It is fitting to pay tribute to Geoff Maitland who died recently in Adelaide, South Australia.  Geoff was a pioneer in manipulative physiotherapy.  He gave his name to one of the most widely used manual therapy concepts around the globe today.  Although his primary clinical interest was in musculoskeletal dysfunction, he can certainly be credited with developing a systematised subjective examination which is used across all physiotherapy specialities.

It is perhaps this ability to systemise the subjective process, the clinical examination and the treatment selection, which are the real legacy of this true pioneer.  I had the privilege of working and meeting Geoff and his wife Anne on several occasions and had the fortunate experience of working on a three day video shoot for a clinical teaching module back in1991. He was a truly humble man whose general demeanour gave no indication of his achievements.

Most who trained in these shores would have been introduced to the Maitland concept as an integral part of undergraduate teaching of musculoskeletal practise.  As an enthusiastic (but somewhat naive) new graduate I remember the mental conflict I experienced when trying to understand Maitland’s classic concept of the “semi permeable brick wall” regarding diagnosis, pathology and clinical findings.  In fact if I am totally honest I was a little dismissive of this idea, which at the time I thought was somewhat woolly, non- specific and a little vague.  Such was my disillusionment that I enrolled in a six month Orthopaedic Medicine training programme which taught the principles of another pioneer James Cyriax.  What appealed to me at the time was the preciseness if somewhat dogmatic nature of Cyriax’s teachings, which appealed greatly to my thought processes at that time.  As the clinical mileage began to increase it became increasingly clear that precise diagnostic patterns were the exception rather than the rule and that my search for a definitive diagnosis based on clear cut symptoms and history were a little fanciful so say the least!

This realisation redirected me back to the more fluid clinical approach, which was such an integral part of the Maitland concept.  This prompted further exploration involving study in Perth, Western Australia in 1990 and remains a core component at my clinical practice, twenty years later.

In these days of multi-structural treatment and integration of concepts the focus on pure manual therapy techniques has moved down the agenda to some extent.  The proverbial “chicken and egg” debate regarding muscle dysfunction causing joint pathology or visa versa is a circular debate.  The clinical reality is that we need tools in our armoury to address these components whatever way we arrive at a system of prioritisation.

To address this Maitland postulated a concept of dysfunction based on:

new use

abuse

disuse

overuse

classification system, which I think all clinicians would do well to bear in mind when assessing any musculoskeletal presentation.

One could be critical that the Maitland system did not teach direct muscle treatment strategies or focus on movement re-education as part of a patient management strategy but it did leave us with an unbelievable rigorous system for evaluation and treatment of joint dysfunction using manual therapy techniques.  Developing the manual therapy skills to assess, treat and exclude joint dysfunction as a component musculoskeletal impairment is an essential daily requirement for every clinician.  It is hard to see how one could dispense with his work if we accept the need to directly treat joint’s exhibiting dysfunction.

A contemporary, Freddy Kaltenborn, simultaneously devised a treatment system based on joint mechanics and accessory motion but in reality much of this fundamental biomechanical understanding was integrated into the Maitland approach. Although Maitland’s writings did not expand in detail on pathology he cleverly integrated manual therapy provocation / exploration tests which could readily identify dysfunction – even if the diagnostic accuracy was not a high priority. As it often boils down to assessing treatment response this is the most practical clinical approach which is true scientific method using comparable sign’s and pre / post-treatment analysis of relevant patient markers. Is this not evidence based practise in its purest form?

I for one am very grateful for his dedication and commitment to the profession and hope he retains a watchful eye in his final place of rest..

Enjoy the clinical challenge.

David

© David for PhysioDigest - an educational resource for the musculoskeletal rehabilitation community, 2010. | Permalink | No comment | Add to del.icio.us
Post tags: cyriax, diagnostic classification, Geoff maitland, Kaltenborn, Maitland, manual therapy, manual therapy concept, movement diagrams, semi-permeable brick wall

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