Physical Therapy of the Cervical and Thoracic Spine, ed 3.

Grant R, ed. Philadelphia, PA 19106, Churchill Livingstone Inc, 2002, hardcover, 459 pp, illus, ISBN: 0-443-06564-0, $59.95.

The purpose of this text is to provide best research evidence on contemporary biomedical knowledge and pathophysiological factors concerning therapeutic intervention in the cervical and thoracic spine.

The text is divided into 3 parts. Part I covers functional and applied anatomy, biomechanics, and innervations and pain patterns of the cervical and thoracic spine, and it includes a new chapter on the biomechanics of the thorax. Part II is devoted to examination and evaluation. Part III, on patient management and evidence-based practice, has been expanded and includes 6 new chapters. The final chapter in part III reflects on the changes in professional practice and on the acquisition and application of knowledge (what the editor calls "knowledge management").

The theme of this work in the management of patients with cervical and thoracic disorders within an evidence-based practice model. As a result, the text draws heavily from research articles. The chapters on anatomy and biomechanics are particularly detailed and are noteworthy for their challenge of earlier studies on spinal biomechanics. In a startling contrast to conventional concepts of spinal motion, for example, the authors cite a study (van Mameren H, Drukker J, Sanches H, Beursgens J. Cervical spine motion in the sagittal plane, I: range of motion of actually performed movements, an x-ray cinematographic study. Eur J Morphol. 1990;28:47-68) that used high-speed cinematographs of cervical flexion and extension in subjects without impairment and that found that the total range of motion of the neck is not the arithmetic sum of its intersegmental ranges of motion. The study also found that the maximal range of spinal movement was often exhibited during some point of the excursion before the neck reached its final position.

The findings are clinically significant in several ways. First, what was formerly quantified as total cervical motion is not directly related to intersegmental motion. Second, differences in intersegmental motion were noted depending on the direction in which the motion occurred (ie, from flexion into extension or from extension into flexion). Third, ranges of movement differed within subjects at different times. These implications present a far more complex picture of spinal biomechanics and challenge earlier notions of spinal movement.

Biomechanical models are presented in depth, supported primarily by references from a variety of peer-reviewed journals. Part I also contains noteworthy discussions of pain patterns in the cervical and thoracic spine and the substantial variances in these patterns that individuals exhibit.

Part II, on examination and evaluation, discusses a broad array of subjects, including manipulation and mobilization procedures, muscle imbalances, posture, and upper-limb tension testing. Although supplemented by clear photographs that demonstrate specific techniques and hand placement, the text assumes at least a moderate degree of proficiency in manual therapy on the part of the reader. This work therefore should not stand alone as a sole reference for the practitioner who is beginning professional practice.

Part III, on clinical management and evidence-based practice, is significant not only for its discussion of the treatment of specific cervical and thoracic conditions, but also for its exploration of theoretical and practical issues surrounding the management of the spine and selected impairments. Research-based information on the physical therapist management of patients is emphasized throughout the text. The chapter authors critically discuss relevant research studies, sometimes critiquing methods and cautioning readers about what conclusions can be drawn from a particular study. They often acknowledge the need for further research. The book places heavy emphasis on clinical reasoning processes in order to assist clinicians in identifying clusters of signs and symptoms that are associated with musculoskeletal syndromes (what the chapter authors call "pattern recognition") and to aid them in hypothesis generation and hypothesis testing.

This text sheds new light on intersegmental motion and vertebral biomechanics and establishes biomechanical models as the basis for manual therapy later in the book. Using a combined movements approach, the authors distinguish between mid-thoracic versus lower thoracic kinematics and between upper and lower cervical spine examination. In addition, the third edition discusses thoracic innervations and pain patterns. Much space is also devoted to the medicolegal issues surrounding manipulative therapy, and the book contains guidelines for cervical testing prior to manipulation.

The work contains comprehensive discussions of posture and soft tissue tightness and discussions on how neck and upper-extremity function are interrelated. Stiffness; impairments of muscle length, muscle force, and motor control; and the effect of habitual postures and movement patterns are discussed in keeping with comprehensive examination procedures and are classified within movement impairment syndromes.

The chapter on neck and upper-extremity pain in the workplace, written by Barbara McPhee and David Worth, also is noteworthy for its organization of knowledge. This chapter contains the authors' proposed classification system using the categories of "traumatic disorders," "degenerative disorders," and "abusive use disorders" in order to solve diagnostic dilemmas, to broaden the overview, and to deal with workplace conditions more successfully. According to the authors, "abusive use disorders" are a group of disorders noted for their lack of specific diagnosis that may present with widespread symptoms, including pain, parasthesia, swelling, and vascular disturbances. The authors also define 3 subgroups of abusive use disorders: postural overload syndromes, overuse syndromes, and environmental condition syndromes. McPhee and Worth, however, do not provide any evidence for the validity or reliability of their proposed classification system nor do they acknowledge the need to establish validity and reliability. The chapter on mechanical diagnosis and therapy for the cervical and thoracic spine, coauthored by Robin McKenzie and Stephen May, offers just an overview of McKenzie's approach; readers who wish to study his treatment method more fully should instead consult McKenzie's landmark text on the subject: The Cervical And Thoracic Spine: Mechanical Diagnosis and Therapy.

Information appears correct and timely and is presented in a depth sufficient for both the clinician and the researcher. An abundance of references, including peer-reviewed journal articles, textbooks, and government studies, follow each chapter. Where appropriate, new and expanded information is cited. The authors synthesize this expanded knowledge base into the framework of intervention and thus guide the reader with the latest information available. The text's multiple authors maintain a consistent, didactic tone. Information follows a logical progression from anatomy and biomechanics to comprehensive patient management. A sufficient number of photographs, diagrams, and charts supplement the text and often summarize key findings of relevant research. Most chapters include a summary section. In addition, the authors use a case study format to highlight certain clinical presentations.

This work is best suited to physical therapists who possess at least a moderate level of clinical sophistication. It succeeds in making the case for patient management in an evidence-based environment, and it relies on numerous studies to support practice within this model, both from a theoretical and a practical, results-oriented perspective. The authors have succeeded in creating a work that cohesively assembles the latest information in a format including up-to-date techniques for conservative manual therapy.

Eugene Pavone, PT

Sports Physical Therapy of New York, PC

Spring Valley, NY

Mr Pavone specializes in orthopedic physical therapy in an outpatient setting.