Maitland
Approach
of the Spine
DR. yasmein
mohammed
The Maitland Concept
"The Maitland Concept of Manipulative
Physiotherapy [as it became to be known],
emphasizes a specific way of thinking,
continuous evaluation and assessment and
the art of manipulative physiotherapy (“know
when, how and which techniques to perform,
and adapt these to the individual Patient”) and
a total commitment to the patient
Key Terms
Accessory Movement - Accessory or joint
play movements are joint movements which
cannot be performed by the individual.
These movements include roll, spin and slide
which accompany physiological movements of
a joint. The accessory movements are
examined passively to assess range and
symptom response in the open pack position of
a joint.
Physiological Movement - The
movements which can be achieved and
performed actively by a person and can be
analyzed for
quality and symptom response.
Injuring Movement - Making the
pain/symptoms 'come on' by moving the joint
in a particular direction during the clinical
assessment.
Overpressure - Each joint has a passive
range of movement which exceeds its
available active range.
To achieve this range a stretch is applied to
the end of normal passive movement. This
range nearly always has a degree of
discomfort and assessment of dislocation or
subluxation should be acquired during the
subjective assessment
Principles of Techniques
The Direction - of the mobilization needs to
be clinically reasoned by the therapist and
needs to be appropriate for the diagnosis
made. Not all directions will be effective for
any dysfunction.
The Desired Effect - what effect of the
mobilization is the therapist wanting? Relieve
pain or stretch stiffness?
The Starting Position - of the patient and the
therapist to make the treatment effective and
comfortable. This also involves thinking about
how the forces from the therapists hands will be
placed to have a localized effect.
The Method of Application - The position,
range, amplitude, rhythm and duration of the
technique.
The Expected Response - Should the patient be
pain-free, have an increased range or have
reduced soreness?
How Might the Technique be Progressed -
Cervical spine
The cervical spine is divided into two separate
zones for biomechanical description:
• The occiput-atlas-axis (OAA) complex.
• The C2-C7 region.
The cervical lordosis averages is 40°.
Too little lordosis will lead to disc •
compression and too much lordosis lead
to facet compression,
Facet joint in cervical
45 degrees; frontal plane; all movements are
possible such as flexion, extension, lateral
flexion, and rotation.
The articulating facets in the cervical vertebrae
face 45 degrees to the transverse plane and lie
parallel to the frontal plane, with the superior
articulating process facing posterior and up and
the inferior articulating processes facing
anteriorly and down.
Normal range of motion:
Flexion 50°
Extension 60°
Side bending 45°
Rotation 80°
Approximately 50% of the flexion-
extension motion occurs at occiput-C1
(atlas) level.
Approximately 50% of the rotation occurs
at C1-2 (atlas-axis) level.
In the case history, the osteopath tries to identify
the nature of the pain:
• Aching pain can be from a ligament, especially
when occurring in the morning with morning
stiffness. Also when it occurs after a longer
period of immobilisation (sitting or standing).
• Sharp pain on specific movements can be
caused by muscle strain or inflammation.
• Fatigue can be caused by bad posture and
cervical muscular balance.
• Sharp pain when coughing often directs
towards inflammation.
• Radiating pain indicates a neurogenic factor,
can be radicular or pseudo radicular.
• Numbness or muscle weakness indicates
severe radicular inflammation, often with hernia
compression on the nerve root.
• Vague, sometimes radiating pain in the arms
during exercise can indicate an ischemic
neuralgia.
• Are there visceral signs associated with the
cervical pain?
• Nocturnal pain often indicates cancer.
Safety tests
1- Vascular: De Kleyn Test:
places the head in a position of hyperextension,
rotation and ipsi-lateral side bending from
supine. The patient keeps the eyes open. This
position is maintained for at least 45 seconds.
One of the vertebral arteries is compressed. If
the following symptoms arise the test is positive
and the head is immediately returned to normal:
• Dizziness. • Headache + neck pain. • Feeling
of fainting. • Nystagmus
2. Hypermobility Test:
The therapist stands behind the patient and
fixes the lateral side of the axis with the
index finger of one hand and uses the index
finger of the other hand to move the atlas to
the opposite side. This test is done in both
directions. A motion of more than 3 mm
indicates a hypermobile segment. This can
be due to a problem of the cervical ligament,
for example in cases of rheumatoid arthritis,
or in Down’s syndrome.
3-Neural: Cervical Compression Test
(Spurling test)
patient is sitting; stands behind the patient with
both hands on the patient’s head. Compression
is given in extension so that the facets are
under maximum compression. Pain from the
compression indicates an intra-articular
problem. This test can also be done unilaterally
by using combined extension and ipsilateral
rotation and sidebending. With the head in
flexion, compression will test the intervertebral
discs. These compression tests also identify
vertebro-basilar artery pathology
Assessment
1- active ROM
2- Passive ROM ( end feel spasm, empty,
bony)
3- Segmental assessment( Mitland
assessment (anterior , posterior, lateral
glide).
Subjective Examination
Palpation
• Temprature
• Soft tissue
• Bony positions
Soft tissue palpetion
Segmental Physiological
Movements
C0 - C1 C1 – C2 C3 – C7 flex
C3 – C7 SB
PAIVM assessment
• PACVM
• PAUM
• APUM
• TVP
• Logtudinal movement
PACVM
PAUM
APUM
TVP
Logtudinal movement
Thoracic vertebra
The facet joints
Thoracic Region = 60 degrees
The facet joints between adjacent thoracic
vertebrae are angled at 60° to the transverse
plane and 20° to the frontal plane, with the
superior facets facing posterior and a little up
and laterally and the inferior facets facing
anteriorly, down, and medially.
Lumbar Region = 90 degrees; The facet joints in the
lumbar region lie in the sagittal plane;. The superior
facets face medially, and the inferior facets face
laterally. ,
