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An Introduction to
Medical Manipulation
An Introduction
to Medical
Manipulation
John K. Paterson,
MB. BS. MRCGP
currently Vice-President and Han. Secretary of the British
Association of Manipulative Medicine and member of the
Scientific Advisory Committee of the International Federation of
Manual Medicine
and
Loic Burn,
BA. MRCS. LRCP. DPhysMed
currently President of the British Association of Manipulative
Medicine. Han. Secretary of the Scientific Section of the British
League against Rheumatism and member of Council of the Back
Pain Association
M.TP PRESS LIM.ITED
~~
~ a member of the KLUWER ACADEMIC PUBLISHERS GROUP
LA CASTER I BOSTON I THE HAG E / DORDRECHT
Published in the UK and Europe by
MTP Press Limited
Falcon House
Lancaster, England
British Library Cataloguing in Publication Data
Paterson, John K.
An introduction to medical manipulation.
1. Manipulation (Therapeutics)
I. Title II. Burn, Loic
615.8'2 RM724
Published in the USA by
MTPPress
A division of Kluwer Boston Inc
190 Old Derby Street
Hingham, MA 02043, USA
Library of Congress Cataloging in Publication Data
Paterson, John K., 1921-
An introduction to medical manipulation.
Bibliography: p.
Includes index.
1. Manipulation (Therapeutics) I. Burn, Loic,
1935- . II. Title. [DNLM: 1. Joint Diseases-
therapy. 2. Manipulation, Orthopedic. 3. Muscular
Diseases-therapy. 4. Pain-therapy. 5. Spinal
Diseases therapy. WE 725 P296i]
RM724.P38 1985 615.8'2 85-137
Copyright © 1985 MTP Press Limited
Softcover reprint of the hardcover 1st edition 1985
All rights reserved. No part of this publication may be reproduced, stored in a
retrieval system, or transmitted in any form or by any means, electronic,
mechanical, photocopying, recording or otherwise, without prior permission from
the publishers.
Typeset and printed by Butler & Tanner Ltd, Frome and London.
ISBN-13: 978-94-011-7842-6 e-ISBN-13: 978-94-011-7840-2
DOl: 10 .1007/978-94-011-7840-2
Contents
Preface ix
Foreword by Professor B. Wyke x
1 General Considerations 1
Orthopaedic neurology 1 - how manipulation works
Orthopaedic neurology 2 - a review of current ideas
relating to manipulation 5
Spinal mobility and its relevance to manipulation 7
Incidence and aetiology of low back pain in general terms 8
Referred pain, referred tenderness and back pain
syndromes 11
Trigger points 13
Some psychological aspects of vertebral pain 14
Indications, contrai ndications and dangers 16
Clinical history and data recording 19
Local examination 32
Conventional radiology 34
Posture and prophylaxis 36
Spondylolisthesis and spinal stenosis 40
Rheumatology and orthopaedics 42
Lay manipulators 45
Drug treatment of musculoskeletal problems 47
Collars and corsets 49
Traction 50
Exercise and exercises 52
Vertebral injections 54
Electro-acupuncture and transcutaneous electrical nerve
stimulation 56
Rhizotomy and rhizolysis 59
Sclerosant therapy 60
Assessment of results and the associated difficulties 61
v
CONTENTS
The British Association of Manipulative Medicine, the
International Federation of Manual Medicine, the
British League Against Rheumatism and the Back
Pain Association 67
Conclusion 69
2 The cervical spine 71
Functional anatomy 71
Symptomatology 75
Brachial and thoracic radiation 78
Examination 80
Conventional radiology 82
Injections 84
3 The thoracic spine 86
Functional anatomy 86
Symptomatology 87
Examination 89
Conventional radiology 91
Injections 91
4 The lumbar spine 94
Functional anatomy 94
A classification of low back pain 97
Examination 103
Conventional radiology 105
Lumbar injections 107
The pelvis 111
The intervertebral disc 113
5 Peripheral joints 117
The shoulder 117
The elbow, wrist and hand 121
The hip 124
The knee and ankle 127
The foot 129
vi
CONTENTS
6 Anatomical illustrations 133
The mobile segment 133
Cervical ligaments - CO-I-2 - sagittal view 134
The vertebral artery 135
7 Diagnostic techniques 136
Apparent difference in leg length 136
Skin drag 138
Posterior skin rolling 139
Anterior skin rolling 140
Lateral spinous process pressure test 141
Springing 142
Muscle tone test 143
Zygoapophyseal tenderness 144
The bellpush sign of Maigne 145
8 Manipulative techniques 146
Upper cervical rotation - supine 147
Lower cervical rotation - supine 148
Upper cervical rotation in traction - sitting 1 149
Upper cervical rotation in traction - sitting 2 150
Lower cervical rotation - sitting 151
Cervical side-bending 152
Prone cervical rotation - chin pivot 153
Lower cervical rotation - prone 154
Sternal thrust - standing 155
Sternal thrust - sitting 156
Sternal thrust - supine 157
Crossed pisiform thrust - 1 159
Crossed pisiform thrust - 2 160
Knee in back 161
Spinous process rotation 162
Thoracic rotation - sitting 163
Lumbar rotation 164
Lumbosacral - prone 1 165
Lumbar rotation - sitting 166
Lumbar extension - sitting 167
vii
CONTENTS
Lumbosacral forward thrust 168
Lumbosacral longitudinal thrust 169
Lumbosacral - prone 2 170
Million dollar roll 171
9 Injections 172
Occipital injections 172
Cervical apophyseal injections 173
Thoracic apophyseal joint injections 174
Lumbar apophyseal injections 175
Caudal epidural anaesthesia 176
10 Back exercises 178
Lying exercise 178
Standing exercise 179
11 Domiciliary traction 180
Cervical autosuspension 180
Lumbar autosuspension 181
References 183
Index 194
viii
Preface
We hope that this book will be of interest to all clinicians involved
in the treatment of musculoskeletal problems, be they medical,
paramedical or lay. It is primarily directed at general practitioners.
Musculoskeletal problems constitute the largest single group of
conditions met with in general practice. There is at present a lack of
teaching of the subject in Britain, in respect of both the nature of
these ill-defined conditions and their therapy. With many years' ex
perience of general practice, both of us are fully aware of the scale
and importance of these issues. We seek to provide a wide and
balanced review of the current state of knowledge in this field, culled
from the available literature.
A method of clinical examination applicable to this group of con
ditions is presented. A collection of therapeutic manoeuvres suitable
for use in general practice is described, with carefully worded texts,
illustrated by photographs and diagrams, together with a variety of
injection techniques, similarly illustrated. Drug therapy and other
forms of treatment are discussed. We include sections on prophy
laxis, together with further topics of relevance to general practice.
If the book appears overcritical of some ideas discussed, this is
not our intention, but is rather the result of our understanding of
the available literature. If we have omitted any relevant evidence, or
if our reasoning is faulty, we will be happy to be so advised.
We would like to thank Mr Jim Norton, of the British League
Against Rheumatism, and Group Captain Cedric Simons, of the
Back Pain Association, for vetting that part of our material which
pertains to those organizations.
Of the many colleagues who have lent help and advice, we wish in
particular to thank Dr A. Maxwell Robertson and Professor Robert
Maigne. However, our greatest debt of gratitude must be to Profes
sor Barry Wyke, for his encouragement and painstaking criticism,
and for doing us the honour of writing a foreword to this book.
14, Wimpole Street, John K. Paterson
London WIM 7AB. Loic Burn
September, 1984
ix
Foreword
By Professor Barry Wyke, M.D.
Formerly Director of the Neurological Unit,
Royal College of Surgeons of England
Manipulative therapy is a technology based on the application of
manual forces through bodily tissues with the object of relieving a
variety of disorders, principally of the musculoskeletal system. It is
one of the most ancient of therapies, having been practised (in some
form or another) throughout human history; but in spite of this
ancient lineage (or perhaps because of it), it has persisted as a largely
empirical body of knowlege split into a variety of 'schools', each
with its (sometimes fanatical) devotees.
This picture is now changing, however, as a result of the applica
tion of scientific investigation to the observations and procedures of
manipulative therapy; and this book is a welcome British reflection
of this change that should assist United Kingdom doctors in under
standing the role of manipulative procedures in contemporary
clinical practice. This is especially desirable, in that while countries
such as Germany, France, Switzerland and The Netherlands each
have a well-established medical speciality of Manual Medicine, such
is not the case in Great Britain.
London, BARRyWYKE
January 1985
