The Upper Limb: Mechanical Diagnosis and Therapy.

Although many years have passed since I sat in the classroom as a physical therapist student, as I settled into reading Mark Laslett's the Upper Limb: Mechanical Diagnosis the Therapy, I imagined I was once again a student. The didactic intent of the book is apparent in the first several chapters, covering definitions, diagnosis, and terminology. Laslett acknowledges the late Dr James Cyriax as "the fattier of orthopaedic medicine," who developed an assessment system that allows clinicians to identify the tissue or structure containing the painful lesion. For example, Cyriax used resistance to test a muscle, a passive stretch to test a ligament, and a movement to test a joint. Robin McKenzie, the author's mentor and colleague, developed the system of mechanical diagnosis and therapy using positions, movements, and other forces to identify the behavior and character of the problem, rather than the specific tissue or structure. For instance, repeated movements, among others, are used to identify mechanical versus chemical pain. Laslett's purpose is to integrate these complementary methods and apply the principles to the upper quarter in order to allow the clinician to evaluate and treat lesions in the shoulder, elbow, and wrist.

Chapters are devoted to the history taking, the physical examination, and general treatment principles. For each question asked in the history taking, the purpose for asking the question, a method of obtaining an answer, and an interpretation of the information given is described. The physical examination includes active movements, passive movements, resisted tests, repeated or sustained loading tests, and auxiliary tests, such as an instability test or gliding mobilization at a specific joint. Not only are the purpose and method for performing the test explained, but also how to interpret the information obtained. The chapter on general principles of treatment emphasizes educating the patient on the natural history of their diagnosis, instruction in selfcare, and minimizing the use of passive modalities. Progressions of treatment for specific tissues and chemical and mechanical lesions in acute, subacute, and chronic stages are outlined.

Following the solid foundation laid in the introductory chapters, the principles are applied to the shoulder, the elbow, and the wrist and hand. Anatomy, history taking, and the physical examination are described in detail for each area. Treatment techniques are described and illustrated, and include not only those of Cyriax and McKenzie, but also Freddy Kaltenborn, Geoffrey Maitland, and Brian Mulligan. The text concludes with a chapter titled "Regional Syndromes Affecting the Upper Limb" that briefly discusses referred pain from the spine, adverse neural tissue tension, and reflex sympathetic dystrophy.

This book is extremely well organized and easy to use as a reference. Many of the author's statements are not referenced and appear therefore to be derived from his clinical experience. Despite this shortcoming, I can highly recommend this book to the entry-level physical therapist student as well as the experienced clinician who may need guidance in integrating the various schools of thought to refine an eclectic approach to the examination and management of patients.