , a n d v a rie d by, c o n s ta n t re­ e x a m in a tio n . L a stly , ra n g e o f m o v e m e n t a n d d e g ree o f fo rc e m u st alw ay s be u n d e r c o n tro l. P a ssiv e m o v e m e n t is m u c h m o re efficient h e re ; th e p h y s io th e ra p is t’s h a n d s feel w h a t is being d o n e a n d a ls o g o v e rn it m o re e x ac tly . S o m e tim es it is n o t p o ss ib le fo r th e p a tie n t h im s e lf to get th e n ecessary force ap p lie d to a p a rtic u la r ra n g e w ith o u t “ ta k in g a r u n a t it” , w hich, as we h a v e seen, is o n e o f th e m a in c a u s e s o f n eedless tra u m a . T h e p h y s io th e ra p is t c a n get b e tte r leverage, k n o w s w h e re th e m o v e m e n t sh o u ld s to p , a n d c a n c o n tro l it p ro p e rly . A ssisted , re sisted , h o ld -relax te c h n iq u e s o v e rla p passive m o v e m e n t m u c h m o re c losely, a n d c a n o fte n b e u sed w ith e x ac tly th e n a m e effect. T h e p h y s io th e ra p is t has her h a n d s o n th e p a tie n t a n d c a n assess a n d c o n tro l p re cise ly w h a t is h a p p e n in g . U se o f th e p a tie n t’s m u sc le s, h ow ever, m u s t n ever d istra c t a tte n tio n fro m th e in e rt tissu e s t h a t a re th e site o f th e lesion. I f m o v e m e n t is to b e th e c u ra tiv e m e a su re , it m u s t b e su b je ct p rim a rily to th e n eed s o f th o s e tis su e s a n d o n ly se c o n d arily to th e n eeds o f th e m uscles. S u m m ary T h e u se o f m a n ip u la tio n b y p h y s io th e ra p is ts is c o n sid ere d as p a r t o f th e use o f p a ssiv e m o v e m e n t. D iffere n c es in d e fin itio n a n d o v e r d ia g n o s is a re discussed. I t is suggested t h a t m a n ip u la tio n m ay be u se d safely a n d w ith goo d effect in sp ite o f th e s e differences, a n d th a t its c ritic a l use c a n d o m u c h t o re so lv e th e m . M e d h o d s w h e reb y th is c a n be d o n e a re p u t fo rw a rd , a n d g e n era l p o in ts a b o u t te c h n iq u e a n d exercises a re discussed. R E F E R E N C E S 1. C y r t a x , J. (1962). T e x tb o o k o f O rthopaedic M edicine, V ol. 1. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )