An attempt to select principles must be confined to discussion of prime constituents, a search for a general formula. The reader must study the literature of the subject for detailed information about the practice of manipulation, particularly about examination, contraindications, and technique.

The endeavour to crystallise such a formula poses three immediate problems:

1. The definition of the word 'manipulation' is by no means agreed. To take extreme examples: it may be used to describe either the forcing of a painful and limited range of movement under anaesthesia, or a small painless movement on the conscious patient.

2. The purpose of manipulation is also by no means generally agreed; success in treatment being ascribed by different experts to the resolution of different pathologies.

3. A statement of general principles seems to reqmre guidelines about the dangers of manipulation. To do this in the midst of confusion about definition and purpose seemed impossible.

The first concern here, therefore, is with terminology and definitions.



TERMINOLOGY AND DEFINITIONS



All manipulation is passive movement, but not all passive movement can properly be called manipulation. Somewhere along the line, as force, speed, complexity or purpose change, a passive movement becomes a manipulation but there might be disagreement about exactly when this occurs.

The use of force

The use of controlled force is essential to manipulation, but the word 'force' is alarming because it has connotations of ruthless intention, lack of control, and provocation of pain.

Terminology in which 'relaxed passive movement' is contrasted th 'forced passive movement' and 'manipulation' carries the mggestion that forced passive movement and manipulation are not relaxed. This in turn suggests that the resistance which is being encountered is that of muscle activity, and an association is often made with the provocation of pain. In fact, of course, the whole art of manipulation lies in having the patient perfectly relaxed, and the resistance that is being overcome is practically never that of muscle activity.

Some re-definition is needed here, and the terms 'free' and 'stressed passive movement' are offered, to be used in the following way:



Force in normal movement

Free passive movement is movement in which there is no encounter with tissue resistance at all, and which therefore requires no force for

its performance. As soon as there is even the lightest encounter with tissue resistance, the movement is called stressed passive movement, necessarily demanding the use of force for its completion.

By the use of the word 'stressed' in this way it is hoped to avoid the rather dire nuances that surround the word 'forced'-, while emphasising that in most movements in the body, full range can only be achieved by using a degree of force to overcome normal increasing tissue resistance.

The term 'end-feel' is used by Cyriax (1978), to describe the quality of the factor limiting a passive movement, as perceived by the hand. It thus refers to the element of palpation which exists in passive movement, and is related to the term 'tissue tension sense' that is used by manipulators.

There are three 'end-feels' in the normal:

The first is bone-to-bone, in which active and passive ranges are equal.

The next two are tissue approximation and tissue tension, and in both of these, passive range is greater than active. Passive movement into such ranges is partly free and partly stressed, and the point at which the change occurs, i.e. the point of encounter with first tissue resistance, is earlier in the range than.is usually recognised.

The term accessory range is here used to denote that part of stressed passive movement which lies beyond the end of active movement. The end of active movement lies somewhere beyond the end of free passive movement and before full stressed passive movement.

The relative proportions of free passive movement, active movement, and stressed passive movement vary endlessly in different movements, positions, physiques and ages, as does the resistance offered by the tissues. A general formula may be offered

DIRECTION OF MOVEMENT

FREE PASSIVE MOVEMENT

STRESSED PASSIVE MOVEMENT

AGAINST INCREASING TISSUE RESISTANCE

ACTIVE MOVEMENT

Full stressed passive movement s greater than active movement and greater than free passive movement



In the normal, bone-to-bone and tissue approximation are painless. Tissue tension may also be painless, but in some physiques it may .be anything from slightly uncomfortable to downright painful in the normal. This must be borne in mind when evaluating the abnormal.

With the gross primary, movements which can be achieved actively there are elements of slide, roll and spin which together constitut prime movement, but which can be isolated when the joint is in ar appropriate position. These" isolated movements together wit distraction of joint surfaces, we tend to call accessory movements Important components of normal movement, therefore, are access nuroement and accessory range; Mennell (1964), uses the term 'join play'. These can only be achieved by applying a degree of force, an, are thus all stressed passive movements. This characteristic ¢ accessory movement and their integrity is an important safeguar against the stresses of normal life.



Force in abnormal movement

Abnormality begins when either discomfort or resistance is grea than normal. The beginnings of the abnormal are to be noticed 1o before there is frank painful limitation of movement and are usually found "in accessory movement before gross primary range is For example:

il. Movement is full, but becomes uncomfortable earlier in the range than is normal Movement is full, but the quality of the resistance is denser, or offeredearlier in the range than in the normal

3. Movement is full, but an element of muscle spasm may be picked up by quick or careless handling.

The ability to distinguish between the resistance of tissue tension and that of muscle activity (be it active resistance or spasm) is one of the first things that the manipulator must acquire. These elements are subtle and difficult to learn, but their recognition forms the basis of informed and safe manipulation. An attempt has been made to illustrate them as Movement Diagrams (Hickling and Maitland, 1970).

It is in talking of this kind of phenomenon that manipulators are sometimes accused of mumbo-jumbo. Critics should be ready to accept that the manipulator may be attempting to convey acute perception with rather inadequate terminology. It is perhaps only fair to add that the manipulator should beware of self-deception about illusory or subjective data.



Amplitude/force/velocity



The word 'amplitude' is used to describe the size of a movement, and an important skill that the manipulator must acquire is to be able to perform a forceful, high velocity movement through a small amplitude.

The distinction between 'positioning' and 'execution' must be drawn here. Many manoeuvres are quite complex and involve considerable joint movement before the position is reached from which the manipulation is performed; insufficient care in the preliminary positioning leads to ineffective, dangerous, or unnecessarily painful manipulation.

To take a single example: the manipulator may wish to apply a high velocity thrust at the end of a generalised rotation of the trunk. During this, from position of rest to the end of the manipulation, the trunk may be seen to move through about 90 degrees represented diagrammatically in Figure 11/2. The major part of this movement is positioning, and only the last few degrees are manipulation proper.

Somewhere about point B various things occur:

1. The manipulator encounters resistance and can only continue by using increased force to enter a stressed passive range.


2. The type of resistance has to be evaluated. Muscle activity (spasm or active resistance) must be distinguished from tissue tension, and the manoeuvre then modified or abandoned.

3. If the resistance is of an expected and acceptable kind, the manipulator may use considerable force and velocity to overcome it, but must be able so to control matters that movement stops at the end of normal range at point C.

4. At the same time, the manipulator must be sure that any pain provoked is of an acceptable degree and position.

If muscle activity is not recognised, or uncontrolled force takes movement beyond normal range, either the joint is not moved effectively, or trauma occurs, or both.


The skilled manipulator may choose to move from resting position to the end of the manoeuvre in one continuous, large amplitude movement, combining positioning and execution. Novices must beware of copying this, for they cannot possibly have the necessary perception and control to make such movement accurate, effective and safe. Students should separate positioning from execution, and realise that skill in the first is more difficult than, and takes precedence over, skill in the second.



Mobilisation



The word 'mobilisation' has now acquired two distinct meanings.

1. The first meaning is of long-standing use in rehabilitation. Here, 'to mobilise' means to induce and encourage mobility by whatever means are suitable. It may range from giving a recumbent patient her first gentle walk down the ward, to chasing young men round a tough training circuit. The implication is to 'push on', to stretch the patient a bit, by whatever means seem appropriate. It thus intention but does not define method.

'.In 1964 Maitland first stressed the view that the manipulator does not always need forceful techniques, but should often use more entle methods. More gentle techniques obviously have to be

carried out for longer to achieve their effect, and Maitland perfected a method of oscillatory passive movement, which he

divided into Grades in order to introduce an idea of 'dosage'. Readers are referred to his books for more detail on this subject.

the word 'mobilisation' for these techniques, and it acquired a second technical meaning: oscillatory passive

with the implication of 'holding back' from more forceful It will be seen that this is quite different from the use of the word described above.

.Doctor and physiotherapist may well misunderstand each other

for example, there is a prescription to 'mobilise' a patient with pain. If either is uncertain what the other means by the use of this rd, they are strongly advised to find out.

In the ensuing text 'mobilisation' is used in the rehabilitative sense, and Maidand techniques are called 'oscillatory mobilisation'.



Manipulation/thrust techniques/Grade V



Recently the word 'manipulation' on the conscious patient has increasingly been reserved to describe a small amplitude, high velocity, forceful passive movement, usually (but not alwgys) at the end of range. It is almost always into a stressed passive range, and the resistance being overcome may be a combination of the normal and abnormal. With few exceptions, however, it does not include forcing muscle activity, and this is an important safety factor.

This kind of manoeuvre is also called a 'thrust technique', or a 'Grade V' (linking it with the other Grades of oscillatory mobilisation described by Maitland). After positioning, the final thrust may not be in the same direction as the posit;oning movement. Osteopathic techniques described by Stoddard (1962), which are aimed at moving the apophyseal joints, give ample examples of this.

The above definition of manipulation is a useful one. The reader should be aware however that the word has other, slightly different meanings in the literature on the subject. For example, Mennell (1964), writes of'examination manipulation' and 'treatment manipulation', an interesting use of the word which emphasises the interlocking relationship of examination and technique in practice.

PATHOLOGY: PURPOSE OF MANIPULATION

As already suggested, those who advocate manipulation by no means agree about what it is for. It only requires a brief acquaintance with both its literature and its exponents to make it abundantly clear that they are at odds about the disorder which responds to this treatment.

To take the simplest example-a common syndrome which presents with unilateral pain in the lumbo-sacral region and asymmetrical limitation of movement may be variously ascribed to disorder of the intervertebral disc, the lapophyseal joint or the sacro-iliac joint. The manipulating physiotherapist who sits in the middle of the argument receiving similar cases with different diagnoses is perhaps peculiarly well able to appreciate this problem.

Where doctors disagree it would be unwise for the physiotherapist to have no doubt, but uncertainty need not lead to inaction. Naturally, confidence in diagnosis is a great help, but in practice no treatment is con:rolled by it. The diagnosis merely helps select the treatment, which is then controlled by reference to the presenting symptoms and signs, and changes which occur in them. The less certain the diagnosis, the more punctilious must re-examination become. It is this punctilious re-examination which enables the manipulator to treat, for example, the syndrome described above in a perfectly safe, methodical and effective way, while preserving a speculative approach to the nature of the underlying problem. This calls for a certain detachment of mind, which some find worrying or unsatisfactory. However, if manipulating physiotherapists can acquire this they may find that they are able to contribute evidence when the diagnosis is unsure, since the response to certain techniques can be retrospectively enlightening.

The reader is reminded that this chapter is about the principles, not the practice,' of manipulation. The manipulating physiotherapist is strongly advised to study all schools of thought, not only one, and to try to cultivate a dispassionate approach of the kind indicated abovei an approach which may cumulatively throw light on what is now opet to argument.



DISORDERS WHICH MAY RESPOND TO MANIPULATION



Disorders which may respond to manipulation are now divido very generally under two headings, mechanical derangement an contracture and adhesion.


derangement



there is limitation of movement due to joint derangement or derangement of some kind; under this heading can be put as disc lesions, displacement of cartilage, impacted bodies, and possibly the impaired mobility described by

The purpose of manipulating is to move something: either a be reduced, returning structures to normal position or it may be shifted to a 'silent position' in which it no pain. Manipulation of this kind does not involve trying fforce the most painful and limited range. It is similar to the task of a bit of jammed machinery-one does not usually achieve by forcing the block, but by disengagement and perceptive in some other direction. Because of this, manipulation for • derangement often includes distraction of the joint, and

t into a painless or minimally affected range It is commonly, though not always, entirely painless. Often it is not certain what manoeuvre will resolve the block. The must re-examine frequently to determine whether to

a manipulation or to use another one, and continuous is needed about the degree and position of any pain

patient's co-olxration in providing this kind of clinical is essential, and anaesthesia is therefore not used.



and adhesion such cases limitation of movement may be due to contracture or of tissues spanning a joint; this may be due to trauma, or immobilisation, or it may be secondary to some underlying In this category may also be placed the localised adhesion.

of manipulating here is to stretch out or rupture the tissue, and the manipulator necessarily moves into a range to achieve this. The treatment cannot be painless, but always remain within the tolerance of the patient and the ktself (not always the same thing). Re-examination to the effects of treatment is usually carried out at the next since some treatment soreness is to be expected and may



an adhesion is characterised by a quick, forceful,

generalised or capsular contracture

requires longer, tougher handling, and 'mobilisation' is better term for this than 'manipulation'.



Findings at examination

Mechanical derangement is characterised b defined by Cyriax (1978). There may be other clues, such as onset, a history of recurrence, and alterations in the position of and pattern of movement.

An adhesion mimics mechanical derangement in that it presents a non-capsular pattern. The history may help to clarify, i that there will be no history of recurrence, or variation in movement, and the onset will lack derangement. Additionally, the movements will be painful limited in a way which suggests that they are the source of the trouble.

• Where contracture is due to arthritis or capsulids, movementi in the characteristic capsular pattern for that joint (Cyriax, value of recognising the classic capsular patterns in this they will help to take the disorder clearly out of the derangement category, and thus simplify purpose in treatment.

At the spine, because of the difficulty of examining one time, these distinctions become blurred.

whole spine is a generalised, symmetrical loss of movemen

" asymmetrical pain and restriction can arguably be attributed t mechanical derangement, localised adhesion or capsulids of tt apophyseal joint.

Where there is doubt about the nature of the disorder, manipulator is reminded of the attitude of mind recommended tt beginning of this sect/on, and must rely on scrupulous re-eva/uation symptoms and signs, something which in any case is mandatory. '. must be remembered that, particularly at the spine, in adch'ti0n I articular symptoms and signs there may be involvement of et structures such as the nervous system, the dura mater or the system. Such involvement may indicate important cem indications, or special precautions to be taken when manipuht/ag.



Manipulation under anaesthesia



This chapter is about manipulation of the conscious patient; menti of manipulation under anaesthesia is therefore brief.


Conditions requiring such manipulation may be either mechanical derangement (such as dislocation) or contracturc. Anaesthesia is required when:

1. The manipulator is clear about the nature and the force of the manipulation needed, without relying on information that can Only be provided by the conscious patient.

2. It has been decided to carry out a manoeuvre which will provoke too much pain and spasm for it to be performed kindly or effectively without anaesthesia.



DANGERS OF MANIPULATION




There are certain obvious contra-indications to manipulation, such as instability, fragility of bone or ligament, active inflammation or malignancy, where any use of force is likely to damage the structures being moved, or harmfully involve others. Examples of such conditions include rheumatoid arthritis, ankylosing spondylitis, cord or cauda equina involvement and vertebral artery involvement. This subject requires close study.

There are other situations in which the dangers of manipulation are less, but in which it is regarded with reserve, as likely to be of little help or as more likely to exacerbate than improve. Examples in this category are the presence.of distal root pain or neurological deficit. It is true that these are less responsive to manipulation, and the mechanism of spontaneous cure in disc lesions must be borne in mind. However, occasional good relief of pain can be .achieved, and it is a :lrity to avoid all such cases. After the proper exclusion of absolute medical contra-indications, safety and effectiveness lie in a methodical ttexamination by the manipulator, in acute perceptiveness in handling joints, and in observation of the rules of safety set out below. is not prescription that can make manipulation safe, but proper and technique.




AND EFFECTIVENESS IN MANIPULATION

hand

hand must have authority, and be strpng, comforting and

It receives indispensable infoCmafion and iS the medium a continuous two-way process. The manip.ulator 'puts in'

of precisely the kind intended, and simultaneously messages from the patient and the joint in the language of tissue resistance and muscle activity. This process is constant, at should be seen not only as part of technique but as continuo examination, which at any moment may modify the manipulatol intention and method.



Pain



The hand should pick up signals of pain long before the patient any need to speak, but clear verbal communication with the pati, about the degree and position of any pain provoked is essential, only after manipulation, but during preliminary positioning.



Never force spasm. There are exceptions to this, but the novice sho beware of them.



Force and amplitude



As force is increased,, reduce amplitude. Movement through degree is unlikely to do much harm, even if the manipulatior ill-chosen.



Examination and recording



A general principle of all treatment is that re-examination is car out at suitable intervals; on some occasions the proper intervals such re-assessment will be longer than on others. Manipula'ti especially manipulation for mechanical derangement, poses necessity for frequent re-examination, since changes in symptoms signs may occur immediately after a particular manoeuvre. examination may be necessary several times in one treatment.

A meticulous and economical method of recording examination technique is an integral part of the process. This cannot and must be skipped. Only so can one keep track of rapidly changing clir patterns in many individual cases; only so can changes in techniqu. remerobered and future moves planned.

This is not different in kind from other forms of physiotherapy. just that the speed with which changes occur in manipulation telescope the process. Grieve (1977), suggests that the allocatio time in treatment should be 'about 90 per cent thinking and cent doing'; these are fair proportions, recognising that the 90 per includes recording and planning future moves. It should be ac though examination must be sufficient to elicit enough to control the treatment, here is such a thing as In acute cases the physiotherapist must select only critical assessment factors and so minimise examination soleness. art of examination and recording is to achieve a balance between all that is essential and eliminating what is not required.



POINTS ON TECHNIQUE



, Body-weight and strength must be used to advantage, and those who are lightly built must recognise that there are some physiques which they cannot handle. Those who have the advantage of strength must remember what has been said about the control of :and sensitivity in handling; otherwise their advantage may be away or, worse, become harmful.

Explanation to the patient about what to expect, and calm :reassuring directives during manipulation help tremendously in achieving the relaxation required. 'Let your foot touch the ground' mid at the right moment may release tension in leg and back, and enable one to move the spinal joint effectively.

iAn ideal in manipulation i.s to localise movement to the affected alone. This may be possible at peripheral joints, but poses iproblems at the spine.

'.(a) Even if it is felt possible to localise spinal movement in this way, is not always clear which joint should be moved (a point already discussed). Techniques developed for moving an apophyseal joint may not be perfect for moving a disc protrusion.

(b) The need for leverage to increase force and the desire for localisation are sometimes at odds, and a choice has to be made them.

. A reasonable rule is to achieve as much localisation as possible, but o bear in mind the point made under (7) below.

A basic principle in manipulating mechanical derangement is to the joint surfaces during movement. In doing 'so one necessarily limits movement somewhat in other directions; again, a

'choice have to be made here.

• y positioning must always be achieved before a

manipulation is performed.

is not forcing of movements under voluntary control that is required (if this were so most patients would cure themselves). The

abnormality to be sought lies within those composite elements of joint movement which include accessory movement and accessory


range. It is within this territory that manipulation has its job to d

7. A few techniques really mastered and done well arc worth a wh bag of esoteric manoeuvres under haphazard control. T repertoire of techniques in constant use by experts is rcmarkat similar and remarkably small. The experienced mauipulal gradually learns that what does not respond to manipulation by c person often will not respond to another; where there is succ after failure it is commonly due to greater skill in performance t to a more complex manoeuvre.

DEFENDING THE LIMITATIONS OF MANIPULATION



The practice of manipulation suffers from the 'hey presto' effect, in the eyes of the public and, sometimes, in the eyes of manipular themselves. This phrase is used here to describe the instant, dram relief of pain and limitation of movement after one quick manoeu, This phenomenon is impressive to the pgtient, particularly if he trailed round the medical and physiotherapy professions with relief, and finally found it outside the medical sphere.

The result of such an event is reputation. What the patient does know, and what. the successful manipulator sometimes seem,, forget, is that this is by far from being the invariable effecl manipulation. If 10 people with back pain are selected indiscrimin ly and all manipulated, the chances are that one will be put immediately; the rest will respond more slowly, not at all, or be w for the experience.

Another factor contributes towards the prestige of manipulat which is that there is a group of people who have a sense of well-be of release and increased mobility, after manipulation of a normal j (these can be matched by others who will feel stiff and sore f while).

These two aspects of manipulation u,nite to produce a fellow: with a profound fidelity to its manipulators, often in the cans prophylactic treatment. Such prophylactic effects have not proved, and continued manipulation after the restoration of no movement may well be harmful. If patients seek it they should that it is not of proven use, and should evaluate it in terms ofwh any pleasant feeling given is worth the money paid for it.

The heart of the matter, perhaps, lies in selecting, a manipu who recognises that manipulation cannot help all conditions, and shows as much readiness to stop this treatment as to begin it in the instance.