Spinal Manual Therapy: an Introduction to Soft Tissue Mobilization, Spinal Manipulation, Therapeutic and Home Exercises.

Spinal Manual Therapy: An Introduction to Soft Tissue Mobilization, Spinal Manipulation, Therapeutic and Home Exercises

Makofsky HW. Thorofare, NJ 08086, Slack Inc, 2003, paperback, 268 pp, illus, ISBN: 1-55642-569-4, $39.95.

"Beauty is in the eye of the beholder," and definitions of manual therapy are in the hands of the writers. Howard Makofsky has written a text on spinal manual therapy in which the overarching construct of manual therapy is never clearly defined, and the book unfortunately suffers from this lack of definition. Ultimately, the author attempted to tie together too many models and approaches, which sometimes conflict, under his unifying theme of spinal manual therapy. Some of the more easily recognized names and models that he tried to integrate include the osteopathic school of thought and the works of McKenzie, Paris, Maitland, Kaltenborn, Rocabodo, Janda, Feldenkrais, and Warmerdam. The foreword praises this as being an "eclectic approach," and, in the hands of a person who is knowledgeable and skillful in each of the approaches, the eclectic model may work. This text, however, is meant to be used as a reference source and laboratory manual for students who are just beginning to work with patients who have problems related to spinal pathology--and it is vital that this target audience understand the theoretical underpinnings and assumptions at the basis of each model.

The book is divided into 7 sections that contain 3 to 5 chapters each. The first section discusses the author's conceptualization of the "essentials of spinal manual therapy." In this section, the reader will find a biomechanical description of vertebral motion dynamics, followed by a chapter discussing McKenzie's 3 diagnostic syndromes and a short chapter on basic principles of examination, diagnosis, and intervention. There is little rationale for including McKenzie's theories, and these theories are a bad fit throughout the remainder of the book. The author himself acknowledges that only by immersing oneself in study is a "true understanding of this problem-based approach" possible. To his credit, the author identifies that much of the writing in these chapters is his own opinion. The reader, however, may wonder what it is that renders Makofsky's opinion valid.

Sections II through VI are each devoted to examination techniques and interventions that are appropriate for specific anatomical regions--the scapulothoracic region, cervical spine, temporomandibular joint, lumbar spine, and pelvic girdle. Within each section, the author has a chapter on examination and evaluation, a chapter on connective tissue techniques, a chapter on manipulation (sometimes called manual therapy), and a chapter on therapeutic exercise. The decisions on which models to present in each chapter and which techniques are "most helpful" are, again, solely based on Makofsky's opinion. For instance, the author's own technique--the "spinal corkscrew"--and a device he has under patent to help people perform this technique are described as having "obvious mechanical effects" and as being capable of breaking "poor postural habits while establishing new ones."

Chapters are written using a language colored heavily by jargon. The book pays heed to APTA's Guide to Physical Therapist Practice (Guide) in its use of terminology; however, the reader is presented with an array of techniques and no guiding approach that clearly follows the patient/client management model or the intervention conceptualization in the Guide. If a physical therapist wanted to learn the techniques presented in the book, the descriptions are clear and the pictures are sufficient as an additional resource to learning in a clinical laboratory environment.

The final section of the book is titled "From the Classroom to the Clinic" and is divided into 2 chapters. The first chapter is supposed to provide an empirical basis for the use of manual therapy in the clinic. To that end, the author offers annotated citations to 15 studies. This presentation hardly serves to address the lack of solid research evidence to support the methods detailed in the book. The author tailed to provide a synthesis or analysis of the evidence, and the 15 annotations support varying pieces of the models that he has weaved together in his book. This leaves the reader still wondering about the empirical rationale behind Makofsky's choices. In the final chapter, Makofsky provides 12 "case studies" with quiz-style questions. The case studies are misnamed and, in fact, are actually short scenarios of the type typically written to ascertain student learning in professional curricula. What a shame--1 or 2 empirically based case studies of the sort published in professional journals could surely have redeemed this section of the book.

Makofsky has impressive credentials and many years of practice on which to draw. No doubt he has helped many thousands of patients and, as an academic, has mentored many students. In this book, he has drawn on his years of experience to write a guide to treating spinal disorders for physical therapist students who are new to this field. The profession, however, would have been better served if he had devoted his efforts to collecting data and documenting the efficacy and outcomes of the eclectic approach he has constructed and described.

Julia Chevan, PT, OCS 

Springfield College Springfield, Mass

Ms Chevan is Associate Professor in the Department of Physical Therapy, where she teaches courses on musculoskeletal examination, evaluation, and intervention. She also manages patients with orthopedic conditions through a local clinic.