Maitland school of thought

Introduced by Geoffrey Douglas Maitland  - in 1950’s
He was born in Australia in 1924, trained as a physiotherapist from 1946 to 1949
Pioneer of musculoskeletal physiotherapy
Emphasized on:
Specific way of thinking
A total commitment to the patient
Continuous evaluation and assessment
Art of manipulative physiotherapy

1. MAITLAND CONCEPT PRESENTOR : MR. KIRAN KUNWAR

2. Introduced by Geoffrey Douglas Maitland  - in 1950’s He was born in Australia in 1924, trained as a physiotherapist from 1946 to 1949 Pioneer of musculoskeletal physiotherapy Emphasized on: Specific way of thinking A total commitment to the patient Continuous evaluation and assessment Art of manipulative physiotherapy

3. THE MAITLAND CONCEPT Fundamental components: The patient-centred approach to dealing with movement disorders The brick wall approach and the primacy of clinical evidence The paradigm of identifying and maximizing movement potential The science and art of assessment

4. 1.THE PATIENT-CENTRED APPROACH TO DEALING WITH MOVEMENT DISORDERS Based on personal commitment to the patient which requires: Developing a level of concentration Being prepared to revisit time and again Being totally non-judgemental Developing skilled understanding of verbal and non-verbal communication Using patients own terminology Knowing what clinician should know

5. 2. THE BRICK WALL APPROACH AND THE PRIMACY OF CLINICAL EVIDENCE Special mode of thinking in two interdependent compartments separated by a symbolic permeable brick wall in the clinician's mind One compartment: all theoretical information Another compartment: all clinical information A free flow of information can take place across the permeable brick wall Allows for all possible hypothesis and speculation

6. 5 Requirements For Permeable Brick Wall Learn to think in two distinctly separate compartments Know history, symptoms & signs very clearly Use words and write in correct ways Choose treatment technique in relation to patients s/s Apply and adapt two-compartmental model

7. 3. THE PARADIGM OF IDENTIFYING AND MAXIMIZING MOVEMENT POTENTIAL Detailed attention in the analysis of quantity and quality of human movement With mobilization/manipulation techniques designed to restore movements to their pain-free ideal state WCPT (1999) 'recognizes that physiotherapy-is concerned with identifying and maximizing movement potential within the spheres of promotion, prevention, treatment and rehabilitation'

8. 4.THE SCIENCE OF ART AND ASSESSMENT Repeated assessment and ongoing analytical assessment are the means of evaluating Clinical proof of whether treatment is working or not is achieved by continually comparing the effects of the selected treatment forms on the patient's symptoms and signs. Hypotheses can be confirmed, discarded or re-ranked regarding: Cause of the problem The structures at fault Pathobiological mechanisms involved Expectations for recovery appropriate management strategies

9. COMMUNICATION AND THE THERAPEUTIC RELATIONSHIP Purpose of well developed communication :- Aid the process of information gathering with regard to diagnosis, treatment planning and reassessment of results. Develop a deeper understanding of the patient's thoughts, beliefs and feelings with regard to the problem Assists in the assessment of psychosocial aspects Development of a therapeutic relationship

10. THE PHYSIOTHERAPIST'S ROLE IN THE THERAPEUTIC RELATIONSHIP Curative Prophylactic Palliative Educational Counselling

11. POSITIVE EFFECTS OF A THERAPEUTIC RELATIONSHIP Actively integrating a patient in the rehabilitation process Patient empowerment Compliance with advice, instructions and exercises Outcomes of treatment, such as increased self-efficacy beliefs Building up trust to reveal information which the patient may consider as discrediting Trust to try certain fearful activities again or re-establishing self-confidence and wellbeing

12. ASPECTS OF COMMUNICATION Verbal components Non-verbal components Such as tone of voice, body posture and movements and so on.

13. COMMUNICATION TECHNIQUES Style of question: Open questions (e.g. 'What is the reason for your visit?') Questions with aim (e.g. 'Could you describe your dizziness more? Half-open questions -. how, when, what (e.g. 'How did it start?' Alternative questions - (e.g. 'Is the pain only in your back or does it also radiate to your leg?') Closed questions –yes/no (e.g. 'Has the pain got any better?') Suggestive questions - (e.g. 'But you are better, aren't you?')

14. Modulation of the voice and body language Summarizing of information Mirroring -in which the physiotherapist neutrally reports what is observed or heard from the patient (Short) pauses before asking a question or giving an answer. Repetition (with a question) of key words or phrases.

15. IMPORTANT STRATEGIES DURING THE INTERVIEW Speak slowly. Speak deliberately. Use the patient's language and wording, if possible. Keep questions short. Ask only one question at a time. Pose the questions in such a manner that as much as possible spontaneous information can be given

16. PARALLEING When a patient is talking about an aspect of their problem, patient should not be stopped Therapist should follows the patient's line of thought Patient could have more than one point they wish to express

17. IMMEDIATE-RESPONSE QUESTION If during the first consultation a patient gives important information, immediate-response questions may be needed Patient: 'I feel it mostly with quick movements.‘ Therapist: 'Quick movements of what?' Following the patient's answer: 'In what direction? Using immediate-response questions during this phase of reassessment prevents time being wasted and valuable information being lost At reassessment, convert statements of fact into comparisons!

18. KEY WORDS AND PHRASES Frequently patients make a statement or use words that could have great significance - the patient may not realize it therapist must latch onto it while the patient's thoughts are moving along the chosen path Physiotherapist could use it either immediately by interjecting or by waiting until the patient has finished

19. BIAS Patient should not be influenced to answer in a particular way 1. 'Do you feel that the last two treatments have helped you?' 2. 'Has there been any change in your symptoms as a result of the last two treatments?‘ 3. 'Have the last two treatments made you any worse in any way?'

20. CRITICAL PHASES OF THE THERAPEUTIC PROCESS

21. 1.WELCOMING AND INFORMATION PHASE Help the patient feel at ease as Inform the patient about the specific movement paradigm of the physiotherapy profession Explain the procedures sufficiently to prevents the patient from developing irritation Physiotherapist starts off with an examination, as this may have already been done by the referring doctor

22. 2. SUBJECTIVE EXAMINATION Pay attention not only to what is said but also to how things are said by the patient Key words, gestures and phrases may open a window to the world of the individual illness experience Ensure that the patient understands the purpose of the questions: baseline for comparison of treatment results in later reassessment procedures or indicative of the physiotherapy diagnosis, including precautions and contraindications. Collaborative goal setting Develop a first general idea of the treatment objectives

23. 3. PLANNING OF THE PHYSICAL EXAMINATION Planning sequence and dosage of the examination procedures. Summarize the relevant points of the subjective examination first and then to describe the preliminary treatment objectives Explain to the patient the purpose of the physical examination.

24. 4. PHYSICAL EXAMINATION Explains why certain test procedures are performed Physiotherapist is interested not only in any symptom the patient may feel but also in the: Range of motion, the quality of the movement and the trust of the patient in the particular movement test. During palpation sessions and the examination of accessory movements, the patient should be encouraged not only to describe any pain but also any sensations of stiffness Inform patients not only about those tests which serve as a reassessment parameter but also about the test movements that have been judged to be normal

25. 5. ENDING A SESSION Sufficient time needs to be planned Instruct the patient about how to observe and compare the possible changes in symptoms and activity levels. Warn the patient of a possible exacerbation of symptoms in certain circumstances. A repetition of the first instructions, recommendations or self-management strategies Attention needs to be given to unexpected key remarks of the patient

26. 6.EVALUATION AND REFLECTION OF THE FIRST SESSION It includes summarizing Relevant subjective and physical examination findings Making hypotheses explicit, Outlining the next step in the process of collaborative goal setting for treatment Collaboratively defining the subjective and physical reassessment parameters.

27. 7. REASSESSMENTS Education of patients may be needed to observe possible changes in terms of comparisons Cognitive reinforcement at the end of a reassessment procedure may be helpful to support the learning processes Integrate questions with regard to self-management strategies in the opening phase of each session

28. 8. RETROSPECTIVE ASSESSMENT Evaluate patients' awareness of changes to their symptoms Evaluate the results of the treatment so far, including the effects of self-management strategies. Redefine collaboratively with the patient the treatment objectives for the next phase of treatment

29. 9. FINAL ANALYTICAL ASSESSMENT Includes the reflection of the overall therapeutic process Assessment is made of which interventions have led to which results. Anticipate on possible future difficulties in activities or work and which self-management interventions

30. PARADIGMS AND THEORETICAL MODELS PROFESSIONAL DECLARATION S AN D THE MOVEMEN T PARADIGM (ICF) THE PAIN REVOLUTION CLINICAL REASONING

31. PARADIGMS AND THEORETICAL MODELS Biomedical paradigm- 19 th century illness and disease by deviations in biological processes Biopsychosocial model- 20 th century

32. BIOPSYCHOSOCIAL MODEL Various factors may contribute to the development and maintenance of disease, pain and disability Biological processes Emotional aspects Cognitive aspects Social factors Cultural factors Behavioural factors 'Individual illness experience‘ plays a central role The psychosocial aspects need to be considered as variables of the human experience and are more likely to be contributing factors to ongoing pain and disability than causative ones

33. The following aspects are emphasized: The illness experience is always culturally shaped and is dependent on what a society regards as appropriate illness behaviour, on the personal biography of the person, and on psychological processes, meanings and relationships, so that the social world is always linked with the inner experience of feeling ill. In this experience powers may exist that can either amplify or reduce suffering and disability, including the behaviours of others as relatives or clinicians. Every professional is trained to translate the illness experience of an individual into theoretical terms of disease and into a profession-specific taxonomy and nomenclature. Interpretation of the narratives of this individual experience should be a core task in medical practice.

34. PHYSIOTHERAPY-SPECIFIC PARADIGMS

35. Movement and its rehabilitation is considered the core of clinical practice and the common denominator to all concepts in physiotherapy PHYSIOTHERAPY PARADIGMS: MOVEMENT AS THE COMMON DENOMINATOR

36. The levels are interdependent, functions of one level influence movement capacity of other levels.

37. PROFESSIONAL DECLARATIONS AND THE MOVEMENT PARADIGM WCPT Physiotherapy is concerned with identifying and maximizing movement potential within the spheres of promotion, prevention, treatment and rehabilitation. This is achieved through interaction between physical therapist, patients or clients and caregivers, in a process of assessing movement potential and in working towards agreed objectives using knowledge and skills unique to physiotherapy .. . . It places full and functional movement at the heart of what it means to be healthy. WCPT (1999, p. 7)

38. PHYSIOTHERAPY DIAGNOSIS Physiotherapists should make a specific diagnosis of the disorders they examine WCPT takes a clear stance with regard to physiotherapy diagnosis and movement functions

39. International Classification of Functioning, Disabilities and Health (ICF) Diagnosis in physiotherapy may be expressed in terms of movement dysfunctions using the levels of disability as described in the InternationaL Classification of Functioning, Disabilities and Health (ICF) (WHO 2001):

40. Model of ICF with the integration of a manual therapy specific taxonomy of impairment analysis.

41. Physiotherapists may guide patients with regard to movement from an 'individual illness experience and illness behaviour‘ towards an 'individual sense of health and health maintaining behaviours

42. Some of the current developments of physiotherapy practice and research expressed in the 'brick wall' analogy.

43. PAIN REVOLUTION Traditional concept (Biomedical paradigm) Pain was considered as a symptom directly related to the extent of bodily damage, with the consequence that treatment was focused on removing or normalizing the underlying pathology of the pain. In the absence of bodily damage the mind was assumed at fault and psychopathology was inferred ( Vlaeyen & Crumbed 1999).

44. Gait Control Theory ( Melzack & Wall 1984) Cortical processing was involved in the integration of both sensory-discriminative and affective- motivational aspects of pain Cognitive, emotional, behavioural, social and cultural dimensions were identified as essential contributing factors to the pain experience of a person Pain was not only the result of nociceptive information ascending from peripheral structures but also that pain could be modulated by descending pathways in the central nervous system Pain could be a result of processing in neuronal networks rather than a consequence of tissue damage alone

45. Cervero and Laird (1991) To assess pain with its underlying neuro -physiological pain mechanisms it is necessary to distinguish between: Nociceptive mechanisms Peripheral neurogenic mechanisms Central nervous system modulation Autonomic nervous system influences.

46. (Wright 1999b) Central nervous system is viewed as an integrated cyclical system rather than a simple cause-and-effect system distinguishing between afferent and efferent aspects of function

47. PAIN AS A DYNAMIC PHENOMENON It is suggested that a pain experience often changes over time as a result of interactions between the individual, the environment and medical professionals And also due to the increasing influence of cognitive, emotional and behavioural factors An increasing sense of distress or suffering may contribute to the experience over time If aspects such as a sense of helplessness, worthlessness and impaired self-esteem also start to play a role in the pain experience and disability Interventions of a physiotherapist have to be adapted with the incorporation self-management and/or educational strategies. From a biological point of view, the brain or central nervous system may be seen as a discrimination centre which continuously scans the environment, the body and relevant past experiences

48. THE ROLE OF MOVEMENT IN THE TREATMENT OF PAIN Focusing on activity intolerance rather than on pain in the rehabilitation of many pain states- fordyce (1995) the terms mechanosensitivity and movement sensitivity should be used if movements provoke pain. An approach of reduced activity rather than bed rest in acute pain states Patients should be guided in resuming their full activity potential at an early stage ( abenhaim et ai2000) Focus on normalizing joint mobility, muscular control, movement patterns and aerobic condition ( dieppe 1998). In fact exercise therapy has been found to have beneficial effects on pain and disability

49. CLINICAL REASONING The thinking and decision-making processes associated with clinical practice' (Higgs & Jones 2000) Mainly a tacit, half-conscious, complex problem solving process.

50. ‘Wise action' in which physiotherapists endeavour to integrate three areas into their decision-making processes (Butler 2000): The best of science The best of current therapies with good assessment procedures and varied treatment strategies The best of the patient-therapist relationship, with a client-centred approach

51. FORMS OF CLINICAL REASONING Diagnostic reasoning - considering movement impairments, activity limitations and participation restrictions and their contributing factors, as well as pathobiological processes. Theoretical reasoning - theory guiding clinical decisions. Procedural reasoning - thinking about disease or disability and deciding on the procedures of assessment and treatment

52. Interactive reasoning - takes place during the direct encounters between therapist and patient Conditional reasoning -therapist thinks about the overall condition of the patient, including the personal illness experience and context, and considers how the future condition and the patient's life might change as a result of the selected interventions Narrative reasoning - 'reasoning by telling stories’

53. PRINCIPLES OF ASSESSMENT

54. PURPOSES OF ASSESSMENT Physiotherapy diagnosis Definition of therapy objectives Determination of treatment interventions Define parameters to monitor the effects of all therapeutic intervention

55. FORMS OF ASSESSMENTS 1.Analytical assessment at the first consultation Information is gathered through the subjective and physical examination Establish and test a working hypothesis about the kind of disorder that the patient has Consideration should also be given to the stage and pathological stability of the disorder.

56. 2.Pretreatment assessment Before every treatment session begins the effects of the previous treatment session should be evaluated. Start each session with the question: 'how have you been since i saw you last time?' Comparisons should be made of the effects of treatment on the patient's signs and symptoms since his last visit.

57. 3. Assessment and reassessment during and immediately after each treatment session Proving or assessing the value of a technique' in treatment. Knowing what the intention of the technique should be while it is being performed Having expectations of what changes the technique will effect following its use The effects of treatment from one session to another should also be evaluated in detail By assessing the immediate effects of treatment, a favourable though slight improvement is detected Reassessment therefore helps in deciding the next course of action or progression of treatment

58. 4. Progressive assessment After every three or four treatment sessions it is wise to compare the patient's signs and symptoms over a longer period of time in order to gain an overview of the rate of improvement of the clinical features of the patient's disorder

59. 5. Retrospective assessment Valuable after a planned break from treatment to assess whether the disorder is: spontaneously recovering, recovered faster during the treatment period, a combination of both of these or not recovering at all.

60. 6. Final analytical assessment At the completion of the episode of care it will be useful to determine: The future prognosis of any mode of treatment Likely recurrence of the patient's disorder

61. PRINCIPLES OF EXAMINATION

62. AIMS OF EXAMINATION PROCEDURES Diagnosis from the specific (movement) perspective of Physiotherapists Determination of precautions and contraindications to physiotherapy interventions Treatment plan Determination of parameters to monitor the results of treatment. Initial preliminary treatment, including first reassessment of effects.

63. SUBJECTIVE EXAMINATION Relates to the patient's account of the disorder and its past history. Information is sought from the patient's perspective of the problem Physiotherapist endeavours to see and record the problem in the patient's terms Follow procedures with open and half-open questions

64. OBJECTIVE OF SUBJECTIVE EXAMINATION Determination of the problem of the patient, from the patient's perspective Defining subjective parameters which serve reassessment procedures Determination of precautions and contraindications to physical examination and treatment procedures Generation of multiple hypotheses to be tested during physical examination procedures and treatment interventions.

65. FIVE PARTS 'Kind' of disorder - establishing the main problem and perceived disability Site of symptoms - body chart Behaviour of symptoms and level of disability History Special questions

66. KIND OF DISORDER Why the patient is seeking the help of a physiotherapist: Pain Stiffness Giving way Sensation of instability Weakness Loss of function (local impairment, activities) After: Surgery Trauma manipulation under anaesthesia immobilization (e.g. plaster) following fracture/ disloca tion

67. SITE OF SYMPTOMS- BODY CHART Area of the symptoms Qualification of the symptoms: - Type of pain (e.g. Sharp, dull, throbbing, pulling) - Intermittent or constant, or constant/variable - Superficial or deep Areas free of symptoms, designated by a tick (✔) on the body chart Chronology of symptoms and relationship between symptoms If symptom distribution and qualification seems atypical Ask control questions with regard to possible involvement of central nervous system

68. BEHAVIOUR OF SYMPTOMS AND LEVEL OF DISABILITY Activities and / or positions which aggravate and ease symptoms General questions with regard to symptom behaviour Course of symptoms over 24 hours or 7 days General level of activity during the day/ week

69. HISTORY Present history - details with regard to the current episode Past history - information with regard to previous episodes of the same or similar disorders

70. PRESENT HISTORY The length of time the patient has noticed the symptoms ('since when') Details on the onset of the symptoms Progression of the symptoms and disability since onset Comparison of the pain and disability now compared with the initial stage of the symptoms

71. PREVIOUS HISTORY

72. Special questions General health Weight loss (especially excessive weight loss over a relatively short period) Use of medication, pain medication, antiinflammatory drugs, use of steroids, anticoagulant medications and other medications Blood pressure History of illnesses Previous operations History of accidents and injuries History of hospitalizations Laboratory results Results from X-ray, MRI or CT Difficulties with eating, digesting, bladder and bowel functions Cardiovascular and pulmonary condition.

73. Physical examination

74. PRINCIPLES AND METHODS OF MOBILIZATION

75. DIRECTION OF MOBILIZATION Direction(s) chosen for passive mobilization treatment techniques are determined from the movement-related 'joint signs' and the starting position adopted Distraction- when the patient has a lot of pain, or if the disorder is very irritable Compression- chronic disorders

76. METHOD OF MOBILIZATION/MANIPULATION Starting position of patient Completely relax Supine, side lying, prone, standing Starting position of physiotherapist Complete control of movement and applied force Core stability and base of support Comfortable, easy and economical Use advantages of levers Use arm, leg ,trunk to block the movment

77. LOCALIZATION OF FORCES Gain patient confidence Firm grip, do not hold tight Embrace the part to be moved / stabilized Feel the joints with tip of thumb Heel of hand or change the grip according to patient feeling Each physiotherapist should modify their point of contact with the patient and method of each technique according to the size and shape of their hands and the size and shape of the part to be embraced

78. APPLICATION OF FORCES Use body and arm to generate force Hand to direct force Grades I-V used

79. Grade I a small amplitude movement performed at the beginning of the available range. Grade II a large amplitude movement performed within a resistance-free part of the available range. Grade Ill a large amplitude movement performed into resistance or up to the limit of the available range. if performed near the beginning of the available range, will be classified as a grade II-, and if taken deep into the range, yet still not reaching resistance, will be classified as a grade II +. Grade IV a small amplitude movement performed into resistance or up to the limit of the available range. Grade V a small amplitude high velocity general movement performed usually, but not always, at the end of the available range

80. RHYTHMS OF MOBILIZATION 2-3glides/sec For pain For joint stiffness

81. DURATION OF TECHNIQUE No set rules For pain- shorter duration (2 minutes) For joint stiffness- longer duration

82. CLINICAL APPLICATION OF MOBILIZATION Pain and irritability Gentle oscillations: II-III Pain free Use accessory than physiological If through range pain- large amplitude

83. Chronic aching End range pain- IV accessory Physiological stretching movements Muscle spasm Stepped passive stretch Hold relax/ contract relax

84. THANK YOU

85. REFRENCES Hengeveld E, Banks K., ed (2006) Maitland’s pheripheral manipulation. 4 th edition. Elsevier