Bourdillon's Spinal Manipulation, 6th ed.

Isaacs ER, Bookhout MR. Woburn, MA 01801-2041, Butterworth-Heinemann Inc, 2002, hardcover, 333 pp, illus, ISBN: 0-7506-7239-0, $75.

The sixth edition of Bourdillon's Spinal Manipulation is a thorough and well-written text that encompasses osteopathy-based spinal examination and treatment procedures. The introduction provides a history of spinal manipulation from Hippocrates and bonesetters to modern osteopathy, chiropractic, and manual physical therapy. The opening chapter also outlines the authors' view that the greatest challenge facing manual therapy is to provide education and advanced skills in an era of decreasing reimbursement. In the authors' opinion, it is necessary to show that manual therapy can be a cost-effective means of managing musculoskeletal conditions and that the goal of manual intervention remains the restoration of function.

Subsequent chapters provide a fine overview of the anatomy and biomechanics of the pelvis, sacroiliac joint, lumbar and thoracic spine, and ribs. A brief description of the autonomic nervous system and the sensory distribution of spinal nerve roots is included. General considerations regarding examination--including osteopathic terminology, nomenclature, and somatic dysfunction--give the reader background for the more detailed examination procedures of the spinal regions in the later chapters. The examination descriptions focus on palpation of landmarks and motion testing, which the authors readily admit require considerable skill and practice.

One chapter is devoted to discussion of the discrepancies found in manipulation terminology and the techniques used to remove or alter joint and soft tissue problems that restrict movement. These techniques are not limited to high-velocity thrust, and they include soft tissue techniques, muscle energy technique, and myofascial and craniosacral manipulation. The neurological effects on the central nervous system and muscle reflex activity attributed to manipulation are discussed, and the reactions of patients to manipulation treatment are also presented.

The chapters that concentrate on treatment of the spinal regions also include "diagnostic points" that pay particular attention to joint position, palpatory findings, and tissue texture changes. Step-by-step instructions of how to perform thrust and muscle energy techniques describe the procedures well. Illustrations and biomechanical model diagrams of the dysfunctional segments offer further opportunities for understanding dysfunctions. These treatment chapters are referenced; however, the supporting evidence for these procedures come from textbooks rather than from clinical research trials. Moreover, the authors indicate that the treatments are based on the authors' clinical experience. A few paragraphs are devoted to special problems such as developmental scoliosis, spondylosis, disk herniation, and hypermobility and instability. Because the majority of the text involves examination and treatment of other spinal dysfunctions, these special problems are not covered in detail.

The last 2 chapters describe examination and treatment of muscle imbalances and describe exercise as a complement to manual therapy. Most physical therapy approaches, however, include a combination of physical agents, patient self-management strategies, therapeutic exercise, and manual therapy. The authors emphasize manual therapy as the primary treatment and maintain that patients may be weaned from manual therapy toward patient self-management. Advocates of other clinical approaches, however, argue that treatment should be implemented in the reverse order, with physical therapist-guided patient management being initiated first and manual therapy techniques being called on only when needed.

Bourdillon's Spinal Manipulation is an excellent reference for physical therapists interested in practicing manual therapy using an osteopathic approach. The reader, however, should be cautioned that the detailed procedures outlined in the text are not evidence-based, and, as presented, they provide a useful learning tool for advancing manual therapy skills but not a justification for manual therapy.

Ron Schenk, PT, PhD, OCS
State University of New York at Buffalo
Buffalo, NY

Dr Schenk is a Clinical Associate Professor of Physical Therapy in the Doctor of Physical Therapy program where he teaches musculoskeletal examination and treatment. His clinical research involves validation of an examination scheme for low back disorders.