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THE AUSTRALIAN JOURNAL OF PHYSIOTHERAPY VOLUME 5 JULY, 1959 Numezr 2 THE TREATMENT OF LESIONS IN THE CERVICAL REGION BY MANIPULATIONA G. D. MairLaND Adelaide Manipulation as a iorm of treatment sufters from considerable prejudice. Per- haps this is the result partly of chiropractic and osteopathic claims implying that all complaints stem from vertebral subluxations and partly because of the laymen's deserip- tions of their treatment which indicate that this had been a rough affair, The accuracy of the pathology described hy these workers is not for discussion here but at least we should not be too critical while ignorant of their methods and results, Probably we have all heard at some time of someone who was miraculously cured by an osteopath after a doctor had told him that there was no cure. If you areas I used to be, you would probably say to your- self “psychological” or “quackery”. My own ideas have changed as I have concentrated more on manipulative therapy. Many patients have had conventional physio- therapy with little or no benefit and have been completely relieved by manipulation in a week. Such results must make us take notice. Tt does not follow that heat, massage and exercises are valueless; they have definite uses. It does mean that we as Physiotherapists should be able to assess our methods of treatment accurately and be able to evaluate the results of manipulation in relation to those of conservative therapy. As manipulation produces speedy results it is better to use it as the first line of treat- ment in suitable and even in doubtful cases. 1Read at the seventh Biennial Congress of the Aus- tratan Physiotherapy Association, May, 1958, Manipulation has been used as a form of therapy since time immemorial, but as more research has been done it has become less empirical. Osteopathy was founded in 1874 by Dr. Andrew 'T. Still, and chiropractics in 1895 by a Mr. D. D. Palmer. Ortho- pedic manipulation, particularly under general angsthesia, has always been in use. James Mennell (1952) reviewed the methods of osteopaths and chiropractors and wrote two books on manipulation. More recently James Cyriax (1954) has done much to make manipulation a scientific method of treatment. Even today many people consider manipu- lation to be a rough or harsh procedure involving a full range of forced movernents. This is wrong. Manipulation, if it is to be tsed effectively, depends upon careful assess- ment of the patient's signs and symptoms before and after every manipulative move- ment and upon performing it “with feeling”. This means “feeling” in regard to pain experienced by the patient during the manipulation and “feeling” for the move- ment which is desired. THE ExXAMINATION The examination of a patient with symp- toms possibly arising in the cervical spine may be considered in two parts. The first consideration is the history: the site and type of pair, the positions, especially those of the head, or activities which aggravate or ease the pain, and whether rest or weather changes have any adverse effect, The second consideration is the elicitation of signs. The 42 movements are tested, noting accurately the range of movement in each direction and the site of auy pain produced. Another test is a compression test for headache and the syndrome of nerve root compression. This is performed by applying vertical pressure to the cranium with the patient sitting, firstly holding the head centrally, then in extension, and then in lateral flexion, The assessment of pain in the arm of doubtful origin is helped by the following two tests. With the patient standing, down- ward traction is applied to the arms and any increase in pain noted; this is followed by active and then by passive elevation of the shoulder girdle to assess any easing of the symptoms. In the thoracic outlet syn- drome there is an increase in symptoms with traction and relief with elevation, whereas pain of cervical origin may be expected to remain unchanged. Secondly, if the pain is thought to be of muscular origin, each muscle in question is tested actively, static- ally and passively. If the pain is muscular a comparatively mild static contraction reproduces it. Occasionally a referred pain which has been present for a long time leads to a local abnormality which may then generate fts own pain; à common example Of this is given below. Each treatment and its effects must be carefully documented if the duration of treatment is to be reduced by à day or so, I have my own abbreviations for recording but the method is unimportant. The manipulation and the method used are recorded as well as the sensation, if any, créated in the patient; the result from the point of view of signs and symptoms is also noted, TecanIQuEs OF MANIPULATION A high proportion of patients will respond to any manipulative movement. This is shown by the number of succcessful results obtained from the common orthopadie pro- cedure of manipulation under general ames- thesia. Tt is only in difficult cases or in those cases in which manipulation under anzsthesia has failed that skilful technique is required. The manipulations in use may be divided into two main groups, the direct and the THE AUSTRALIAN JOURNAL OF PHYSIOTHERAPY indirect manipulations. Direct manipulations are those ih which the operator applies pressure directly to individual vertebre; indirect manipulations use the head as a lever. None of the manipulations to be Ficuee [: Direct pressure on the spinous process, described is original; I am sure that every possible manceuvre has been mentioned in the literature at some time. Only the basic varieties are illustrated in this paper; there are many others which may be used. Figure II: Direct pressure over the articular pillar. Direct Mamipulations The first of the direct manipulations is pressure of the thumb or finger, reinforced 1 necessary, on the centre of the spinous process of the vertebra. The spines of the first and third cervical vertebrae are rela- tively inaccessible, because of the occipital protuberance and the size of the spinous process of the second cervical vertebra, but they can be reached with the patient lying 44 Tre AUSTRALIAN JOURNAL OF PEYSIOTHERAPY “cracks” obtained during this manipulation usually serve no other purpose than to indicate good intervertebral movement. The degree of traction necessary during this manipulation varies with the condition. For a patient with migraine or headache minimal traction and maximum rotation are reguired (Fig. V), but when there are neurological changes associated with herniation of the disc maximum traction is necessary together with rotation within the limits granted by the full traction (Fig. VI). When the degree Picure VI: Application of maximum traction with limited rotation. of traction being used necessitates counter- traction, the latter should be applied at the shoulders; traction applied through the lumbar or thoracic spine can aggravate any existing lesion or even initiate a minor thoracic one. As a rule this manipulation is directed away from the painful side, The remaining two basic indirect manipu- lations are those of extension and of lateral fiexion. These can be controlled in such a way that the movement is directed mainly at the upper or lower cervical spine. Figure VII shows extension applied to the whole of the cervical spine but particularly to the lower part. tis in this position that a thoracic lesion may be aggravated. Figure VIII shows that by altering the line of pull and by wsing the index finger of the under- neath hand as a lever the effect of the move- ment is isolated to the upper cervical spine. Froure VII: Extension of the cervical spine, especially of the lower part. Figures IX and X show ihe lateral flexion movement being applied to the upper and lower cervical spine respectively. Traction, which is merely another method of indirect manipulation, must be mentioned. Scott (1956) has shown three basic head Ticure VII. Extension of the cervical spine, especially of the upper part. positions for neck traction, with the head held in flexion, mid-position or extension, but it can also be applied in lateral fexion. The two essentials in treatment by traction are relaxation, particularly of the cervical muscle groups, to enable intervertebral elongation and relief, or at least easing, of TREATMENT OF CERVICAL LestoNS EY MANIPULATION 45 symptoms while the traction is maintained. The position chosen for traction depends on the position aftording most relieí from pain, complete relief being the aim. Jf the patient cannot tolerate neck extension, the position for the traction is slight flexion. This is easier to achieve with the patient lying down. It is a generally accepted principle that traction is the first method of treat- ment used, manipulation being resorted to onty if progress is not as anticipated, but as many of the good results gained by cervical traction can be achieved more quickly by manipulation it is suggested that this pro- cedute might often be reversed. Fiure IX: Lateral flexion, chiefly of the upper cervical spine. Occasionally during treatment of a cer- vical condition by manipulation a patienf's signs and symptoms are easily and com- pletely relieved at any one session but they return the following day. Under such cir- cumstances a cervical collar helps to main- tain some cf the improvement gained by manipulation; the end-resnits are obtained more quickly with the combination than with either alone. Case HistorIES Casz L—Mr, C, aged 43 years! 28 years ago he fell on his head and was concussed for two hours. Eleven years later he developed head- ache with sinusitis, for which an operation was performed, but the headaches continued and symptoms of sinusitis persisted. He was treated with shortwave diathermy without benefit. From 1953 to 1956 he lived in the Northern Territory and was free of pain and simusitis. On his reterm south the symptoms returned, imtialiy about every three weeks and later, continuously. At Ficure X: Lateral flexon, clmefly of the lower cervical spine, this stage he complained of “dulled” and “blurry” eyes, although vision was tested and found to be normal, a “blocked-np fecling” in his face, nausea, dull occipital ache with parictal jabs of pain, and a continuous dull ache behind the eves. On examination, extension of the head was limited by pain in the region of the first cervical vertebra, Rotation with the head in flexion and extension caused pain to the left of this vertebra; com- pression did not increase the pain. Rotationary manipulation was applied to both sides with maximum rotation and minimum trac- tion for the first three days. At the end of this time there was only a slight “band feeling” around the head with slightly more pam to the left of the first vertebra than to the right. Rotation was applied to the right only for the 
