Introduction to the Maitland

 A tribute to Geoffrey Douglas Maitland


MBE, AUA, FCSP, FACP, MAppSc
 1924 to Fri 20 Feb 2010

 GD Maitland born in 1924 in Adelaide, Australia, was trained as

physiotherapist from 1946 to 1949
 First job at Royal Adelaide Hospital, (main interest was treatment
of orthopedic and neurological conditions)
 Part time tutor at School of physiotherapy in South Australian
Institute of Technology, now University of South Australia
 He used to spend half day each week in barr-smith library and
excellent library at Medical School of the University of the
Adelaide
 He became interested in learning clinical examination and
assessment
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 Introduction to the Maitland Cont…

 He has studied the techniques from osteopath, chiropractor, bonesetter books as well
as from medical books such as those of Marlin, Joster, James B. Mennell, John Mc
Millan Mennell, Alan stoddard, Robert Maignee, Edgar Cyriax, James Cyriax, and
many others available
 1954, He started teaching manipulative therapy sessions
 1961, He was awarded with special scholarship for overseas study tour, he visited
James Cyriax, and Georgy P. Grieve in UK along with others
 1962, he wrote an article of “the problems of teaching vertebral manipulation”
 1964, first edition of vertebral manipulation (Latest 7th Edition 2005)
 1970, first edition of peripheral manipulation (Latest 4th Edition 2005)
 He remained in working practice till 1995
 He died on 20th Feb 2010
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Fundamental components of the Maitland’s Concept


A. The patient centered approach to dealing with movement disorders

B. The brick wall approach and the primacy of clinical evidence

C. The paradigm of identifying and maximizing movement potential

D. The science and art of assessment

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 A. The patient centered approach to
dealing with movement disorders

 Personal commitment to the patient
1. Concentration
 What it is
 How it can be improved
2. Prepared to revisit
 Follow up
3. Non judgmental
 why
4. Verbal and non verbal communication
 Communication error? Who will be responsible for it?
5. Patients own terminology
 Physiotherapist’s duty to explore and modify accordingly
6. Patients frame of reference
 Put yourself in patients shoes to have true idea
7. Therapeutic relationship
 Environment should be comfortable, trusting 6
B. The brick wall approach and the primacy of clinical
evidence

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 C. The paradigm of identifying and
maximizing movement potential

Physiotherapist is concerned with identifying and
maximizing movement potential within the spheres
of promotion, prevention, treatment and
rehabilitation.

(WCPT,1999)

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 C. The paradigm of identifying and
maximizing movement potential

THE MAITLAND CONCEPT with attention to detail in the
analysis of
QUANTITY AND QUALITY OF HUMAN MOVEMENT

AND
with MOBILIZATION/MANIPULATION techniques
designed to restore movements to their pain free ideal state,
is well placed to contributes to the realization of such a
paradigm
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 C. The paradigm of identifying and
maximizing movement potential

 The Physical Examination – Maitland Concept emphasized on
 Present Pain
 Observation
 Functional movement assessment (functionally reproducing movements)
 Re-enacting the injuring movement
 Differentiation tests
 Brief Appraisal Tests
 Pain response to
 Accessory movements
 Physiological movements
 Combined movements
 Physiological and accessory movement with joint surfaces compressed together
 Over pressure
 Movements
 Palpation
 Isometric Testing
 Neurological Examination and Neurodynamic Testing
 Division of Tests in Different Positions (Supine, Side lying(L,R), Prone, Sitting)
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 D. The science and art of assessment


 Science of assessment
 Cause of the problem
 The structures at fault
 Pathobiological mechanisms
 Art of Assessment
 Repeated assessment and ongoing analytical assessment
 Clinical decision making about treatment strategies (selection and application of the
techniques)

It is open-mindedness, mental agility and mental discipline linked with a logical and
methodical process of assessing cause and effect which are the demands of the
concept
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 Assessment

 Analytical Assessment at 1st consultation
 Pretreatment Assessment
 Assessment and Reassessment during and
immediately after each treatment session
 Progressive assessment
 3rd to 4th session
 Retrospective assessment
 After a planned break from treatment
 Like 2 weeks on and 2 weeks off
 Final Analytical Assessment
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 

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THE MAITLAND’S CONCEPT
Basic Definitions from
Maitland’s Concept


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 Mobilization

It is passive movement performed in such a manner
and speed that all the times it is within the control of
the patient so that the movement can be prevented if
patient chooses so

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 Manipulation

A passive movement consisting of a high velocity, small amplitude thurst
within the joint’s anatomical limit, performed at such a speed that
renders the patient powerless to prevent it
MUA (Manipulation Under Anaesthsia)
is a medical procedure, performed under anaesthesia, and is used to
stretch a periarticular and intraarticular joint structures to restore a full
range of movement by breaking adhesions.
The procedure is not sudden forceful thurst, but it is done as steady
controlled stretch, and also termed as manipulation
if any break down (sudden) of adhesions during mobilization
technique may be classified as manipulation even though a sudden
thurst has not been used

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 Passive Movement

 Any movement of any part of one person which
is performed on that person by another person
or piece of equipment
 Physiological and Accessory Movements are two
types of passive Movements

 It is important to restore both physiological and

accessory movements to restore normal joint
mobility

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 Passive Movements

Physiological movements are those
movements that patients can perform actively by
themselves
Accessory movements are those that the
individual can not perform actively but which can be
performed on them by another person.

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

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 Grades of Mobilization

Grading based on amplitude of movement & where
within available ROM the force is applied.
 Grade I
 Small amplitude rhythmic oscillating movement at the
beginning of range of movement
 Manage pain and spasm

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 Grades of Mobilization
 Grade II

 Large amplitude rhythmic oscillating movement within
midrange of movement
 Manage pain and spasm
 Grades I & II – often used before & after treatment
with grades III & IV

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 Grades of Mobilization
 Grade III

 Large amplitude rhythmic oscillating movement up to
point of limitation (PL) in range of movement
 Used to gain motion within the joint
 Stretches capsule & CT structures

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 Grades of Mobilization
 Grade IV

 Small amplitude rhythmic oscillating movement at very
end range of movement
 Used to gain motion within the joint
 Used when resistance limits movement in absence of pain

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 Grades of Mobilization

 Grade V – (thrust technique) - Manipulation
 Small amplitude, quick thrust at end of range
 Accompanied by popping sound (manipulation)
 Velocity vs. force
 Requires training

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 Example of grades


The best way to learn is to practice, practice and practice……

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 Maitland’s Key Points regarding
Shoulder


Shoulder Joint Nerve Supply: Musculocutaneous, Suprascpular and Subscapular Nerve (C4 to C7)
 Screening: Quardrant and Locking Position should be painfree to rule out acromiohumeral as a
source
 If SC joint stiffness accompany with the morning stiffness in other areas it indicates towards
Ankylosing spondylitis
 Adapted shortening of scapular muscles is also a factor in the development of movement related
dysfunctions
 Schneider (1989) selected 14 patients with a gross restriction of shoulder lateral rotation and
mobilized their cervical spines, resulting in an overall improvement in the range of shoulder
lateral rotation.
 Stimulation of the anterior and inferior articular branches to the shoulder joint elicited EMG
activity in biceps, subscapularis and supraspinatus muscles

 Stimulation of posterior articular nerve elicited EMG activity in the acromiodeltoid muscle
 When transaction of the articular branches was performed there was an absence of EMG activity
in the relevant muscles, thus suggesting that the sensory function of the joint capsule is closely
related to the functioning of the muscles around the shoulder



Effects of Joint Mobilization
&
Contraindications

 Effects of Joint Mobilization
 Neurophysiological effects – 
 Stimulates mechanoreceptors to  pain
 Affect muscle spasm & muscle guarding – nociceptive stimulation
 Increase in awareness of position & motion because of afferent nerve
impulses
 Nutritional effects –
 Distraction or small gliding movements – cause synovial fluid movement
 Movement can improve nutrient exchange due to joint swelling &
immobilization
 Mechanical effects –
 Improve mobility of hypomobile joints (adhesions & thickened CT from
immobilization – loosens)
 Maintains extensibility & tensile strength of articular tissues
 Cracking noise may sometimes occur
Contraindications to Manual therapy

 Infections, or osteopenia (e.g.,

  Dermatological problems aggravated
osteoporosis, osteomalacia) by skin contact and
 Active collagen vascular disorders  Open or healing skin lesions
 Massive degenerative changes  Inflammatory arthritis
 Loss of skeletal or ligamentous  Malignancy
stability in the spine (e.g.secondary to  Tuberculosis
inflammation or infection or after  Ligamentous rupture
trauma)
 Herniated disks with nerve
 Certain congenital anomalies compression
 Anomalies or patbological changes in  Bone disease
vessels
 Neurological involvement
 Coagulation problems (e.g.,
 Bone fracture
anticoagulation factors,hemophilia)
 Joint effusion
Maitland’s Techniques
on the Shoulder


Glenohumeral
Graded PPM

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