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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I’ve recently been reflecting on the clinical relevance of evaluating end-fee in clinical practice. The issue arose from  a conversation about interpreting patient response to manual therapy and whether “useful clinical change” was being achieved. Changing end-feel is certainly part of the manual therapists armory and needs to be considered in conjunction with range of motion as a measure of effectiveness. However in situations of established degenerative change the clinical objective may be to improve tolerance of static positions (typically lying in spinal conditions) and in these cases improving end-feel is often the key criteria in reducing symptoms without tangible range changes.

Conversely, failure to alter end- feel is a poor prognostic indicator and one where the clinician must be vigilant.

Knowing when not to treat is also a skill we must embrace.

I’ve included a refresher summary below of the issues associated with end-feel in spinal examination.

Different sensations of movement barriers can be perceived according to the tissues limiting motion, the anatomical region, and pathological change.  Cyriax describe a number of characteristic End-feels

1. Bone to bone
2. Spasm
3. Capsular feel
4. Springy block
5. Tissue approximation
6. Empty feel

Kaltenborn summary of end-feel

1. Normal soft end-feel due to soft tissue approximation
2. Normal firm end-feel due to capsular ligamentous stretching
3. Normal hard end-feel (bone to bone)

In pathological states the variations may be:

1. A firm less elastic feel (indicative of scar tissue or shortened connective tissue)
2. An elastic less soft end-feel (indicative of increased muscle tone)
3. An empty end-feel (patient limits movement prior to resistance)

(This is indicative of inflammation, serious pathology or fear avoidance behaviour)

ACCESSORY MOVEMENT

In order to allow physiological movement joint surfaces undergo combinations of rotation and translation.  These characteristics are determined by the shape of the joint surfaces, the ligament us and capsular tension and the inherent bony structures.

When a concave surface moves on a convex the direction of translation (slide) is in the same direction as that of the motion (rotation).  When a convex surface moves on a concave the translation is in the opposite direction to the motion.

Manual Examination

Objective: to determine the presence presence of vertebral motion (somatic) dysfunction.

Passive Physiological Intervertebral Motion (PPIVM’s)

Passive Accessory Intervertebral Motion (PAIVM’s)

Functional Technique

Flexion / Extension

- segmental range

- total range

Side flexion / Rotation

- segmental range

- total range

- coupled motion

- position dependent

Correlation of active movement , PPIVM’s & PAIVM’s to define diagnosis and prescribe optimal treatment strategies.

Saggittal plane motion: nutation / counternutation

Range:

Intra-pelvic motion a function of:

Inominate position (functional test in Siting)

Sacral position

Spinal position

Manual Examination Techniques

Physiological Motion

Lumbar flexion

Lumbar extension

Lumbar side flexion

Lumbar rotation

Lumbar shear

Accessory Motion

PA’s

Unilateral’s

Transvers’s

In combined positions

Positional assessment:

ASIS

PSIS

Iliac Crest

Standing hip flexion test

Standing hip extension test

Positional assessment:

Sacral base

Inferior lateral angles

Accessory glide

Shear (stress) test

Enjoy the clinical challenge

David

Gertzbein, S. D., R. Holtby, et al. (1984). “Determination of a locus of instantaneous centres of rotation of the lumbar disc by moire fringes.” Spine 9(4): 409-413.

Gertzbein, S. D., J. Seligman, et al. (1985). “Centrode patterns and segmental instability in degenerative disc disease.”  Spine 10(3): 257-261.

Loeble, W. Y. (1967). “Measurement of spinal posture and range of spinal movement.”  Annals of physical medicine 9: 103-110.

McFadden, K. D. and J. R. Taylor (1990). “Axial rotation in the lumbar spine and gaping of the zygapophyseal joints.”   Spine15(4): 295-299.

Panjabi, M., I. Yamamato, et al. (1989). “How does posture affect coupling in the lumbar spine.”  Spine 14(9): 1002-1011.

Pearcy, M. (1984). “Is there instability in spondylolisthesis.”  Spine 10(2): 175-177.

Pearcy, M., I. Portek, et al. (1984). “Three-dimensional x-ray analysis of normal movement in the lumbar spine.”  Spine 9(3): 294-297.

Seligman, J. V., S. D. Gertzbein, et al. (1984). “Computer analysis of spinal segmemt motion in degenerative disc disease with and without axial loading.”  Spine 9(6): 566-573.

Stokes, I. A. F. (1986). Three dimensional biplanar radiography of the lumbar spine. Modern Manual Therapy, London, Churchill Livingstone.

Stokes, I. A. F., D. G. Wilder, et al. (1981). “Assessment of patients with low back pain by biplanar radiographic measurement of intervertebral motion.”  Spine 6(3): 233-239

© David for PhysioDigest - an educational resource for the musculoskeletal rehabilitation community, 2009. | Permalink | No comment | Add to del.icio.us
Post tags: ACCESSORY MOVEMENT, Characteristics of End-feel, Clinical Assessment, Convex - Concave rule, End-feel, Kaltenborn, lunbar spine, manual therapy, pelvis, poor prognostic indicator, si joint, useful clinical change

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