Orthopedic Physical Assessment E

Book (Musculoskeletal Rehabilitation)

6th Edition, (Ebook PDF)
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Contents
1 Principles and Concepts, 1 Active Movements, 163
Passive Movements, 169
Patient History, 1 Resisted Isometric Movements, 171
Observation, 17 Scanning Examination, 172
Examination, 18 Functional Assessment, 179
Principles, 18 Special Tests, 180
Vital Signs, 19 Reflexes and Cutaneous Distribution, 199
Scanning Examination, 20 Joint Play Movements, 202
Examination of Specific Joints, 31 Palpation, 205
Functional Assessment, 43 Diagnostic Imaging, 207
Special (Diagnostic) Tests, 48
Reflexes and Cutaneous Distribution, 57
Joint Play Movements, 61
Palpation, 61
4 Temporomandibular Joint, 224
Diagnostic Imaging, 64
Applied Anatomy, 224
Précis, 75
Patient History, 226
Case Studies, 75
Observation, 231
Conclusion, 76
Examination, 234
Active Movements, 234
Passive Movements, 237
2 Head and Face, 84 Resisted Isometric Movements, 237
Functional Assessment, 237
Applied Anatomy, 84
Special Tests, 239
Patient History, 86
Reflexes and Cutaneous Distribution, 240
Observation, 110
Joint Play Movements, 240
Examination, 116
Palpation, 242
Examination of the Head, 116
Diagnostic Imaging, 244
Examination of the Face, 124
Examination of the Eye, 127
Examination of the Nose, 132
Examination of the Teeth, 132 5 Shoulder, 252
Examination of the Ear, 133
Special Tests, 134 Applied Anatomy, 252
Reflexes and Cutaneous Distribution, 136 Patient History, 257
Joint Play Movements, 137 Observation, 264
Palpation, 137 Anterior View, 264
Diagnostic Imaging, 139 Posterior View, 266
Examination, 270
Active Movements, 271
3 Cervical Spine, 148 Passive Movements, 283
Resisted Isometric Movements, 286
Applied Anatomy, 148 Functional Assessment, 286
Patient History, 152 Special Tests, 290
Observation, 162 Reflexes and Cutaneous Distribution, 346
Examination, 163 Joint Play Movements, 351

vii
viii Contents

Palpation, 353 Joint Play Movements, 536

Diagnostic Imaging, 356 Palpation, 538
Diagnostic Imaging, 541

6 Elbow, 388
9 Lumbar Spine, 550
Applied Anatomy, 388
Patient History, 390 Applied Anatomy, 550
Observation, 392 Patient History, 555
Examination, 394 Observation, 562
Active Movements, 394 Body Type, 562
Passive Movements, 395 Gait, 562
Resisted Isometric Movements, 396 Attitude, 562
Functional Assessment, 398 Total Spinal Posture, 566
Special Tests, 402 Markings, 568
Reflexes and Cutaneous Distribution, 412 Step Deformity, 569
Joint Play Movements, 416 Examination, 569
Palpation, 417 Active Movements, 570
Diagnostic Imaging, 419 Passive Movements, 577
Resisted Isometric Movements, 577
Peripheral Joint Scanning Examination, 583
7 Forearm, Wrist, and Hand, 429 Myotomes, 585
Functional Assessment, 588
Applied Anatomy, 429 Special Tests, 593
Patient History, 434 Reflexes and Cutaneous Distribution, 612
Observation, 434 Joint Play Movements, 616
Common Hand and Finger Deformities, 436 Palpation, 618
Other Physical Findings, 440 Diagnostic Imaging, 620
Examination, 441
Active Movements, 445
Passive Movements, 447 10 Pelvis, 649
Resisted Isometric Movements, 448
Functional Assessment (Grip), 451 Applied Anatomy, 649
Special Tests, 465 Patient History, 650
Reflexes and Cutaneous Distribution, 478 Observation, 654
Joint Play Movements, 484 Examination, 659
Palpation, 486 Active Movements, 659
Diagnostic Imaging, 491 Passive Movements, 663
Resisted Isometric Movements, 667
Functional Assessment, 668
8 Thoracic (Dorsal) Spine, 508 Special Tests, 668
Reflexes and Cutaneous Distribution, 675
Applied Anatomy, 508 Joint Play Movements, 676
Patient History, 511 Palpation, 679
Observation, 513 Diagnostic Imaging, 681
Kyphosis, 514
Scoliosis, 515
Breathing, 518 11 Hip, 689
Chest Deformities, 518
Examination, 519 Applied Anatomy, 689
Active Movements, 521 Patient History, 689
Passive Movements, 527 Observation, 695
Resisted Isometric Movements, 528 Examination, 696
Functional Assessment, 529 Active Movements, 697
Special Tests, 529 Passive Movements, 700
Reflexes and Cutaneous Distribution, 535 Resisted Isometric Movements, 700
 Contents ix

Functional Assessment, 702 Normal Parameters of Gait, 985

Special Tests, 705 Base (Step) Width, 985
Reflexes and Cutaneous Distribution, 731 Step Length, 985
Joint Play Movements, 732 Stride Length, 986
Palpation, 733 Lateral Pelvic Shift (Pelvic List), 986
Diagnostic Imaging, 736 Vertical Pelvic Shift, 987
Pelvic Rotation, 987
Center of Gravity, 987
Normal Cadence, 987
12 Knee, 765 Normal Pattern of Gait, 987
Stance Phase, 987
Applied Anatomy, 765 Swing Phase, 991
Patient History, 766 Joint Motion During Normal Gait, 993
Observation, 771 Overview and Patient History, 994
Examination, 780 Observation, 994
Active Movements, 781 Examination, 996
Passive Movements, 782 Locomotion Scores, 997
Resisted Isometric Movements, 783 Compensatory Mechanisms, 1000
Functional Assessment, 786 Abnormal Gait, 1000
Ligament Stability, 790 Antalgic (Painful) Gait, 1007
Special Tests, 834 Arthrogenic (Stiff Hip or Knee)
Reflexes and Cutaneous Distribution, 851 Gait, 1007
Joint Play Movements, 855 Ataxic Gait, 1007
Palpation, 857 Contracture Gaits, 1007
Diagnostic Imaging, 859 Equinus Gait (Toe Walking), 1008
Gluteus Maximus Gait, 1008
Gluteus Medius (Trendelenburg)
13 Lower Leg, Ankle, and Foot, 888 Gait, 1009
Hemiplegic or Hemiparetic Gait, 1009
Applied Anatomy, 888 Parkinsonian Gait, 1010
Hindfoot (Rearfoot), 888 Plantar Flexor Gait, 1010
Midfoot (Midtarsal Joints), 890 Psoatic Limp, 1010
Forefoot, 891 Quadriceps Avoidance Gait, 1010
Patient History, 891 Scissors Gait, 1010
Observation, 895 Short Leg Gait, 1010
Examination, 914 Steppage or Drop Foot Gait, 1011
Active Movements, 914
Passive Movements, 919
Resisted Isometric Movements, 920
Functional Assessment, 920 15 Assessment of Posture, 1017
Special Tests, 924
Reflexes and Cutaneous Distribution, 941 Postural Development, 1017
Joint Play Movements, 947 Factors Affecting Posture, 1022
Palpation, 950 Causes of Poor Posture, 1022
Diagnostic Imaging, 955 Common Spinal Deformities, 1022
Lordosis, 1022
Kyphosis, 1024
Scoliosis, 1027
14 Assessment of Gait, 981 Patient History, 1029
Observation, 1031
Definitions, 981 Standing, 1032
Gait Cycle, 981 Forward Flexion, 1044
Stance Phase, 982 Sitting, 1046
Swing Phase, 982 Supine Lying, 1048
Double-Leg Stance, 984 Prone Lying, 1049
Single-Leg Stance, 984 Examination, 1049
x Contents
16 Assessment of the Amputee, 1054
Levels of Amputation, 1054
Patient History, 1057
Observation, 1061
Examination, 1065
Measurements Related to Amputation, 1065
Active Movements, 1065
Passive Movements, 1069
Resisted Isometric Movements, 1069
Functional Assessment, 1069
Sensation Testing, 1069
Psychological Testing, 1069
Palpation, 1070
Diagnostic Imaging, 1070
17 Primary Care Assessment, 1072
Objectives of the Evaluation, 1076
Primary Care History, 1076
Examination, 1077
Vital Signs, 1078
General Medical Problems, 1078
Head and Face, 1078
Neurological Examination and Convulsive
Disorders (Including Head Injury), 1079
Musculoskeletal Examination, 1080
Cardiovascular Examination, 1081
Pulmonary Examination, 1085
Gastrointestinal Examination, 1085
Urogenital Examination, 1086
Dermatological Examination, 1086
Examination for Heat (Hyperthermic)
Disorders, 1087
Examination for Cold (Hypothermic)
Disorders, 1087
Laboratory Tests, 1087
Diagnostic Imaging, 1088
Physical Fitness Profile (Functional
Assessment), 1088
Tests for Return to Activity Following
Injury, 1096
Sports Participation, 1099
18 Emergency Sports Assessment, 1105
Pre-Event Preparation, 1105
Primary Assessment, 1105
Level of Consciousness, 1107
Establishing the Airway, 1109
Establishing Circulation, 1111
Assessment for Bleeding, Fluid Loss, and
Shock, 1113
Pupil Check, 1114
Assessment for Spinal Cord Injury, 1114
Assessment for Head Injury (Neural
Watch), 1116
Assessment for Heat Injury, 1118
Assessment for Movement, 1119
Positioning the Patient, 1119
Injury Severity, 1122
Secondary Assessment, 1122

Principles and Concepts
A musculoskeletal assessment requires a proper and thor-
ough systematic examination of the patient. A correct
diagnosis depends on a knowledge of functional anatomy,
an accurate patient history, diligent observation, and a
thorough examination. The differential diagnosis process
involves the use of clinical signs and symptoms, physical
examination, a knowledge of pathology and mechanisms
of injury, provocative and palpation (motion) tests, and
laboratory and diagnostic imaging techniques. It is only
through a complete and systematic assessment that an
accurate diagnosis can be made. The purpose of the
assessment should be to fully and clearly understand the
patient’s problems, from the patient’s perspective as well
as the clinician’s, and the physical basis for the symptoms
that have caused the patient to complain. As James Cyriax
stated, “Diagnosis is only a matter of applying one’s
anatomy.”1
One of the more common assessment recording tech-
niques is the problem-oriented medical records method,
which uses “SOAP” notes.2 SOAP stands for the four
parts of the assessment: Subjective, Objective, Assess-
ment, and Plan. This method is especially useful in helping
the examiner to solve a problem. In this book, the subjec-
tive portion of the assessment is covered under the
heading Patient History, objective under Observation,
and assessment under Examination.
Although the text deals primarily with musculoskeletal
physical assessment on an outpatient basis, it can easily be
adapted to evaluate inpatients. The primary difference is
in adapting the assessment to the needs of a bedridden
patient. Often, an inpatient’s diagnosis has been made
previously, and any continuing assessment is modified to
determine how the patient’s condition is responding to
treatment. Likewise, an outpatient is assessed continually
during treatment, and the assessment is modified to
reflect the patient’s response to treatment.
Regardless of which system is selected for assessment,
the examiner should establish a sequential method
to ensure that nothing is overlooked. The assessment
must be organized, comprehensive, and reproducible. In
general, the examiner compares one side of the body,
which is assumed to be normal, with the other side of the
body, which is abnormal or injured. For this reason, the
examiner must come to understand and know the wide
variability in what is considered normal. In addition, the
CHAPTER 1
examiner should focus attention on only one aspect of
the assessment at a time, for example, ensuring a thor-
ough history is taken before completing the examination
component. When assessing an individual joint, the
examiner must look at the joint and injury in the context
of how the injury may affect other joints in the kinetic
chain. These other joints may demonstrate changes as
they try to compensate for the injured joint.
Total Musculoskeletal Assessment
• Patient history
• Observation
• Examination of movement
• Special tests
• Reflexes and cutaneous distribution
• Joint play movements
• Palpation
• Diagnostic imaging
Each chapter ends with a summary, or précis, of the
assessment procedures identified in that chapter. This
section enables the examiner to quickly review the perti-
nent steps of assessment for the joint or structure being
assessed. For further information, the examiner can refer
to the more detailed sections of the chapter.
PATIENT HISTORY
A complete medical and injury history should be
taken and written to ensure reliability. This requires effec-
tive and efficient communication on the part of the exam-
iner and the ability to develop a good rapport with the
patient and, in some cases, family members and other
members of the health care team. This includes speaking
at a level and using terms the patient will understand;
taking the time to listen; and being empathic, interested,
caring, and professional.3 Naturally, emphasis in taking
the history should be placed on the portion of the assess-
ment that has the greatest clinical relevance. Often the
examiner can make the diagnosis by simply listening
to the patient. No subject areas should be skipped. Rep-
etition helps the examiner to become familiar with the
characteristic history of the patient’s complaints so that
1
2 Chapter 1 Principles and Concepts

unusual deviation, which often indicates problems, is TABLE 1-1

noticed immediately. Even if the diagnosis is obvious,
Red Flag Findings in Patient History That Indicate
the history provides valuable information about the Need for Referral to Physician
disorder, its present state, its prognosis, and the appropri-
ate treatment. The history also enables the examiner to Cancer Persistent pain at night
Constant pain anywhere in the body
determine the type of person the patient is, his or her
Unexplained weight loss (e.g., 4.5 to
language and cognitive ability, the patient’s ability to
6.8 kg [10 to 15 lbs] in 2 weeks or
articulate, any treatment the patient has received, and the less)
behavior of the injury. In addition to the history of the Loss of appetite
present illness or injury, the examiner should note rele- Unusual lumps or growths
vant past history, treatment, and results. Past medical Unwarranted fatigue
history should include any major illnesses, surgery, acci- Cardiovascular Shortness of breath
dents, or allergies. In some cases, it may be necessary to Dizziness
delve into the social and family histories of the patient if Pain or a feeling of heaviness in the
they appear relevant. Lifestyle habit patterns, including chest
sleep patterns, stress, workload, and recreational pursuits, Pulsating pain anywhere in the body
should also be noted. Constant and severe pain in lower leg
It is important that the examiner politely but firmly (calf) or arm
keeps the patient focused and discourages irrelevant infor- Discolored or painful feet
Swelling (no history of injury)
mation. Questions and answers should provide practical
Gastrointestinal/ Frequent or severe abdominal pain
information about the problem. At the same time, to Genitourinary Frequent heartburn or indigestion
obtain optimum results in the assessment, it is important Frequent nausea or vomiting
for the examiner to establish a good rapport with the Change in or problems with bowel
patient. In addition, the examiner should listen for any and/or bladder function (e.g.,
potential red flag signs and symptoms (Table 1-1) that urinary tract infection)
would indicate the problem is not a musculoskeletal Unusual menstrual irregularities
one or a more serious problem that should be referred Miscellaneous Fever or night sweats
to the appropriate health care professional.4,5 Yellow Recent severe emotional disturbances
flag signs and symptoms are also important for the exam- Swelling or redness in any joint with
iner to note as they denote problems that may be more no history of injury
Pregnancy
severe or may involve more than one area requiring a
Neurological Changes in hearing
more extensive examination, or they may relate to cau- Frequent or severe headaches with no
tions and contraindications to treatment that the exam- history of injury
iner might have to consider, or they may indicate overlying Problems with swallowing or changes
psychosocial issues that may affect treatment.6 in speech
The patient’s history is usually taken in an orderly Changes in vision (e.g., blurriness or
sequence. It offers the patient an opportunity to describe loss of sight)
the problem and the limitations caused by the problem Problems with balance, coordination,
as he or she perceives them. To achieve a good functional or falling
outcome, it is essential that the clinician heed to the Faint spells (drop attacks)
patient’s concerns and expectations for treatment. After Sudden weakness
all, the history is the patient’s report of his or her own
Data from Stith JS, Sahrmann SA, Dixon KK, et al: Curriculum to
condition. The clinician should ask questions that are prepare diagnosticians in physical therapy. J Phys Ther Educ 9:50, 1995.
easy to understand and should not lead the patient.
For example, the examiner should not say, “Does this
increase your pain?” It would be better to say, “Does
this alter your pain in any way?” The examiner should ask
one question at a time and receive an answer to each 1. What is the patient’s age and sex? Many conditions
question before proceeding with another question. Open- occur within certain age ranges. For example, various
ended questions ask for narrative information; closed growth disorders, such as Legg-Perthes disease or
or direct questions ask for specific information. Direct Scheuermann disease, are seen in adolescents or teen-
questions are often used to fill in details of information agers. Degenerative conditions, such as osteoarthritis
given in open-ended questions, and they frequently and osteoporosis, are more likely to be seen in an
require only a one-word answer, such as yes or no. In any older population. Shoulder impingement in young
musculoskeletal assessment, the examiner should seek people (15 to 35 years) is more likely to result from
answers to the following pertinent questions. muscle weakness, primarily in the muscles controlling

Yellow Flag Findings in Patient History That
Indicate a More Extensive Examination May
Be Required
• Abnormal signs and symptoms (unusual patterns of
complaint)
• Bilateral symptoms
• Symptoms peripheralizing
• Neurological symptoms (nerve root or peripheral
nerve)
• Multiple nerve root involvement
• Abnormal sensation patterns (do not follow
dermatome or peripheral nerve patterns)
• Saddle anesthesia
• Upper motor neuron symptoms (spinal cord) signs
• Fainting
• Drop attacks
• Vertigo
• Autonomic nervous system symptoms
• Progressive weakness
• Progressive gait disturbances
• Multiple inflamed joints
• Psychosocial stresses
• Circulatory or skin changes
the scapula, whereas the condition in older people
(40+ years) is more likely to be the result of degen-
erative changes in the shoulder complex. Some con-
ditions show sex and even race differences. For
example, some cancers are more prevalent in men
(e.g., prostrate, bladder), whereas others occur more
frequently in women (e.g., cervical, breast), yet still
others are more common in white people.
2. What is the patient’s occupation? What does the
patient do at work? What is the working environment
like? What are the demands and postures assumed?7
For example, a laborer probably has stronger muscles
than a sedentary worker and may be less likely to
suffer a muscle strain. However, laborers are more
susceptible to injury because of the types of jobs they
have. Because sedentary workers usually have no need
for high levels of muscle strength, they may overstress
their muscles or joints on weekends because of over-
activity or participation in activity that they are not
used to. Habitual postures and repetitive strain caused
by some occupations may indicate the location or
source of the problem.
3. Why has the patient come for help? This is often referred
to as the history of the present illness or chief com-
plaint. This part of the history provides an opportu-
nity for patients to describe in their own words what
is bothering them and the extent to which it bothers
them. It is important for the clinician to determine
what the patient wants to be able to do functionally
and what the patient is unable to do functionally. It is
Chapter 1 Principles and Concepts 3
also essential to ensure that the clinician knows what
is important to the patient in terms of outcome,
whether the patient’s expectations for the following
treatment are realistic, and what direction functional
treatment should take to ensure the patient can, if at
all possible, return to his or her previous level of activ-
ity or realize his or her expected outcome.8
4. Was there any inciting trauma (macrotrauma) or
repetitive activity (microtrauma)? In other words,
what was the mechanism of injury, and were there
any predisposing factors? If the patient was in a motor
vehicle accident, for example, was the patient the
driver or the passenger? Was he or she the cause of
the accident? What part of the car was hit? How fast
were the cars going? Was the patient wearing a seat
belt? When asking questions about the mechanism(s)
of injury, the examiner must try to determine the
direction and magnitude of the injuring force and
how the force was applied. By carefully listening to
the patient, the examiner can often determine which
structures were injured and how severely by knowing
the force and mechanism of injury. For example,
anterior dislocations of the shoulder usually occur
when the arm is abducted and laterally rotated beyond
the normal range of motion (ROM), and the “ter-
rible triad” injury to the knee (i.e., medial collateral
ligament, anterior cruciate ligament, and medial
meniscus injury) usually results from a blow to the
lateral side of the knee while the knee is flexed, the
full weight of the patient is on the knee, and the foot
is fixed. Likewise, the examiner should determine
whether there were any predisposing, unusual, or
new factors (such as, sustained postures or repetitive
activities, general health, or familial or genetic prob-
lems) that may have led to the problem.9
5. Was the onset of the problem slow or sudden? Did the
condition start as an insidious, mild ache and then
progress to continuous pain, or was there a specific
episode in which the body part was injured? If incit-
ing trauma has occurred, it is often relatively easy to
determine the location of the problem. Does the pain
get worse as the day progresses? Was the sudden
onset caused by trauma, or was it sudden with locking
because of muscle spasm (spasm lock) or pain? Is
there anything that relieves the symptoms? Knowl-
edge of these facts helps the examiner make a dif-
ferential diagnosis.
6. Where are the symptoms that bother the patient? If pos-
sible, have the patient point to the area. Does the
patient point to a specific structure or a more general
area? The latter may indicate a more severe condition
or referral of symptoms (yellow flag). The way in
which the patient describes the symptoms often helps
to delineate problems. Has the dominant or non-
dominant side been injured? Injury to the dominant
side may lead to greater functional limitations.
4 Chapter 1 Principles and Concepts
Sensory
Physiological
Intensity
Location Quality
Onset Pattern
Duration
Etiology
Syndrome
PAIN
Cognitive Behavioral
Meaning of pain Communication
View of self Interpersonal interaction
Coping skills and strategies Physical activity
Previous treatment Pain behaviours
Attitudes and beliefs Medications
Factors influencing pain Interventions
Sleep
Figure 1-1 The dimensions of pain. (Redrawn from Petty NJ, Moore AP: Neuromusculoskeletal examination and assessment: a handbook for
therapists, London, 1998, Churchill-Livingstone, p. 8.)
7. Where was the pain or other symptoms when the patient
first had the complaint? Pain is subjective, and its
manifestations are unique to each individual. It is a
complex experience involving several dimensions
(Figure 1-1).10 If the intensity of the pain or symp-
toms is such that the patient is unable to move in a
certain direction or hold a particular posture because
of the symptoms, the symptoms are said to be severe.
If the symptoms or pain become progressively worse
with movement or the longer a position is held, the
symptoms are said to be irritable.11,12 Acute pain is
new pain that is often severe, continuous, and perhaps
disabling and is of sufficient quality or duration that
the patient seeks help. Acute injuries tend to be more
irritable resulting in pain earlier in the movement, or
minimal activity will bring on symptoms, and often
the pain will remain after movement has stopped.3
Chronic pain is more aggravating, is not as intense,
has been experienced before, and in many cases, the
patient knows how to deal with it. Acute pain is more
often accompanied by anxiety, whereas chronic pain
is associated with depression.13 When tissue has been
damaged, substances are released leading to inflam-
mation and peripheral sensitization of the nocicep-
tors (also called primary hyperalgesia) resulting in
localized pain. If the injury does not follow a normal
healing pathway and becomes chronic, central sen-
sitization (also called secondary hyperalgesia)
may occur. Peripheral sensitization is a local phenom-
enon whereas central sensitization is a more central
process involving the spinal cord and brain. Central
Affective
Mood state
Anxiety
Depression
Well-being
Sociocultural-Ethnocultural
Family and social life
Work and home responsibilities
Recreation and leisure
Environmental factors
Attitudes and beliefs
Social influences
sensitization manifests itself as widespread hypersen-
sitivity to such physical, mental, and emotional stress-
ors as touch, mechanical pressure, noise, bright light,
temperature, and medication.14,15
Has the pain moved or spread? The location and
spread of pain may be marked on a body chart, which
is part of the assessment sheet (see Appendix 1-1).
The examiner should ask the patient to point to
exactly where the pain was and where it is now. Are
trigger points present? Trigger points are localized
areas of hyperirritability within the tissues; they are
tender to compression, are often accompanied by
tight bands of tissue, and, if sufficiently hypersensi-
tive, may give rise to referred pain that is steady, deep,
and aching. These trigger points can lead to a diag-
nosis, because pressure on them reproduces the
patient’s symptoms. Trigger points are not found in
normal muscles.16
In general, the area of pain enlarges or becomes
more distal as the lesion worsens and becomes smaller
or more localized as it improves. Some examiners call
the former peripheralization of symptoms and the
latter, centralization of symptoms.17–19 The more
distal and superficial the problem, the more accu-
rately the patient can determine the location of the
pain. In the case of referred pain, the patient usually
points out a general area; with a localized lesion, the
patient points to a specific location. Referred pain
tends to be felt deeply; its boundaries are indistinct,
and it radiates segmentally without crossing the
midline. The term, referred pain, means that the pain
 Chapter 1 Principles and Concepts 5

is felt at a site other than the injured tissue because TABLE 1-2
the same or adjacent neural segments supply the
Differentiation of Systemic and Musculoskeletal Pain
referred site. Pain also may shift as the lesion shifts.
For example, with an internal derangement of the Systemic Musculoskeletal
knee, pain may occur in flexion one time and in • Disturbs sleep • Generally lessens at
extension another time if it is caused by a loose body • Deep aching or throbbing night
within the joint. The examiner must clearly under- • Reduced by pressure • Sharp or superficial
stand where the patient feels the pain. For example, • Constant or waves of pain ache
does the pain occur only at the end of the ROM, in and spasm • Usually decreases with
part of the range, or throughout the ROM?9 • Is not aggravated by cessation of activity
8. What are the exact movements or activities that cause mechanical stress • Usually continuous or
pain? At this stage, the examiner should not ask the • Associated with the intermittent
patient to do the movements or activities; this will following: • Is aggravated by
 Jaundice mechanical stress
take place during the examination. However, the  Migratory arthralgias
examiner should remember which movements the  Skin rash
patient says are painful so that when the examination  Fatigue
is carried out, the patient can do these movements  Weight loss
last to avoid an overflow of painful symptoms. With  Low-grade fever
cessation of the activity, does the pain stay the same,  Generalized weakness
or how long does it take for the pain to return to its  Cyclic and progressive
previous level? Are there any other factors that aggra- symptoms
vate or help to relieve the pain? Do these activities  Tumors
alter the intensity of the pain? The answers to these  History of infection
questions give the examiner some idea of the irritabil-
ity of the joint. They also help the examiner to dif- From Meadows JT: Orthopedic differential diagnosis in physical
therapy—a case study approach, New York, 1999, McGraw Hill, p. 100.
ferentiate between musculoskeletal or mechanical Reproduced with permission of the McGraw-Hill Companies.
pain and systemic pain, which is pain arising from one
of the body’s systems other than the musculoskeletal
system (Table 1-2).18 Functionally, pain can be subacute conditions have been present for 10 days to
divided into different levels, especially for repetitive 7 weeks, and chronic conditions or symptoms have
stress conditions. been present for longer than 7 weeks. In acute on
chronic cases, the injured tissues usually have been
reinjured. This knowledge is also beneficial in terms of
how vigorously the patient can be examined. For
Pain and Its Relation to Severity of Repetitive example, the more acute the condition, the less stress
Stress Activity the examiner is able to apply to the joints and tissues
during the assessment. A full examination may not be
• Level 1: Pain after specific activity
• Level 2: Pain at start of activity resolving with warm-up possible in very acute conditions. In that case, the
• Level 3: Pain during and after specific activity that does not affect examiner must select those procedures of assessment
performance that will give the greatest amount of information with
• Level 4: Pain during and after specific activity that does affect the least stress to the patient. Does the patient protect
performance or support the injured part? If so, this behavior signi-
• Level 5: Pain with activities of daily living (ADLs) fies discomfort and fear of pain if the part moves,
• Level 6: Constant dull aching pain at rest that does not usually indicating a more acute condition.
disturb sleep 10. Has the condition occurred before? If so, what was the
• Level 7: Dull aching pain that does disturb sleep onset like the first time? Where was the site of the
NOTE: Level 7 indicates highest level of severity. original condition, and has there been any radiation
(spread) of the symptoms? If the patient is feeling
better, how long did the recovery take? Did any treat-
9. How long has the problem existed? What are the dura- ment relieve symptoms? Does the current problem
tion and frequency of the symptoms? Answers to these appear to be the same as the previous problem, or is
questions help the examiner to determine whether the it different? If it is different, how is it different?
condition is acute, subacute, chronic, or acute on Answers to these questions help the examiner to
chronic and to develop some understanding of the determine the location and severity of the injury.
patient’s tolerance to pain. Generally, acute condi- 11. Has there been an injury to another part of the kinetic
tions are those that have been present for 7 to 10 days, chain as well? For example, foot problems can lead
6 Chapter 1 Principles and Concepts
to knee, hip, pelvic, and/or spinal problems; elbow
problems may contribute to shoulder problems; and
hip problems can contribute to knee problems.
12. Are the intensity, duration, or frequency of pain or
other symptoms increasing? These changes usually
mean the condition is getting worse. A decrease in
pain or other symptoms usually means the condition
is improving. Is the pain static? If so, how long has
it been that way? This question may help the exam-
iner to determine the present state of the problem.
These factors may become important in treatment
and may help to determine whether a treatment is
Figure 1-2 McGill-Melzack pain questionnaire. (From Melzack R: The McGill pain questionnaire: major properties and scoring methods. Pain
1:280–281, 1975.)
helping. Are pain or other symptoms associated with
other physiological functions? For example, is the
pain worse with menstruation? If so, when did the
patient last have a pelvic examination? Questions
such as these may give the examiner an indication of
what is causing the problem or what factors may
affect the problem. It is often worthwhile to give the
patient a pain questionnaire, visual analog scale
(VAS), numerical rating scale, box scale, or verbal
rating scale that can be completed while the patient
is waiting to be assessed.20,21 The McGill-Melzack
pain questionnaire and its short form (Figures 1-2
 Chapter 1 Principles and Concepts 7

SHORT-FORM McGILL PAIN QUESTIONNAIRE

RONALD MELZACK

PATIENT'S NAME: DATE:

NONE MILD MODERATE SEVERE

1. THROBBING 0) 1) 2) 3)
2. SHOOTING 0) 1) 2) 3)
3. STABBING 0) 1) 2) 3)
4. SHARP 0) 1) 2) 3)
5. CRAMPING 0) 1) 2) 3)
6. GNAWING 0) 1) 2) 3)
7. HOT-BURNING 0) 1) 2) 3)
8. ACHING 0) 1) 2) 3)
9. HEAVY 0) 1) 2) 3)
10. TENDER 0) 1) 2) 3)
11. SPLITTING 0) 1) 2) 3)
12. TIRING-EXHAUSTING 0) 1) 2) 3)
13. SICKENING 0) 1) 2) 3)
14. FEARFUL 0) 1) 2) 3)
15. PUNISHING-CRUEL 0) 1) 2) 3)

Figure 1-3 The short-form McGill pain question-

0 10
naire. Descriptors 1 to 11 represent the sensory
NO WORST dimension of pain experience, and descriptors 12 to
PAIN POSSIBLE 15 represent the affective dimension. Each descriptor
PPI PAIN is ranked on an intensity scale of 0 = none, 1 = mild,
0 NO PAIN 2 = moderate, 3 = severe. The present pain intensity
1 MILD (PPI) of the standard long-form McGill pain ques-
2 DISCOMFORTING tionnaire and the visual analogue scale (VAS) are also
3 DISTRESSING included to provide overall intensity scores. For actual
4 HORRIBLE examination, line would be 10 cm long. (Modified
5 EXCRUCIATING from Melzack R: The short-form McGill pain ques-
tionnaire. Pain 30:193, 1987.)

and 1-3)22–24 provide the patient with three major

classes of word descriptors—sensory, affective, and
evaluative—to describe their pain experience. These
designations are used to differentiate patients who
have a true sensory pain experience from those who
think they have experienced pain (affective pain
state). Other pain-rating scales allow the patient to
visually gauge the amount of pain along a solid 10-cm
line (visual analogue scale) (Figure 1-4) or on a
thermometer-type scale (Figure 1-5).25 It has been
shown that an examiner should consistently use the
same pain scales when assessing or reassessing patients
to increase consistent results.26–29 The examiner can
use the completed questionnaire or scale as an indica-
tion of the pain as described or perceived by the
patient. Alternatively, a self-report pain drawing Figure 1-4 Visual analog scales (VASs) for pain. Example only. Note:
(see Appendix 1-1), which (with the training and For an actual examination, the lines would be 10 cm long.
8 Chapter 1 Principles and Concepts
Pain Rating Scale
Instructions:
Below is a thermometer with various
grades of pain on it from "No pain at all"
to "The pain is almost unbearable." Put
an X by the words that describe your
pain best. Mark how bad your pain is
at this moment in time.
The pain is
almost unbearable
Very bad pain
Quite bad pain
Moderate pain
Little pain
No pain at all
Figure 1-5 “Thermometer” pain rating scale. (Redrawn from Brodie
DJ, Burnett JV, Walker JM, et al: Evaluation of low back pain by patient
questionnaires and therapist assessment. J Orthop Sports Phys Ther
11[11]:528, 1990.)
guidelines of the raters) has been shown to have reli-
ability, can be used for the same purpose.30
13. Is the pain constant, periodic, episodic (occurring with
certain activities), or occasional? Does the condition
bother the patient at that exact moment? If the
patient is not bothered at that exact moment, the
pain is not constant. Constant pain suggests chemi-
cal irritation, tumors, or possibly visceral lesions.18 It
is always there, although its intensity may vary. If
periodic or occasional pain is present, the examiner
should try to determine the activity, position, or
posture that irritates or brings on the symptoms,
because this may help determine what tissues are at
fault. This type of pain is more likely to be mechanical
and related to movement and stress.18 Episodic pain
is related to specific activities. At the same time, the
examiner should be observing the patient. Does
the patient appear to be in constant pain? Does the
patient appear to be lacking sleep because of pain?
Does the patient move around a great deal in an
attempt to find a comfortable position?
14. Is the pain associated with rest? Activity? Certain pos-
tures? Visceral function? Time of day? Pain on activity
that decreases with rest usually indicates a mechanical
problem interfering with movement, such as adhe-
sions. Morning pain with stiffness that improves with
activity usually indicates chronic inflammation and
edema, which decrease with motion. Pain or aching
as the day progresses usually indicates increased con-
gestion in a joint. Pain at rest and pain that is worse
at the beginning of activity than at the end implies
acute inflammation. Pain that is not affected by rest
or activity usually indicates bone pain or could be
related to organic or systemic disorders, such as
cancer or diseases of the viscera. Chronic pain is often
associated with multiple factors, such as fatigue or
certain postures or activities. If the pain occurs at
night, how does the patient lie in bed: supine, on the
side, or prone? Does sleeping alter the pain, or
does the patient wake when he or she changes posi-
tion? Intractable pain at night may indicate serious
pathology (e.g., a tumor). Movement seldom affects
visceral pain unless the movement compresses or
stretches the structure.11 Symptoms of peripheral
nerve entrapment (e.g., carpal tunnel syndrome) and
thoracic outlet syndromes tend to be worse at night.
Pain and cramping with prolonged walking may indi-
cate lumbar spinal stenosis (neurogenic intermittent
claudication) or vascular problems (circulatory or vas-
cular intermittent claudication). Intervertebral disc
pain is aggravated by sitting and bending forward.
Facet joint pain is often relieved by sitting and
bending forward and is aggravated by extension and
rotation. What type of mattress and pillow does the
patient use? Foam pillows often cause more problems
for persons with cervical disorders because these
pillows have more “bounce” to them than do feather
or buckwheat pillows. Too many pillows, pillows
improperly positioned, or too soft a mattress may also
cause problems.
15. What type or quality of pain is exhibited? Nerve pain
tends to be sharp (lancinating), bright, and burning
and also tends to run in the distribution of specific
nerves. Thus, the examiner must have detailed knowl-
edge of the sensory distribution of nerve roots (der-
matomes) and peripheral nerves as the different
distributions may tell where the pathology or problem
is if the nerve is involved. Bone pain tends to be
deep, boring, and localized. Vascular pain tends to
be diffuse, aching, and poorly localized and may be
referred to other areas of the body. Muscle pain is
usually hard to localize, is dull and aching, is often
aggravated by injury, and may be referred to other
areas (Table 1-3). If a muscle is injured, when the
muscle contracts or is stretched, the pain will increase.
Inert tissue, such as ligaments, joint capsules, and
bursa, tend to exhibit pain similar to muscle pain and
may be indistinguishable from muscle pain in the
resting state (e.g., when the examiner is taking the
history); however, pain in inert tissue is increased
 Chapter 1 Principles and Concepts 9

when the structures are stretched or pinched. Each developed to determine if neuropathic causes domi-
of these specific tissue pains is sometimes grouped as nate the pain experience.31 Somatic pain, on the
neuropathic pain and follows specific anatomical other hand, is a severe chronic or aching pain that is
pathways and affect specific anatomical structures.18 inconsistent with injury or pathology to specific ana-
The Leeds Assessment of Neuropathic Symptoms tomical structures and cannot be explained by any
and Signs (LANSS) Pain Scale (Figure 1-6) has been physical cause because the sensory input can come
from so many different structures supplied by the
TABLE 1-3 same nerve root.12 Superficial somatic pain may be
localized, but deep somatic pain is more diffuse and
Pain Descriptions and Related Structures may be referred.32 On examination, somatic pain may
Type of Pain Structure be reproduced, but visceral pain is not reproduced by
movement.32
Cramping, dull, aching Muscle 16. What types of sensations does the patient feel, and where
Dull, aching Ligament, joint capsule
are these abnormal sensations? If the problem is in
Sharp, shooting Nerve root
Sharp, bright, lightning-like Nerve
bone, there usually is very little radiation of pain. If
Burning, pressure-like, Sympathetic nerve pressure is applied to a nerve root, radicular pain
stinging, aching (radiating pain) results from pressure on the dura
Deep, nagging, dull Bone mater, which is the outermost covering of the spinal
Sharp, severe, intolerable Fracture cord. If there is pressure on the nerve trunk, no pain
Throbbing, diffuse Vasculature occurs, but there is paresthesia, or an abnormal sensa-
tion, such as a “pins and needles” feeling or tingling.

THE LANSS PAIN SCALE

B. SENSORY TESTING
Leeds Assessment of Neuropathic Symptoms and Signs
Skin sensitivity can be examined by comparing the painful area with a contralateral
NAME DATE
or adjacent non-painful area for the presence of allodynia and an altered pin-prick
This pain scale can help to determine whether the nerves that are carrying your pain signals are threshold (PPT).
working normally or not. It is important to find this out in case different treatments are needed to
control your pain.
1) ALLODYNIA (Pain caused by something that normally would not cause pain)
A. PAIN QUESTIONNAIRE Examine the response to lightly stroking cotton wool across the non-painful area
and then the painful area. If normal sensations are experienced in the non-painful
• Think about how your pain has felt over the last week. site, but pain or unpleasant sensations (e.g., tingling, nausea) are experienced in the
• Please say whether any of the descriptions match your pain exactly. painful area when stroking, allodynia is present.

1) Does your pain feel like strange, unpleasant sensations in your skin? Words like a) NO, normal sensation in both areas ..................................... (0)
pricking, tingling, pins and needles might describe these sensations.
b) YES, allodynia in painful area only ....................................... (5)
a) NO - My pain doesn’t really feel like this ...................................... (0)

b) YES - I get these sensations quite a lot ....................................... (5) 2) ALTERED PIN-PRICK THRESHOLD
Determine the pin-prick threshold by comparing the response to a 23 gauge
2) Does your pain make the skin in the painful area look different from normal? (blue) needle mounted inside a 2 ml syringe barrel placed gently on to the skin in
Words like mottled or looking more red or pink might describe the appearance. a non-painful and then painful areas.

a) NO - My pain doesn’t affect the colour of my skin ........................ (0) If a sharp pin prick is felt in the non-painful area, but a different sensation is
experienced in the painful area (e.g., none/blunt only [raised PPT] or a very
b) YES - I’ve noticed that the pain does make my skin look different from normal ..... (5) painful sensation [lowered PPT]), an altered PPT is present.

3) Does your pain make the affected skin abnormally sensitive to touch? Getting If a pinprick is not felt in either area, mount the syringe onto the needle to
unpleasant sensations when lightly stroking the skin, or getting pain when increase the weight and repeat.
wearing tight clothes might describe the abnormal sensitivity.
a) NO, equal sensation in both areas ........................................ (0)
a) NO - My pain doesn’t make my skin abnormally sensitive in that area ........... (0)
b) YES, altered PPT in painful area ........................................... (3)
b) YES - My skin seems abnormally sensitive to touch in that area .................... (3)

4) Does your pain come on suddenly and in bursts for no apparent reason when you’re
still. Words like electric shocks, jumping, and bursting describe these sensations. SCORING:

a) NO - My pain doesn’t really feel like this ............................................. (0) Add values in parentheses for sensory description and examination findings to obtain
overall score.
b) YES - I get these sensations quite a lot ............................................... (2)

5) Does your pain feel as if the skin temperature in the painful area has changed TOTAL SCORE (maximum 24) .................................
abnormally? Words like hot and burning describe these sensations

a) NO - I don’t really get these sensations ............................................... (0) If score <12, neuropathic mechanisms are unlikely to be contribution to the patient’s pain.

b) YES - I get these sensations quite a lot ............................................... (1)

If score ≥12, neuropathic mechanisms are likely to be contribution to the patient’s pain.

Figure 1-6 The Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) Pain Scale. (Modified from Bennett M: The LANSS Pain
Scale: the Leeds assessment of neuropathic symptoms and signs, Pain 92:156–157, 2001.)
10 Chapter 1 Principles and Concepts

Paresthesia is an unpleasant sensation that occurs

without an apparent stimulus or cause (to the patient).
Autonomic pain is more likely to be a burning type
of pain. If the nerve itself is affected, regardless of
where the irritation occurs along the nerve, the brain
perceives the pain as coming from the periphery. This
is an example of referred pain.
17. Does a joint exhibit locking, unlocking, twinges, insta-
bility, or giving way? Seldom does locking mean that
the joint will not move at all. Locking may mean that
the joint cannot be fully extended, as is the case with
a meniscal tear in the knee, or it may mean that it
does not extend one time and does not flex the next
time (pseudolocking), as in the case of a loose body
moving within the joint. Locking may mean that the
joint cannot be put through a full ROM because of
muscle spasm or because the movement was too fast;
this is sometimes referred to as spasm locking.
Giving way is often caused by reflex inhibition or
weakness of the muscles, and so the patient feels that
the limb will buckle if weight is placed on it or the
pain will be too great. Inhibition may be caused by
anticipated pain or instability.
In nonpathological states, excessive ROM in a
joint is called laxity or hypermobility. Laxity implies
the patient has excessive ROM but can control move- Figure 1-7 Congenital laxity at the elbow leading to hyperextension.
ment in that range and no pathology is present. It is This may also be called nonpathological hypermobility.
a function of the ligaments and joint capsule resis-
tance.33 This differs from flexibility, which is the
ROM available in one or more joints and is a function joint during movement. Anatomical instability
of contractile tissue resistance primarily as well as (also called clinical or gross instability, or pathological
ligament and joint capsule resistance.33 Gleim and hypermobility) refers to excessive or gross physiologi-
McHugh33 describe flexibility in two parts: static cal movement in a joint where the patient becomes
and dynamic. Static flexibility is related to the ROM apprehensive at the end of the ROM because a sub-
available in one or more joints; dynamic flexibility is luxation or dislocation is imminent. It should be
related to stiffness and ease of movement. Laxity may noted that there is confusion in the application of the
be caused by familial factors or may be job or activity terms used to describe the two types of instability.
(e.g., sports) related. In any case, laxity, when found, For example, mechanical instability is sometimes used
should be considered normal (Figure 1-7). If symp- to mean anatomical instability because of anatomical
toms occur, then laxity is considered to be hypermo- or pathological dysfunction. Functional instability
bility and has a pathological component, which may mean either or both types of instability and
commonly indicates the patient’s inability to control implies an inability to control either arthrokinematic
the joint during movement, especially at end range, or osteokinematic movement in the available ROM
which implies instability of the joint. Instability can either consciously or unconsciously during functional
cover a wide range of pathological hypermobility movement. These instabilities are more likely to be
from a loss of control of arthrokinematic joint move- evident during high-speed or loaded movements.
ments to anatomical instability where subluxation Both types of instability can cause symptoms, and
or dislocation is imminent or has occurred. For treatment centers on teaching the patient to develop
assessment purposes, instability can be divided into muscular control of the joint and to improve reaction
translational (loss of arthrokinematic control) and time and proprioceptive control. Both types of insta-
anatomical (dislocation or subluxation) instability.34 bility may be voluntary or involuntary. Voluntary
Translational instability (also called pathological or instability is initiated by muscle contraction, and
mechanical instability) refers to loss of control of the involuntary instability is the result of positioning.
small, arthrokinematic joint movements (e.g., spin, Another concept worth remembering during assess-
slide, roll, translation) that occur when the patient ment for instability is the circle concept of instabil-
attempts to stabilize (statically or dynamically) the ity, which was originally developed from shoulder

studies35,36 but is equally applicable to other joints.
This concept states that injury to structures on one
side of a joint leading to instability can, at the same
time, cause injury to structures on the other side or
other parts of the joint. Thus, an anterior shoulder
dislocation can lead to injury of the posterior capsule.
Similarly, anterolateral rotary instability of the knee
leads to injury to posterior structures (e.g., arcuate-
popliteus complex, posterior capsule) as well as ante-
rior (e.g., anterior cruciate ligament) and lateral
(e.g., lateral collateral ligament) structures. Thus, the
examiner must be aware of potential injuries on the
opposite side of the joint even if symptoms are pre-
dominantly on one side, especially when the mecha-
nism of injury is trauma.
18. Has the patient experienced any bilateral spinal cord
symptoms, fainting, or drop attacks? Is bladder func-
tion normal? Is there any “saddle” involvement
(abnormal sensation in the perianal region, buttocks,
and superior aspect of the posterior thighs) or vertigo?
“Vertigo” and “dizziness” are terms often used syn-
onymously, although vertigo usually indicates more
severe symptoms. The terms describe a swaying, spin-
ning sensation accompanied by feelings of unsteadi-
ness and loss of balance. These symptoms indicate
severe neurological problems, such as cervical
myelopathy, which must be dealt with carefully and
can (e.g., in cases of altered bladder function) be
emergency conditions potentially requiring surgery.
Drop attacks occur when the patient suddenly falls
without warning or provocation but remains con-
scious.18 It is caused by neurological dysfunction
especially in the brain.
19. Are there any changes in the color of the limb? Ischemic
changes resulting from circulatory problems may
include white, brittle skin; loss of hair; and abnormal
nails on the foot or hand. Conditions such as reflex
sympathetic dystrophy, which is an autonomic nerve
response to trauma, however minor, can cause these
symptoms, as can circulatory problems such as
Raynaud’s disease.
20. Has the patient been experiencing any life or economic
stresses? These psychological stressors are sometimes
considered to be yellow flags that alter both the
assessment and subsequent treatment.37,38 Divorce,
marital problems, financial problems, or job stress or
insecurity can contribute to increasing the pain or
symptoms because of psychological stress. What
support systems and resources are available? Are there
any cultural issues one should be aware of? Does the
patient have an easily accessible living environment?
Each of these issues may increase stress to the patient.
Pain is often accentuated in patients with anxiety,
depression, or hysteria, or patients may exaggerate
their symptoms (symptom magnification) in the
absence of objective signs, which may be called
Chapter 1 Principles and Concepts 11
psychogenic pain.3,39,40 Thus, psychosocial aspects
can play a significant role with injury.41–44 Because of
the importance of these psychosocial aspects related
to movement, questionnaires such as the Fear-
Avoidance Beliefs Questionnaire (FABQ)45 (Figure
1-8) and the Tampa Scale for Kinesiophobia46–49 have
been developed. Most of the studies related to the
psychosocial aspects of injury have been related to
the low back but could be used for other joints. The
focus of these questionnaires is on the patient’s beliefs
about how physical activity and work affect his or her
injury and pain.42,50,51 Table 1-4 outlines some of the
psychological processes affecting pain.42 These pro-
cesses have been divided into different colored “flags”
(Table 1-5), but it is important to note that these
psychological flags, other than the red flag, are dif-
ferent from pathological “flags” previously men-
tioned.44 Waddell and Main37 consider illness behavior
normal with patients who are exhibiting both a physi-
cal problem and varying degrees of illness behavior
(Table 1-6). In these cases, it may be beneficial to
determine the level of psychological stress or to refer
the patient to another appropriate health care profes-
sional.38 When symptoms (such as, pain) appear to
be exaggerated, the examiner must also consider the
possibility that the patient is malingering. Malinger-
ing implies trying to obtain a particular gain by a
conscious effort to deceive.52
Reactions to Stress
• Aches and pains
• Anxiety
• Changed appetite
• Chronic fatigue
• Difficulty concentrating
• Difficulty sleeping
• Irritability and impatience
• Loss of interest and enjoyment in life
• Muscle tension (headaches)
• Sweaty hands
• Trembling
• Withdrawal
21. Does the patient have any chronic or serious systemic
illnesses or adverse social habits (e.g., smoking, drink-
ing) that may influence the course of the pathology or
the treatment? In some cases, the examiner may use
a medical history screening form (Figure 1-9) to
determine the presence of conditions that may affect
treatment or require referral to another health care
professional.
22. Is there anything in the family or developmental history
that may be related, such as tumors, arthritis, heart
12 Chapter 1 Principles and Concepts

Fear-Avoidance Beliefs Questionnaire (FABQ)

Here are some of the things which other patients have told us about their pain. For each statement please
circle any number from 0 to 6 to say how much physical activities such as bending, lifting, walking, or
driving affect or would affect your back pain.

Completely Unsure Completely

disagree agree
1. My pain was caused by physical activity ............................................. 0 1 2 3 4 5 6
2. Physical activity makes my pain worse ................................................ 0 1 2 3 4 5 6
3. Physical activity might harm my back .................................................... 0 1 2 3 4 5 6
4. I should not do physical activities which (might) make my pain worse 0 1 2 3 4 5 6
5. I cannot do physical activities which (might) make my pain worse ..... 0 1 2 3 4 5 6

The following statements are about how your normal work affects or would affect your back pain
Completely Unsure Completely
disagree agree
6. My pain was caused by my work or by an accident at work ................ 0 1 2 3 4 5 6
7. My work aggravated my pain ............................................................... 0 1 2 3 4 5 6
8. I have a claim for compensation for my pain ........................................ 0 1 2 3 4 5 6
9. My work is too heavy for me ................................................................. 0 1 2 3 4 5 6
10. My work makes or would make my pain worse .................................. 0 1 2 3 4 5 6
11. My work might harm my back ............................................................. 0 1 2 3 4 5 6
12. I should not do my normal work with my present pain ........................ 0 1 2 3 4 5 6
13. I cannot do my normal work with my present pain .............................. 0 1 2 3 4 5 6
14. I cannot do my normal work till my pain is treated .............................. 0 1 2 3 4 5 6
15. I do not think that I will be back to my normal work within 3 months. 0 1 2 3 4 5 6
16. I do not think that I will ever be able to go back to that work ............... 0 1 2 3 4 5 6

Scoring:
fear-avoidance beliefs about work (scale 1) = (points for item 6) + (points for item 7) + (points for item 9) + (points for item 10)
+ (points for item 11) + (points for item 12) + (points for item 15)

fear-avoidance beliefs about physical activity (scale 2) = (points for item 2) + (points for item 3) + (points for item 4)
+ (points for item 5)

Items not in scale 1 or 2: 1 8 13 14 16

Interpretation:

• Minimal scale scores: 0

• Maximum scale 1 score: 42 (7 items)

• Maximum scale 2 score: 24 (4 items)

• The higher the scale scores the greater the degree of fear and avoidance beliefs shown by the patient.

Figure 1-8 Fear-Avoidance Beliefs Questionnaire (FABQ). (Modified from Waddell G, Newton M, Henderson I, et al: A fear-avoidance beliefs
questionnaire [FABQ] and the role of fear-avoidance beliefs in chronic low back pain and disability. Pain 52:166, 1993.)

TABLE 1-4
Summary of Psychological Processes
Factor Description
Attention Pain demands our attention
Cognitions How we think about our
pain may influence it
Emotions and Pain often generates negative
emotion feelings; these negative
regulation feelings may influence
the pain as well as fuel
cognitions, attention, and
overt behaviors
Overt behavior What we do to cope with
our pain influences our
perception of pain
Modified from Linton SJ, Shaw WS: Impact of psychological factors in the experience of pain. Phys Ther 91:703, 2011.
TABLE 1-5
Summary of Different Types of Psychological Flags
Chapter 1 Principles and Concepts 13
Possible Effect on Pain and Disability Example of Treatment Strategy
• Vigilance may increase pain • Distraction techniques
intensity • Interceptive exposure
• Distraction may decrease its pain
intensity
• Interpretations and beliefs may • Cognitive restructuring
increase pain and disability • Behavioral experiments
• Catastrophizing (irrational designed, for example,
thoughts that something is far to disconfirm unrealistic
worse than it is) may increase pain expectations and
• Negative thoughts and beliefs may catastrophizing
increase pain and disability
• Expectations may influence pain
and disability
• Cognitive sets may reduce
flexibility in dealing with pain and
disability
• Fear may increase avoidance • Cognitive-behavioral therapy
behavior and disability programs for anxiety and
• Anxiety may increase pain depression
disability • Activation (to increase
• Depression may increase pain positive emotion)
disability • Relaxation
• Distress, in general, fuels negative • Positive psychology
cognitions and pain disability techniques that promote
• Positive emotions might decrease well-being and positive
pain emotions
• Avoidance behavior may increase • Operant, graded activity
disability training
• Unlimited activity (overactivity) • Exposure in vivo
may provoke pain • Coping strategies training
• Pain behaviors communicate pain
14 Chapter 1 Principles and Concepts

TABLE 1-6

Spectrum of Clinical Symptoms and Signs

Physical Disease Illness Behavior
Pain
Pain drawing Localized Nonanatomic
Anatomic Regional
Magnified
Pain adjectives Sensory Emotional

Symptoms
Pain Musculoskeletal or neurologic distribution Whole leg pain
Pain at the tip of the tailbone
Numbness Dermatomal Whole leg numbness
Weakness Myotomal Whole leg giving way
Time pattern Varies with time and activity Never free of pain
Response to treatment Variable benefit Intolerance of treatments
Emergency hospitalization

Signs
Tenderness Musculoskeletal distribution Superficial
Nonanatomic
Axial loading Neck pain Low back pain
Simulated rotation Nerve root pain Low back pain
Straight leg raising Limited on formal examination Marked improvement with distraction
No improvement on distraction
Motor Myotomal Regional, jerky, giving way
Sensory Dermatomal Regional

From Waddell G, Main CJ: Illness behavior. In Waddell G, editor: The back pain revolution, Edinburgh, 1998, Churchill Livingstone, p. 162.

disease, diabetes, allergies, and congenital anomalies?
Some disease processes and pathologies have a famil-
ial incidence.
23. Has the patient undergone an x-ray examination or
other imaging techniques? If so, x-ray overexposure
must be considered; if not, an x-ray examination may
help yield a diagnosis.
24. Has the patient been receiving analgesic, steroid, or any
other medication? If so, for how long? High dosages of
steroids taken for long periods may lead to problems,
such as osteoporosis. Has the patient been taking any
other medication that is pertinent? Anticoagulants
(such as, aspirin or anticoagulant therapy) increase
the chance of bruising or hemarthrosis because the
clotting mechanism is altered. Patients may not
regard over-the-counter formulations, birth control
pills, and so on as medications. If such medications
have been taken for a long period, their use may not
seem pertinent to the patient. How long has the
patient been taking the medication? When did he or
she last take the medication? Did the medication
help?53 It is also important to determine whether
medication is being taken for the condition under
review. If analgesics or anti-inflammatories were
taken just before the patient’s visit for the assessment,
some symptoms may be masked.
25. Does the patient have a history of surgery or past/present
illness? If so, when was the surgery performed, what
was the site of operation, and what condition was
being treated? Sometimes, the condition the exam-
iner is asked to treat is the result of the surgery.
Has the patient ever been hospitalized? If so, why?
Health conditions such as high blood pressure, heart
and circulatory problems, and systemic diseases
(e.g., diabetes) should be noted because of their
effect on healing, exercise prescription, and func-
tional activities.3
Taking an accurate, detailed history is very important.
Listen to the patient—he or she is telling you what is
wrong! With experience, the examiner should be able to
make a preliminary “working” diagnosis from the
history alone. The observation and examination phases of
the assessment are then used to confirm, alter, or refute
the possible diagnoses. What an examiner looks for in
observation and tests for in examination is often related
to what she or he has found when taking a history.
 Chapter 1 Principles and Concepts 15

Date:
Patient's Name: DOB: Age:
Diagnosis: Date of Onset:
Physician: Therapist: Precautions:
Medical History Do Not Complete, For Clinician
Have you or any immediate family member Relation to Date of Current
ever been told you have: Circle one: Patient Onset Status
Cancer Yes No
Diabetes Yes No
Hypoglycemia Yes No
Hypertension or high blood pressure Yes No
Heart disease Yes No
Angina or chest pain Yes No
Shortness of breath Yes No
Stroke Yes No
Kidney disease/stones Yes No
Urinary tract infection Yes No
Allergies Yes No
Asthma, hay fever Yes No
Rheumatic/scarlet fever Yes No
Hepatitis/jaundice Yes No
Cirrhosis/liver disease Yes No
Polio Yes No
Chronic bronchitis Yes No
Pneumonia Yes No
Emphysema Yes No
Migraine headaches Yes No
Anemia Yes No
Ulcers/stomach problems Yes No
Arthritis/gout Yes No
Other Yes No
Medical Testing
1. Are you taking any prescription or over-the-counter medications? Yes No
If yes, please list:
2. Have you had any x-rays, sonograms, computed tomography (CT) Yes No
scans, or magnetic resonance imaging (MRI) done recently?
If yes, when? Where? Results?
3. Have you had any laboratory work done recently (urinalysis or blood tests)? Yes No
If yes, when? Where? Results?
4. Please list any operations that you have ever had and the date(s) of surgery.
Surgery/Date:
General Health
1. Have you had any recent illnesses within the last 3 weeks (e.g., colds, Yes No
influenza, bladder or kidney infection)?
Figure 1-9 Medical history screening card. (From Goodman CC, Snyder TK: Differential diagnosis in physical therapy, Philadelphia, 1990, WB
Saunders.) Continued
16 Chapter 1 Principles and Concepts

2. Have you noticed any lumps or thickening of skin or muscle anywhere Yes No
on your body?
3. Do you have any sores that have not healed or any changes in size, Yes No
shape, or color of a wart or mole?
4. Have you had any unexplained weight loss in the last month? Yes No
5. Do you smoke or chew tobacco? Yes No
If yes, how many packs/day?
For how many months or years?
6. How much alcohol do you drink in the course of a week?
7. How much caffeine to you consume daily (including soft drinks, coffee,
tea, or chocolate)?
8. Are you on any special diet prescribed by a physician? Yes No
Special Questions for Women
1. Last Pap smear:
2. Last breast examination:
3. Do you perform a monthly self-breast examination? Yes No
4. Do you take birth control pills or do you use an intrauterine device (IUD)? Yes No
Special Questions for Men
1. Do you ever have difficulty with urination (e.g., difficulty in starting or Yes No
continuing flow or a very slow flow or urine)?
2. Do you ever have blood in your urine? Yes No
3. Do you ever have pain on urination? Yes No
Work Environment
1. Occupation:
2. Does your job involve:
prolonged sitting (e.g., desk, computer, driving) Yes No
prolonged standing (e.g., equipment operator, sales clerk) Yes No
prolonged walking (e.g., mill worker, delivery service) Yes No
use of large or small equipment (e.g., telephone, fork lift, typewriter, Yes No
drill press, cash register)
lifting, bending, twisting, climbing, turning Yes No
exposure to chemicals or gases Yes No
other: please describe
3. Do you use any special supports:
back cushion, neck cushion Yes No
back brace, corset Yes No
other kind of brace or support for any body part Yes No
For Clinician
Vital signs:
Resting pulse rate:
Oral temperature:
Blood pressure: 1st reading: 2nd reading:
Position: Extremity:
Figure 1-9, cont’d

OBSERVATION
In an assessment, observation is the “looking” or inspec-
tion phase. Its purpose is to gain information on visible
defects, functional deficits, and abnormalities of align-
ment. Much of the observation phase involves assessment
of normal standing posture (see Chapter 15). Normal
posture covers a wide range, and asymmetric findings are
common. The key is to determine whether these findings
are related to the pathology being presented. The exam-
iner should note the patient’s way of moving as well as
the general posture, manner, attitude, willingness to
cooperate, and any signs of overt pain behavior.54 Obser-
vation may begin in the waiting room or as the patient is
being taken to the assessment area. Often the patient is
unaware that observation is occurring at this stage and
may present a different picture. The patient must be
adequately undressed in a private assessment area to be
observed properly. Male patients should wear only shorts,
and female patients should wear a bra or halter top and
shorts. Because the patient is in a state of undress, it is
essential for the examiner to explain that observation and
detailed looking at the patient are integral parts of the
assessment. This explanation may prevent a potentially
embarrassing situation that can have legal ramifications.
Overt Pain Behavior54
• Guarding—Abnormally stiff, interrupted or rigid movement while
moving the joint or body from one position to an other
• Bracing—A stationary position in which a fully extended limb
supports and maintains an abnormal distribution of weight
• Rubbing—Any contact between hand and injured area (i.e.,
touching, rubbing, or holding the painful area)
• Grimacing—Obvious facial expression of pain that may include
furrowed brow, narrowed eyes, tightened lips, corners of mouth
pulled back and clenched teeth
• Sighing—Obvious exaggerated exhalation of air usually
accompanied by the shoulders first rising and then falling; patients
may expand their cheeks first
As the patient enters the assessment area, the examiner
should observe his or her gait (see Chapter 14). This
initial gait assessment is only a cursory one; however,
problems, such as Trendelenburg sign or drop foot, are
easily noticed. If there appears to be an abnormality, the
gait may be checked in greater detail after the patient has
undressed.
The examiner should be positioned so that the domi-
nant eye is used, and both sides of the patient should be
compared simultaneously. During the observation stage,
the examiner is only looking at the patient and does not
ask the patient to move; the examiner usually does not
Chapter 1 Principles and Concepts 17
palpate, except possibly to learn whether an area is warm
or hot or to find specific landmarks.
After the patient has undressed, the examiner should
observe the posture, looking for asymmetries and deter-
mining whether the asymmetries are significant or appli-
cable to the problem being assessed. In doing so, the
examiner should attempt to answer the following ques-
tions often by comparing both sides:
1. What is the normal body alignment? Anteriorly, the
nose, xiphisternum, and umbilicus should be in a
straight line. From the side, the tip of the ear, the tip
of the acromion, the high point of the iliac crest, and
the lateral malleolus (anterior aspect) should be in a
straight line.
2. Is there any obvious deformity? Deformities may take
the form of restricted ROM (e.g., flexion deformity),
malalignment (e.g., genu varum), alteration in the
shape of a bone (e.g., fracture), or alteration in the
relationship of two articulating structures (e.g., sub-
luxation, dislocation). Structural deformities are
present even at rest; examples include torticollis, frac-
tures, scoliosis, and kyphosis. Functional deformi-
ties are the result of assumed postures and disappear
when posture is changed. For example, a scoliosis
due to a short leg seen in an upright posture disap-
pears on forward flexion. A pes planus (flatfoot) on
weight bearing may disappear on non-weight-bear-
ing. Dynamic deformities are caused by muscle
action and are present when muscles contract or joints
move. Therefore, they are not usually evident when
the muscles are relaxed. Dynamic deformities are
more likely to be seen during the examination phase.
3. Are the bony contours of the body normal and sym-
metric, or is there an obvious deviation? The body is
not perfectly symmetric, and deviation may have no
clinical implications. For example, many people have
a lower shoulder on the dominant side or demonstrate
a slight scoliosis of the spine adjacent to the heart.
However, any deviation should be noted, because it
may contribute to a more accurate diagnosis.
4. Are the soft-tissue contours (e.g., muscle, skin, fat)
normal and symmetric? Is there any obvious muscle
wasting?
5. Are the limb positions equal and symmetric? The
examiner should compare limb size, shape, position,
any atrophy, color, and temperature.
6. Because pelvic position plays such an important role
in correct posture of the whole body, the examiner
should determine if the patient can position the
pelvis in the “neutral pelvis” position. This dynamic
position is such that the anterior superior iliac
spines are one-to-two finger widths lower than the
posterior superior iliac spines on the same side in
normal standing. When looking for the “neutral
pelvis” position, the examiner must be able to answer
three questions in the affirmative. If not, there are
18 Chapter 1 Principles and Concepts

probably hypomobile and/or hypermobile structures 8. Are there any scars that indicate recent injury or
affecting the pelvic position. The three questions are: surgery? Recent scars are red because they are still
1) Can the patient get into the “neutral pelvis” posi- healing and contain capillaries; older scars are white
tion? (If not, why not?) and primarily avascular. Fibers of the dermis (skin)
2) Can the patient hold the “neutral pelvis” position tend to run in one direction, along so-called cleavage
while doing distal dynamic movement? (If not, or tension lines. Lacerations or surgical cuts along
why not?) these lines produce less scarring. Cuts across joint
3) Can the patient control the dynamic “neutral flexion lines frequently produce excessive (hypertro-
pelvis” while doing dynamic movement (e.g., phic) scarring. Some individuals are also prone to
walking, running, jumping)? keloid (excessive) or hypertrophic scarring. Hyper-
If the answer to any of these questions is “no,” the trophic scars are scars that have excessive scar tissue
examiner should consider adding pelvic “core muscle” but stay within the margins of the wound. Keloid
control activities to any treatment protocol. scars expand beyond the margins of the wound. Are
7. Are the color and texture of the skin normal? Does there any callosities, blisters, or inflamed bursae,
the appearance of the skin differ in the area of pain indicative of excessive pressure or friction to the skin?
or symptoms, compared with other areas of the body? Are there any sinuses that may indicate infection? If
Ecchymosis or bruising indicates bleeding under the so, are the sinuses draining or dry?
skin from injury to tissues (Figure 1-10). In some 9. Is there any crepitus, snapping, or abnormal sound
cases, this ecchymosis may track away from the injury in the joints when the patient moves them? Sounds,
site because of gravity. Trophic changes in the skin by themselves, do not necessarily indicate pathology.
resulting from peripheral nerve lesions include loss of Sounds on movement only become significant when
skin elasticity, shiny skin, hair loss on the skin, and they are related to the patient’s symptoms. Crepitus
skin that breaks down easily and heals slowly. The may vary from a loud grinding noise to a squeaking
nails may become brittle and ridged. Skin disorders noise. Snapping, especially if not painful, may be
(such as, psoriasis) may affect joints (psoriatic arthri- caused by a tendon moving over a bony protuber-
tis). Cyanosis, or a bluish color to the skin, is usually ance. Clicking is sometimes heard in the temporo-
an indication of poor blood perfusion. Redness indi- mandibular joint and may be an indication of early
cates increased blood flow or inflammation. nonsymptomatic pathology.
10. Is there any heat, swelling, or redness in the area
being observed? All of these signs along with pain
and loss of function are indications of inflammation
or an active inflammatory condition.
11. What attitude does the patient appear to have toward
the condition or toward the examiner? Is the patient
apprehensive, restless, resentful, or depressed? These
questions give the examiner some indication of the
patient’s psychological state and how he or she will
respond to the examination and treatment.
12. What is the patient’s facial expression? Does the
patient appear to be apprehensive, in discomfort, or
lacking sleep?
13. Is the patient willing to move? Are patterns of move-
ment normal? If not, how are they abnormal? Any
alteration should be noted and included in the obser-
vation portion of the assessment.
On completion of the observation phase of the assess-
ment, the examiner should return to the original prelimi-
nary working diagnosis made at the end of the history to
see if any alteration in the diagnosis should be made with
the additional information found in this phase.

EXAMINATION
Figure 1-10 Ecchymosis around the knee following rupture of the Principles
quadriceps and dislocation of the patella. Note how the ecchymosis is
tracking distally toward the foot because of gravity from the leg hanging Because the examination portion of the assessment
dependent. involves touching the patient and may, in some cases,

cause the patient discomfort, the examiner must obtain a
valid consent to perform the examination before it
begins. A valid consent must be voluntary, must cover
the procedures to be done (informed consent), and the
patient must be legally competent to give the consent
(Appendix 1-2).55,56
The examination is used to confirm or refute the sus-
pected diagnosis, which is based on the history and obser-
vation. The examination must be performed systematically
with the examiner looking for a consistent pattern of signs
and symptoms that leads to a differential diagnosis. Special
care must be taken if the condition of the joint is irritable
or acute. This is especially true if the area is in severe
spasm or if the patient complains of severe unremitting
pain that is not affected by position or medication, severe
night pain, severe pain with no history of injury, or non-
mechanical behavior of the joint.
Red Flags in Examination Indicating the Need
for Medical Consultation57
• Severe unremitting pain
• Pain unaffected by medication or position
• Severe night pain
• Severe pain with no history of injury
• Severe spasm
• Inability to urinate or hold urine
• Elevated temperature (especially if prolonged)
• Psychological overlay
In the examination portion of the assessment, a number
of principles must be followed.
1. Unless bilateral movement is required, the normal
side is tested first. Testing the normal side first allows
the examiner to establish a baseline for normal move-
ment for the joint being tested58 and shows the
patient what to expect, resulting in increased patient
confidence and less patient apprehension when the
injured side is tested.
2. The patient does active movements before the exam-
iner does passive movements. Passive movements are
followed by resisted isometric movements (see later
discussion). In this way, the examiner has a better
idea of what the patient thinks he or she can do
before the structures are fully tested.
3. Any movements that are painful are done last, if pos-
sible, to prevent an overflow of painful symptoms
to the next movement that, in reality, may be
symptom free.
4. If active range of motion (AROM) is not full, over-
pressure is applied only with extreme care to prevent
the exacerbation of symptoms.
Chapter 1 Principles and Concepts 19
5. During AROM, if the ROM is full, overpressure may
be carefully applied to determine the end feel of the
joint. This often negates the need to do passive
movements.
6. Each active, passive, or resisted isometric movement
may be repeated several times or held (sustained)
for a certain amount of time to see whether symp-
toms increase or decrease, whether a different pattern
of movement results, whether there is increased
weakness, or whether there is possible vascular insuf-
ficiency. This repetitive or sustained activity is espe-
cially important if the patient has complained that
repetitive movement or sustained postures alter
symptoms.
7. Resisted isometric movements are done with the joint
in a neutral or resting position so that stress on the
inert tissues is minimal. Any symptoms produced by
the movement are then more likely to be caused by
problems with contractile tissue.
8. For passive range of motion (PROM) or ligamentous
tests, it is not only the degree (i.e., the amount) of
the opening but also the quality (i.e., the end feel)
of the opening that is important.
9. When the examiner is testing the ligaments, the
appropriate stress is applied gently and repeated
several times. The stress is increased up to but not
beyond the point of pain, thereby demonstrating
maximum instability without causing muscle
spasm.
10. When testing myotomes (groups of muscles supplied
by a single nerve root), each contraction is held for
a minimum of 5 seconds to see whether weakness
becomes evident. Myotomal weakness takes time to
develop.
11. At the completion of an assessment, because a good
examination commonly involves stressing different
tissues, the examiner must warn the patient that
symptoms may exacerbate as a result of the assess-
ment. This will prevent the patient from thinking
any initial treatment may have made the patient
worse and thus be hesitant to return for further
treatments.
12. If, at the conclusion of the examination, the examiner
has found that the patient has shown unusual signs
and symptoms or if the condition appears to be
beyond his or her scope of practice, the examiner
should not hesitate to refer the patient to another
appropriate health care professional.
Vital Signs
In some cases, the examiner may want to begin the exami-
nation by taking the patient’s vital signs to establish
the patient’s baseline physiological parameters and vital
signs (Table 1-7) and review the medical history screen-
ing card (see Figure 1-9). These include the pulse (most
commonly the radial pulse at the wrist is used), blood
20 Chapter 1 Principles and Concepts

TABLE 1-7

Vital Sign Normal Ranges

Respiratory Diastolic Blood Systolic Blood Weight
Age Group Rate Heart Rate Pressure Pressure Temperature (kg) Weight (lbs)
Newborn 30–50 120–160 Varies 50–70 97.7° F (36.5° C) 2–3 4.5–7

Infant 20–30 80–140 Varies 70–100 98.6° F (37.0° C)* 4–10 9–22
(1–12 months)
Toddler 20–30 80–130 48–80 80–110 98.6° F (37.0° C)* 10–14 22–31
(1–3 years)
Preschooler 20–30 80–120 48–80 80–110 98.6° F (37.0° C)* 14–18 31–40
(3–5 years)
School Age 20–30 70–110 50–90 80–120 98.6° F (37.0° C)* 20–42 41–92
(6–12 years)
Adolescent 12–20 55–105 60–92 110–120 98.6° F (37.0° C)* >50 >110
(13–17 years)
Adults 18–20 60–100 <85 <130 98.6° F (37.0° C)* Varies Depends on
(18+ years) body size

*Ranges from 97.8° F to 99.1° F (36.5° C to 37.3° C).

Remember these points:
• The patient’s normal range should always be taken into consideration.
• Heart rate, blood pressure, and respiratory rate are expected to increase during times of fever or stress.
• Respiratory rate for infants should be counted for a full 60 seconds.

(Table 1-9). If the readings remain high, further investi-

Principles of Examination gation may be warranted.59–61

• Tell the patient what you are doing

• Test the normal (uninvolved) side first
• Do active movements first, then passive movements, and then
resisted isometric movements
• Do painful movements last
• Apply overpressure with care to test end feel
• Repeat movements or sustain certain postures or positions if
history indicates
• Do resisted isometric movements in a resting position
• Remember that with passive movements and ligamentous testing,
both the degree and quality (end feel) of opening are important
• With ligamentous testing, repeat with increasing stress
• With myotome testing, make sure that contractions are held for
5 seconds
• Warn the patient of possible exacerbations
• Maintain the patient’s dignity
• Refer if necessary
pressure, respiratory rate, temperature (98.4° F or 37° C
is normal, but it may range from 96.5° F [35.8° C] to
99.4° F [37.4° C]), and weight. Table 1-8 outlines guide-
lines for blood pressure measurement. High blood pres-
sure values should be checked several times at 15- to
30-minute intervals with the patient resting in between
to determine whether a high reading is accurate or is
being caused by anxiety (“white coat syndrome”) or some
similar reason. If three consecutive readings are high, the
patient is said to have high blood pressure (hypertension)
Scanning Examination
The examination described in this book emphasizes the
joints of the body, their movement and stability. It is
necessary to examine all appropriate tissues to delineate
the affected area, which can then be examined in detail.
Application of tension, stretch, or isometric contraction
to specific tissues produces either a normal or an appropri-
ate abnormal response. This action enables the examiner
to determine the nature and site of the present symptoms
and the patient’s response to these symptoms. The exami-
nation shows whether certain activities provoke or change
the patient’s pain; in this way, the examiner can focus on
the subjective response (i.e., the patient’s feelings or opin-
ions) as well as the test findings. The patient must be clear
about his or her side of the examination. For instance,
the patient must not confuse questions about movement-
associated pain (“Does the movement make any differ-
ence to the pain?” “Does the movement bring on or
change the pain?”) with questions about already existing
pain. In addition, the examiner attempts to see whether
patient responses are measurably abnormal. Do the move-
ments cause any abnormalities in function? A loss of
movement or weakness in muscles can be measured and
therefore is an objective response. Throughout the assess-
ment, the examiner looks for two sets of data: (1) what
the patient feels (subjective) and (2) responses that can
be measured or are found by the examiner (objective).
 Chapter 1 Principles and Concepts 21

TABLE 1-8

Guidelines for Measurement of Blood Pressure

Posture Blood pressure obtained in the sitting position is recommended. The subject should sit quietly for
5 minutes, with the back supported and the arm supported at the level of the heart, before blood
pressure is recorded.
Circumstances No caffeine during the hour preceding the reading.
No smoking during the 30 minutes preceding the reading.
A quiet, warm setting.
Equipment Cuff size: The bladder should encircle and cover two thirds of the length of the arm; if it does not, place
the bladder over the brachial artery. If bladder is too short, misleading high readings may result.
Manometer: Aneroid gauges should be calibrated every 6 months against a mercury manometer.
Technique Number of readings:
• On each occasion, take at least two readings, separated by as much time as is practical. If readings
vary by more than 5 mm Hg, take additional readings until two consecutive readings are close.
• If the initial values are elevated, obtain two other sets of readings at least 1 week apart.
• Initially, take pressure in both arms; if the pressures differ, use the arm with the higher pressure.
• If the arm pressure is elevated, take the pressure in one leg (particularly in patients younger than
30 years of age).
Performance:
• Inflate the bladder quickly to a pressure 20 mm Hg above the systolic pressure, as recognized by
disappearance of the radial pulse.
• Deflate the bladder by 3 mm Hg every second.
• Record the Korotkoff phase V (disappearance), except in children, in whom use of phase IV
(muffling) may be preferable if disappearance of the sounds is not perceived.
• If the Korotkoff sounds are weak, have the patient raise the arm and open and close the hand 5 to
10 times, and then reinflate the bladder quickly.
Recordings Blood pressure, patient position, arm and cuff size.

From Kaplan NM, Deveraux RB, Miller HS: Systemic hyperextension. Med Sci Sports Exerc 26:S269, 1994.

TABLE 1-9

Classification of Hypertension by Age

MAGNITUDE OF HYPERTENSION
Normal Mild, Stage 1 Moderate, Stage 2 Severe, Stage 3 Very Severe, Stage 4
Child (6–9 years)
Systolic 80–120 120–124 125–129 130–139 ≥140
Diastolic 50–75 75–79 80–84 85–89 ≥90
Child (10–12 years)
Systolic 80–120 125–129 130–134 135–144 ≥145
Diastolic 50–80 80–84 85–89 90–94 ≥95
Adolescent (13–15 years)
Systolic 110–120 135–139 140–149 150–159 ≥160
Diastolic 60–85 85–89 90–94 95–99 ≥100
Adolescent (16–18 years)
Systolic 110–120 140–149 150–159 160–179 ≥180
Diastolic 60–90 90–94 95–99 100–109 ≥110
Adult (>18 years)
Systolic 110–130 140–159 160–179 180–209 ≥210
Diastolic 80–90 90–99 100–109 110–119 ≥120

Reprinted, by permission, from McGrew CA: Clinical implications of the AHA preparticipation cardiovascular screening guidelines. Athletic Ther
Today 5(4):55, 2000.
22 Chapter 1 Principles and Concepts

History

Observation

DECISION:
Spinal joints or peripheral joint problem?

A. Spinal Assessment B. Peripheral Assessment

Active movements Active movements

of specific
Passive movements of spine Passive movements
peripheral joint
Resisted isometric movements Resisted isometric movements

Active movements
Passive movements Cervical
Peripheral joint scan Resisted isometric or lumbar
Scanning Myotomes movements spine Scanning
Examination Sensory scan Peripheral joint scan Examination
Myotomes
Sensory scan

DECISION:
Spinal joints or peripheral joint problem?

Special tests (for specific spinal area) Special tests (for specific peripheral joint)
Joint play (Sensory tests*)
Palpation (Reflexes*)
Imaging techniques Joint play
Palpation
Imaging techniques

Figure 1-11 The scanning examination used to rule out referral of symptoms from the spine. A, Spinal assessment (i.e., based on the history, the
clinician feels the problem is in the spine). B, Peripheral joint assessment (i.e., based on the history, the clinician feels the problem is in a peripheral
joint). (*These are done if scanning examination is not done.)

referred from one part of the body to another. It is

When to Use the Scanning Examination
• There is no history of trauma
• There are radicular signs
• There is trauma with radicular signs
• There is altered sensation in the limb
• There are spinal cord (“long track”) signs
• The patient presents with abnormal patterns
• There is suspected psychogenic pain
To ensure that all possible sources of pathology are
assessed, the examination must be extensive. This is espe-
cially true if there are symptoms when no history of
trauma is present. In this case, a scanning or screening
examination is performed to rule out the possibility of
referral of symptoms, especially from the spine. Similarly,
if there is any doubt about where the pathology is located,
the scanning examination is essential to ensure a correct
diagnosis. The scanning examination is a “quick look” or
scan of a part of the body involving the spine and extremi-
ties. It is used to rule out symptoms, which may be
divided into two scans: the upper limb scan and the lower
limb scan. It is part of the examination that is used, where
necessary, along with a detailed and focused examination
of one or more of the joints.
As with all assessments, the use of a scanning examina-
tion depends on what the examiner found in the history
and observation. For assessment of the spine, the scan-
ning examination is integrated into the examination as a
regular part of the cervical or lumbar assessment (Figure
1-11, A) and includes a peripheral joint scan, myotome
testing, and a sensory scan. If, when assessing the periph-
eral joints, the examiner suspects a problem is being
referred from the spine, the scanning examination is
“inserted” into the examination of that joint (Figure
1-11, B). For the scanning examination, the peripheral
joints are “scanned,” with the patient doing only a few
key movements at each joint. The movements should
include those that may be expected to exacerbate symp-
toms that are derived from the history. The examiner then
tests the upper or lower limb myotomes (key muscles
representing a specific nerve root). After these tests, a
 Chapter 1 Principles and Concepts 23

sensory scanning examination (sensory scan) can be per-
formed that may include the appropriate reflexes, the
sensory distributions of the dermatomes and peripheral
nerve distribution, and selected neurodynamic tests (e.g.,
upper limb tension test, slump test) if the examiner sus-
pects some neurological involvement. At this point, the
examiner makes a decision or an “educated guess” as to
whether the problem is in the cervical spine, lumbar spine,
or the peripheral joint, based on the information gained.
Once the decision is made, the examiner either completes
the spinal assessment (in the case of a suspected spinal
problem) or turns instead to completing the assessment
of the appropriate peripheral joint (see Figure 1-11). The
scanning examination should add no more than 5 or 10
minutes to the assessment.
The idea of the scanning examination was developed
by James Cyriax,1 who also, more than any other author,
originated the concepts of “contractile” and “inert”
tissue, “end feel,” and “capsular patterns” and contrib-
uted greatly to development of a comprehensive and sys-
tematic physical examination of the moving parts of the
body. Although several of his constructs and paradigms
have been questioned,62–64 the basic principles of ensuring
that all tissues are tested remains sound.
Spinal Cord and Nerve Roots
To further comprehend and ensure the value of the scan-
ning examination, the examiner must have a clear under-
standing of signs and symptoms arising from the spinal
cord and nerve roots of the body and those arising from
peripheral nerves. The scanning examination helps to
determine whether the pathology is caused by tissues
innervated by a nerve root or peripheral nerve that is
referring symptoms distally.
The nerve root is that portion of a peripheral nerve
that “connects” the nerve to the spinal cord. Nerve roots
arise from each level of the spinal cord (e.g., C3, C4),
and many, but not all, intermingle in a plexus (brachial,
lumbar, or lumbosacral) to form different peripheral
nerves (Figure 1-12). This arrangement can result in a
single nerve root supplying more than one peripheral
nerve. For example, the median nerve is derived from the
C6, C7, C8, and T1 nerve roots, whereas the ulnar nerve
is derived from C7, C8, and T1 (Table 1-10). For this
reason, if pressure is applied to the nerve root, the distri-
bution of the sensation or motor function is often felt or
exhibited in more than one peripheral nerve distribution
(Table 1-11). Therefore, although the symptoms seen in
a nerve root lesion (e.g., paresthesia, pain, muscle weak-
ness) may be similar to those seen in peripheral nerves,
the signs (e.g., area of paresthesia, where pain occurs,
which muscles are weak) are commonly different. The
examiner must be able to differentiate a dermatome
(nerve root) from the sensory distribution of a peripheral
nerve, and a myotome (nerve root) from muscles supplied
by a specific peripheral nerve. In addition, neurological
signs and symptoms, such as paresthesia and pain, may
result from inflammation or irritation of tissues, such as

Roots
Contribution to
phrenic nerve
Dorsal
Trunks scapular From C4
nerve C5

Suprascapular nerve C5
Subdivisions
Nerve to C6
subclavius
Cords C6
per C7
Up
ior C7
ter
st.

An dle C8
Mid
Po

Lateral
pectoral nerve Anterior
ior we
r
s ter Lo T1 T1
al Po
er
Nerves Lat
Posterior
or r Long thoracic nerve
steri io
Po ter
An
Musculocutaneous
nerve l
dia
Me
Axillary nerve 1st rib
Radial nerve Medial pectoral nerve
Medial brachial cutaneous nerve
Median nerve Medial antebrachial cutaneous nerve
Ulnar nerve Upper subscapular nerve
Thoracodorsal nerve
Lower subscapular nerve
Figure 1-12 The brachial plexus. (From Neuman DA: Kinesiology of the musculoskeletal system—foundations for rehabilitation, St Louis, 2010,
Mosby Elsevier, p. 150.)
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 DANCE ON STILTS AT THE GIRLS’ UNYAGO, NIUCHI

Newala, too, suffers from the distance of its water-supply—at least

the Newala of to-day does; there was once another Newala in a lovely
valley at the foot of the plateau. I visited it and found scarcely a trace
of houses, only a Christian cemetery, with the graves of several
missionaries and their converts, remaining as a monument of its
former glories. But the surroundings are wonderfully beautiful. A
thick grove of splendid mango-trees closes in the weather-worn
crosses and headstones; behind them, combining the useful and the
agreeable, is a whole plantation of lemon-trees covered with ripe
fruit; not the small African kind, but a much larger and also juicier
imported variety, which drops into the hands of the passing traveller,
without calling for any exertion on his part. Old Newala is now under
the jurisdiction of the native pastor, Daudi, at Chingulungulu, who,
as I am on very friendly terms with him, allows me, as a matter of
course, the use of this lemon-grove during my stay at Newala.
 FEET MUTILATED BY THE RAVAGES OF THE “JIGGER”
(Sarcopsylla penetrans)

The water-supply of New Newala is in the bottom of the valley,

some 1,600 feet lower down. The way is not only long and fatiguing,
but the water, when we get it, is thoroughly bad. We are suffering not
only from this, but from the fact that the arrangements at Newala are
nothing short of luxurious. We have a separate kitchen—a hut built
against the boma palisade on the right of the baraza, the interior of
which is not visible from our usual position. Our two cooks were not
long in finding this out, and they consequently do—or rather neglect
to do—what they please. In any case they do not seem to be very
particular about the boiling of our drinking-water—at least I can
attribute to no other cause certain attacks of a dysenteric nature,
from which both Knudsen and I have suffered for some time. If a
man like Omari has to be left unwatched for a moment, he is capable
of anything. Besides this complaint, we are inconvenienced by the
state of our nails, which have become as hard as glass, and crack on
the slightest provocation, and I have the additional infliction of
pimples all over me. As if all this were not enough, we have also, for
the last week been waging war against the jigger, who has found his
Eldorado in the hot sand of the Makonde plateau. Our men are seen
all day long—whenever their chronic colds and the dysentery likewise
raging among them permit—occupied in removing this scourge of
Africa from their feet and trying to prevent the disastrous
consequences of its presence. It is quite common to see natives of
this place with one or two toes missing; many have lost all their toes,
or even the whole front part of the foot, so that a well-formed leg
ends in a shapeless stump. These ravages are caused by the female of
Sarcopsylla penetrans, which bores its way under the skin and there
develops an egg-sac the size of a pea. In all books on the subject, it is
stated that one’s attention is called to the presence of this parasite by
an intolerable itching. This agrees very well with my experience, so
far as the softer parts of the sole, the spaces between and under the
toes, and the side of the foot are concerned, but if the creature
penetrates through the harder parts of the heel or ball of the foot, it
may escape even the most careful search till it has reached maturity.
Then there is no time to be lost, if the horrible ulceration, of which
we see cases by the dozen every day, is to be prevented. It is much
easier, by the way, to discover the insect on the white skin of a
European than on that of a native, on which the dark speck scarcely
shows. The four or five jiggers which, in spite of the fact that I
constantly wore high laced boots, chose my feet to settle in, were
taken out for me by the all-accomplished Knudsen, after which I
thought it advisable to wash out the cavities with corrosive
sublimate. The natives have a different sort of disinfectant—they fill
the hole with scraped roots. In a tiny Makua village on the slope of
the plateau south of Newala, we saw an old woman who had filled all
the spaces under her toe-nails with powdered roots by way of
prophylactic treatment. What will be the result, if any, who can say?
The rest of the many trifling ills which trouble our existence are
really more comic than serious. In the absence of anything else to
smoke, Knudsen and I at last opened a box of cigars procured from
the Indian store-keeper at Lindi, and tried them, with the most
distressing results. Whether they contain opium or some other
narcotic, neither of us can say, but after the tenth puff we were both
“off,” three-quarters stupefied and unspeakably wretched. Slowly we
recovered—and what happened next? Half-an-hour later we were
once more smoking these poisonous concoctions—so insatiable is the
craving for tobacco in the tropics.
Even my present attacks of fever scarcely deserve to be taken
seriously. I have had no less than three here at Newala, all of which
have run their course in an incredibly short time. In the early
afternoon, I am busy with my old natives, asking questions and
making notes. The strong midday coffee has stimulated my spirits to
an extraordinary degree, the brain is active and vigorous, and work
progresses rapidly, while a pleasant warmth pervades the whole
body. Suddenly this gives place to a violent chill, forcing me to put on
my overcoat, though it is only half-past three and the afternoon sun
is at its hottest. Now the brain no longer works with such acuteness
and logical precision; more especially does it fail me in trying to
establish the syntax of the difficult Makua language on which I have
ventured, as if I had not enough to do without it. Under the
circumstances it seems advisable to take my temperature, and I do
so, to save trouble, without leaving my seat, and while going on with
my work. On examination, I find it to be 101·48°. My tutors are
abruptly dismissed and my bed set up in the baraza; a few minutes
later I am in it and treating myself internally with hot water and
lemon-juice.
Three hours later, the thermometer marks nearly 104°, and I make
them carry me back into the tent, bed and all, as I am now perspiring
heavily, and exposure to the cold wind just beginning to blow might
mean a fatal chill. I lie still for a little while, and then find, to my
great relief, that the temperature is not rising, but rather falling. This
is about 7.30 p.m. At 8 p.m. I find, to my unbounded astonishment,
that it has fallen below 98·6°, and I feel perfectly well. I read for an
hour or two, and could very well enjoy a smoke, if I had the
wherewithal—Indian cigars being out of the question.
Having no medical training, I am at a loss to account for this state
of things. It is impossible that these transitory attacks of high fever
should be malarial; it seems more probable that they are due to a
kind of sunstroke. On consulting my note-book, I become more and
more inclined to think this is the case, for these attacks regularly
follow extreme fatigue and long exposure to strong sunshine. They at
least have the advantage of being only short interruptions to my
work, as on the following morning I am always quite fresh and fit.
My treasure of a cook is suffering from an enormous hydrocele which
makes it difficult for him to get up, and Moritz is obliged to keep in
the dark on account of his inflamed eyes. Knudsen’s cook, a raw boy
from somewhere in the bush, knows still less of cooking than Omari;
consequently Nils Knudsen himself has been promoted to the vacant
post. Finding that we had come to the end of our supplies, he began
by sending to Chingulungulu for the four sucking-pigs which we had
bought from Matola and temporarily left in his charge; and when
they came up, neatly packed in a large crate, he callously slaughtered
the biggest of them. The first joint we were thoughtless enough to
entrust for roasting to Knudsen’s mshenzi cook, and it was
consequently uneatable; but we made the rest of the animal into a
jelly which we ate with great relish after weeks of underfeeding,
consuming incredible helpings of it at both midday and evening
meals. The only drawback is a certain want of variety in the tinned
vegetables. Dr. Jäger, to whom the Geographical Commission
entrusted the provisioning of the expeditions—mine as well as his
own—because he had more time on his hands than the rest of us,
seems to have laid in a huge stock of Teltow turnips,[46] an article of
food which is all very well for occasional use, but which quickly palls
when set before one every day; and we seem to have no other tins
left. There is no help for it—we must put up with the turnips; but I
am certain that, once I am home again, I shall not touch them for ten
years to come.
Amid all these minor evils, which, after all, go to make up the
genuine flavour of Africa, there is at least one cheering touch:
Knudsen has, with the dexterity of a skilled mechanic, repaired my 9
× 12 cm. camera, at least so far that I can use it with a little care.
How, in the absence of finger-nails, he was able to accomplish such a
ticklish piece of work, having no tool but a clumsy screw-driver for
taking to pieces and putting together again the complicated
mechanism of the instantaneous shutter, is still a mystery to me; but
he did it successfully. The loss of his finger-nails shows him in a light
contrasting curiously enough with the intelligence evinced by the
above operation; though, after all, it is scarcely surprising after his
ten years’ residence in the bush. One day, at Lindi, he had occasion
to wash a dog, which must have been in need of very thorough
cleansing, for the bottle handed to our friend for the purpose had an
extremely strong smell. Having performed his task in the most
conscientious manner, he perceived with some surprise that the dog
did not appear much the better for it, and was further surprised by
finding his own nails ulcerating away in the course of the next few
days. “How was I to know that carbolic acid has to be diluted?” he
mutters indignantly, from time to time, with a troubled gaze at his
mutilated finger-tips.
 Since we came to Newala we have been making excursions in all
directions through the surrounding country, in accordance with old
habit, and also because the akida Sefu did not get together the tribal
elders from whom I wanted information so speedily as he had
promised. There is, however, no harm done, as, even if seen only
from the outside, the country and people are interesting enough.
The Makonde plateau is like a large rectangular table rounded off
at the corners. Measured from the Indian Ocean to Newala, it is
about seventy-five miles long, and between the Rovuma and the
Lukuledi it averages fifty miles in breadth, so that its superficial area
is about two-thirds of that of the kingdom of Saxony. The surface,
however, is not level, but uniformly inclined from its south-western
edge to the ocean. From the upper edge, on which Newala lies, the
eye ranges for many miles east and north-east, without encountering
any obstacle, over the Makonde bush. It is a green sea, from which
here and there thick clouds of smoke rise, to show that it, too, is
inhabited by men who carry on their tillage like so many other
primitive peoples, by cutting down and burning the bush, and
manuring with the ashes. Even in the radiant light of a tropical day
such a fire is a grand sight.
Much less effective is the impression produced just now by the
great western plain as seen from the edge of the plateau. As often as
time permits, I stroll along this edge, sometimes in one direction,
sometimes in another, in the hope of finding the air clear enough to
let me enjoy the view; but I have always been disappointed.
Wherever one looks, clouds of smoke rise from the burning bush,
and the air is full of smoke and vapour. It is a pity, for under more
favourable circumstances the panorama of the whole country up to
the distant Majeje hills must be truly magnificent. It is of little use
taking photographs now, and an outline sketch gives a very poor idea
of the scenery. In one of these excursions I went out of my way to
make a personal attempt on the Makonde bush. The present edge of
the plateau is the result of a far-reaching process of destruction
through erosion and denudation. The Makonde strata are
everywhere cut into by ravines, which, though short, are hundreds of
yards in depth. In consequence of the loose stratification of these
beds, not only are the walls of these ravines nearly vertical, but their
upper end is closed by an equally steep escarpment, so that the
western edge of the Makonde plateau is hemmed in by a series of
deep, basin-like valleys. In order to get from one side of such a ravine
to the other, I cut my way through the bush with a dozen of my men.
It was a very open part, with more grass than scrub, but even so the
short stretch of less than two hundred yards was very hard work; at
the end of it the men’s calicoes were in rags and they themselves
bleeding from hundreds of scratches, while even our strong khaki
suits had not escaped scatheless.

NATIVE PATH THROUGH THE MAKONDE BUSH, NEAR

MAHUTA

I see increasing reason to believe that the view formed some time
back as to the origin of the Makonde bush is the correct one. I have
no doubt that it is not a natural product, but the result of human
occupation. Those parts of the high country where man—as a very
slight amount of practice enables the eye to perceive at once—has not
yet penetrated with axe and hoe, are still occupied by a splendid
timber forest quite able to sustain a comparison with our mixed
forests in Germany. But wherever man has once built his hut or tilled
his field, this horrible bush springs up. Every phase of this process
may be seen in the course of a couple of hours’ walk along the main
road. From the bush to right or left, one hears the sound of the axe—
not from one spot only, but from several directions at once. A few
steps further on, we can see what is taking place. The brush has been
cut down and piled up in heaps to the height of a yard or more,
between which the trunks of the large trees stand up like the last
pillars of a magnificent ruined building. These, too, present a
melancholy spectacle: the destructive Makonde have ringed them—
cut a broad strip of bark all round to ensure their dying off—and also
piled up pyramids of brush round them. Father and son, mother and
son-in-law, are chopping away perseveringly in the background—too
busy, almost, to look round at the white stranger, who usually excites
so much interest. If you pass by the same place a week later, the piles
of brushwood have disappeared and a thick layer of ashes has taken
the place of the green forest. The large trees stretch their
smouldering trunks and branches in dumb accusation to heaven—if
they have not already fallen and been more or less reduced to ashes,
perhaps only showing as a white stripe on the dark ground.
This work of destruction is carried out by the Makonde alike on the
virgin forest and on the bush which has sprung up on sites already
cultivated and deserted. In the second case they are saved the trouble
of burning the large trees, these being entirely absent in the
secondary bush.
After burning this piece of forest ground and loosening it with the
hoe, the native sows his corn and plants his vegetables. All over the
country, he goes in for bed-culture, which requires, and, in fact,
receives, the most careful attention. Weeds are nowhere tolerated in
the south of German East Africa. The crops may fail on the plains,
where droughts are frequent, but never on the plateau with its
abundant rains and heavy dews. Its fortunate inhabitants even have
the satisfaction of seeing the proud Wayao and Wamakua working
for them as labourers, driven by hunger to serve where they were
accustomed to rule.
But the light, sandy soil is soon exhausted, and would yield no
harvest the second year if cultivated twice running. This fact has
been familiar to the native for ages; consequently he provides in
time, and, while his crop is growing, prepares the next plot with axe
and firebrand. Next year he plants this with his various crops and
lets the first piece lie fallow. For a short time it remains waste and
desolate; then nature steps in to repair the destruction wrought by
man; a thousand new growths spring out of the exhausted soil, and
even the old stumps put forth fresh shoots. Next year the new growth
is up to one’s knees, and in a few years more it is that terrible,
impenetrable bush, which maintains its position till the black
occupier of the land has made the round of all the available sites and
come back to his starting point.
The Makonde are, body and soul, so to speak, one with this bush.
According to my Yao informants, indeed, their name means nothing
else but “bush people.” Their own tradition says that they have been
settled up here for a very long time, but to my surprise they laid great
stress on an original immigration. Their old homes were in the
south-east, near Mikindani and the mouth of the Rovuma, whence
their peaceful forefathers were driven by the continual raids of the
Sakalavas from Madagascar and the warlike Shirazis[47] of the coast,
to take refuge on the almost inaccessible plateau. I have studied
African ethnology for twenty years, but the fact that changes of
population in this apparently quiet and peaceable corner of the earth
could have been occasioned by outside enterprises taking place on
the high seas, was completely new to me. It is, no doubt, however,
correct.
The charming tribal legend of the Makonde—besides informing us
of other interesting matters—explains why they have to live in the
thickest of the bush and a long way from the edge of the plateau,
instead of making their permanent homes beside the purling brooks
and springs of the low country.
“The place where the tribe originated is Mahuta, on the southern
side of the plateau towards the Rovuma, where of old time there was
nothing but thick bush. Out of this bush came a man who never
washed himself or shaved his head, and who ate and drank but little.
He went out and made a human figure from the wood of a tree
growing in the open country, which he took home to his abode in the
bush and there set it upright. In the night this image came to life and
was a woman. The man and woman went down together to the
Rovuma to wash themselves. Here the woman gave birth to a still-
born child. They left that place and passed over the high land into the
valley of the Mbemkuru, where the woman had another child, which
was also born dead. Then they returned to the high bush country of
Mahuta, where the third child was born, which lived and grew up. In
course of time, the couple had many more children, and called
themselves Wamatanda. These were the ancestral stock of the
Makonde, also called Wamakonde,[48] i.e., aborigines. Their
forefather, the man from the bush, gave his children the command to
bury their dead upright, in memory of the mother of their race who
was cut out of wood and awoke to life when standing upright. He also
warned them against settling in the valleys and near large streams,
for sickness and death dwelt there. They were to make it a rule to
have their huts at least an hour’s walk from the nearest watering-
place; then their children would thrive and escape illness.”
The explanation of the name Makonde given by my informants is
somewhat different from that contained in the above legend, which I
extract from a little book (small, but packed with information), by
Pater Adams, entitled Lindi und sein Hinterland. Otherwise, my
results agree exactly with the statements of the legend. Washing?
Hapana—there is no such thing. Why should they do so? As it is, the
supply of water scarcely suffices for cooking and drinking; other
people do not wash, so why should the Makonde distinguish himself
by such needless eccentricity? As for shaving the head, the short,
woolly crop scarcely needs it,[49] so the second ancestral precept is
likewise easy enough to follow. Beyond this, however, there is
nothing ridiculous in the ancestor’s advice. I have obtained from
various local artists a fairly large number of figures carved in wood,
ranging from fifteen to twenty-three inches in height, and
representing women belonging to the great group of the Mavia,
Makonde, and Matambwe tribes. The carving is remarkably well
done and renders the female type with great accuracy, especially the
keloid ornamentation, to be described later on. As to the object and
meaning of their works the sculptors either could or (more probably)
would tell me nothing, and I was forced to content myself with the
scanty information vouchsafed by one man, who said that the figures
were merely intended to represent the nembo—the artificial
deformations of pelele, ear-discs, and keloids. The legend recorded
by Pater Adams places these figures in a new light. They must surely
be more than mere dolls; and we may even venture to assume that
they are—though the majority of present-day Makonde are probably
unaware of the fact—representations of the tribal ancestress.
 The references in the legend to the descent from Mahuta to the
Rovuma, and to a journey across the highlands into the Mbekuru
valley, undoubtedly indicate the previous history of the tribe, the
travels of the ancestral pair typifying the migrations of their
descendants. The descent to the neighbouring Rovuma valley, with
its extraordinary fertility and great abundance of game, is intelligible
at a glance—but the crossing of the Lukuledi depression, the ascent
to the Rondo Plateau and the descent to the Mbemkuru, also lie
within the bounds of probability, for all these districts have exactly
the same character as the extreme south. Now, however, comes a
point of especial interest for our bacteriological age. The primitive
Makonde did not enjoy their lives in the marshy river-valleys.
Disease raged among them, and many died. It was only after they
had returned to their original home near Mahuta, that the health
conditions of these people improved. We are very apt to think of the
African as a stupid person whose ignorance of nature is only equalled
by his fear of it, and who looks on all mishaps as caused by evil
spirits and malignant natural powers. It is much more correct to
assume in this case that the people very early learnt to distinguish
districts infested with malaria from those where it is absent.
This knowledge is crystallized in the
ancestral warning against settling in the
valleys and near the great waters, the
dwelling-places of disease and death. At the
same time, for security against the hostile
Mavia south of the Rovuma, it was enacted
that every settlement must be not less than a
certain distance from the southern edge of the
plateau. Such in fact is their mode of life at the
present day. It is not such a bad one, and
certainly they are both safer and more
comfortable than the Makua, the recent
intruders from the south, who have made USUAL METHOD OF
good their footing on the western edge of the CLOSING HUT-DOOR
plateau, extending over a fairly wide belt of
country. Neither Makua nor Makonde show in their dwellings
anything of the size and comeliness of the Yao houses in the plain,
especially at Masasi, Chingulungulu and Zuza’s. Jumbe Chauro, a
Makonde hamlet not far from Newala, on the road to Mahuta, is the
most important settlement of the tribe I have yet seen, and has fairly
spacious huts. But how slovenly is their construction compared with
the palatial residences of the elephant-hunters living in the plain.
The roofs are still more untidy than in the general run of huts during
the dry season, the walls show here and there the scanty beginnings
or the lamentable remains of the mud plastering, and the interior is a
veritable dog-kennel; dirt, dust and disorder everywhere. A few huts
only show any attempt at division into rooms, and this consists
merely of very roughly-made bamboo partitions. In one point alone
have I noticed any indication of progress—in the method of fastening
the door. Houses all over the south are secured in a simple but
ingenious manner. The door consists of a set of stout pieces of wood
or bamboo, tied with bark-string to two cross-pieces, and moving in
two grooves round one of the door-posts, so as to open inwards. If
the owner wishes to leave home, he takes two logs as thick as a man’s
upper arm and about a yard long. One of these is placed obliquely
against the middle of the door from the inside, so as to form an angle
of from 60° to 75° with the ground. He then places the second piece
horizontally across the first, pressing it downward with all his might.
It is kept in place by two strong posts planted in the ground a few
inches inside the door. This fastening is absolutely safe, but of course
cannot be applied to both doors at once, otherwise how could the
owner leave or enter his house? I have not yet succeeded in finding
out how the back door is fastened.

MAKONDE LOCK AND KEY AT JUMBE CHAURO

 This is the general way of closing a house. The Makonde at Jumbe
Chauro, however, have a much more complicated, solid and original
one. Here, too, the door is as already described, except that there is
only one post on the inside, standing by itself about six inches from
one side of the doorway. Opposite this post is a hole in the wall just
large enough to admit a man’s arm. The door is closed inside by a
large wooden bolt passing through a hole in this post and pressing
with its free end against the door. The other end has three holes into
which fit three pegs running in vertical grooves inside the post. The
door is opened with a wooden key about a foot long, somewhat
curved and sloped off at the butt; the other end has three pegs
corresponding to the holes, in the bolt, so that, when it is thrust
through the hole in the wall and inserted into the rectangular
opening in the post, the pegs can be lifted and the bolt drawn out.[50]

MODE OF INSERTING THE KEY

With no small pride first one householder and then a second

showed me on the spot the action of this greatest invention of the
Makonde Highlands. To both with an admiring exclamation of
“Vizuri sana!” (“Very fine!”). I expressed the wish to take back these
marvels with me to Ulaya, to show the Wazungu what clever fellows
the Makonde are. Scarcely five minutes after my return to camp at
Newala, the two men came up sweating under the weight of two
heavy logs which they laid down at my feet, handing over at the same
time the keys of the fallen fortress. Arguing, logically enough, that if
the key was wanted, the lock would be wanted with it, they had taken
their axes and chopped down the posts—as it never occurred to them
to dig them out of the ground and so bring them intact. Thus I have
two badly damaged specimens, and the owners, instead of praise,
come in for a blowing-up.
The Makua huts in the environs of Newala are especially
miserable; their more than slovenly construction reminds one of the
temporary erections of the Makua at Hatia’s, though the people here
have not been concerned in a war. It must therefore be due to
congenital idleness, or else to the absence of a powerful chief. Even
the baraza at Mlipa’s, a short hour’s walk south-east of Newala,
shares in this general neglect. While public buildings in this country
are usually looked after more or less carefully, this is in evident
danger of being blown over by the first strong easterly gale. The only
attractive object in this whole district is the grave of the late chief
Mlipa. I visited it in the morning, while the sun was still trying with
partial success to break through the rolling mists, and the circular
grove of tall euphorbias, which, with a broken pot, is all that marks
the old king’s resting-place, impressed one with a touch of pathos.
Even my very materially-minded carriers seemed to feel something
of the sort, for instead of their usual ribald songs, they chanted
solemnly, as we marched on through the dense green of the Makonde
bush:—
 “We shall arrive with the great master; we stand in a row and have
no fear about getting our food and our money from the Serkali (the
Government). We are not afraid; we are going along with the great
master, the lion; we are going down to the coast and back.”
With regard to the characteristic features of the various tribes here
on the western edge of the plateau, I can arrive at no other
conclusion than the one already come to in the plain, viz., that it is
impossible for anyone but a trained anthropologist to assign any
given individual at once to his proper tribe. In fact, I think that even
an anthropological specialist, after the most careful examination,
might find it a difficult task to decide. The whole congeries of peoples
collected in the region bounded on the west by the great Central
African rift, Tanganyika and Nyasa, and on the east by the Indian
Ocean, are closely related to each other—some of their languages are
only distinguished from one another as dialects of the same speech,
and no doubt all the tribes present the same shape of skull and
structure of skeleton. Thus, surely, there can be no very striking
differences in outward appearance.
 Even did such exist, I should have no time
to concern myself with them, for day after day,
I have to see or hear, as the case may be—in
any case to grasp and record—an
extraordinary number of ethnographic
phenomena. I am almost disposed to think it
fortunate that some departments of inquiry, at
least, are barred by external circumstances.
Chief among these is the subject of iron-
working. We are apt to think of Africa as a
country where iron ore is everywhere, so to
speak, to be picked up by the roadside, and
where it would be quite surprising if the
inhabitants had not learnt to smelt the
material ready to their hand. In fact, the
knowledge of this art ranges all over the
continent, from the Kabyles in the north to the
Kafirs in the south. Here between the Rovuma
and the Lukuledi the conditions are not so
favourable. According to the statements of the
Makonde, neither ironstone nor any other
form of iron ore is known to them. They have
not therefore advanced to the art of smelting
the metal, but have hitherto bought all their
THE ANCESTRESS OF
THE MAKONDE
iron implements from neighbouring tribes.
Even in the plain the inhabitants are not much
better off. Only one man now living is said to
understand the art of smelting iron. This old fundi lives close to
Huwe, that isolated, steep-sided block of granite which rises out of
the green solitude between Masasi and Chingulungulu, and whose
jagged and splintered top meets the traveller’s eye everywhere. While
still at Masasi I wished to see this man at work, but was told that,
frightened by the rising, he had retired across the Rovuma, though
he would soon return. All subsequent inquiries as to whether the
fundi had come back met with the genuine African answer, “Bado”
(“Not yet”).
 BRAZIER

Some consolation was afforded me by a brassfounder, whom I

came across in the bush near Akundonde’s. This man is the favourite
of women, and therefore no doubt of the gods; he welds the glittering
brass rods purchased at the coast into those massive, heavy rings
which, on the wrists and ankles of the local fair ones, continually give
me fresh food for admiration. Like every decent master-craftsman he
had all his tools with him, consisting of a pair of bellows, three
crucibles and a hammer—nothing more, apparently. He was quite
willing to show his skill, and in a twinkling had fixed his bellows on
the ground. They are simply two goat-skins, taken off whole, the four
legs being closed by knots, while the upper opening, intended to
admit the air, is kept stretched by two pieces of wood. At the lower
end of the skin a smaller opening is left into which a wooden tube is
stuck. The fundi has quickly borrowed a heap of wood-embers from
the nearest hut; he then fixes the free ends of the two tubes into an
earthen pipe, and clamps them to the ground by means of a bent
piece of wood. Now he fills one of his small clay crucibles, the dross
on which shows that they have been long in use, with the yellow
material, places it in the midst of the embers, which, at present are
only faintly glimmering, and begins his work. In quick alternation
the smith’s two hands move up and down with the open ends of the
bellows; as he raises his hand he holds the slit wide open, so as to let
the air enter the skin bag unhindered. In pressing it down he closes
the bag, and the air puffs through the bamboo tube and clay pipe into
the fire, which quickly burns up. The smith, however, does not keep
on with this work, but beckons to another man, who relieves him at
the bellows, while he takes some more tools out of a large skin pouch
carried on his back. I look on in wonder as, with a smooth round
stick about the thickness of a finger, he bores a few vertical holes into
the clean sand of the soil. This should not be difficult, yet the man
seems to be taking great pains over it. Then he fastens down to the
ground, with a couple of wooden clamps, a neat little trough made by
splitting a joint of bamboo in half, so that the ends are closed by the
two knots. At last the yellow metal has attained the right consistency,
and the fundi lifts the crucible from the fire by means of two sticks
split at the end to serve as tongs. A short swift turn to the left—a
tilting of the crucible—and the molten brass, hissing and giving forth
clouds of smoke, flows first into the bamboo mould and then into the
holes in the ground.
The technique of this backwoods craftsman may not be very far
advanced, but it cannot be denied that he knows how to obtain an
adequate result by the simplest means. The ladies of highest rank in
this country—that is to say, those who can afford it, wear two kinds
of these massive brass rings, one cylindrical, the other semicircular
in section. The latter are cast in the most ingenious way in the
bamboo mould, the former in the circular hole in the sand. It is quite
a simple matter for the fundi to fit these bars to the limbs of his fair
customers; with a few light strokes of his hammer he bends the
pliable brass round arm or ankle without further inconvenience to
the wearer.
SHAPING THE POT

SMOOTHING WITH MAIZE-COB

CUTTING THE EDGE

 FINISHING THE BOTTOM

LAST SMOOTHING BEFORE

BURNING

FIRING THE BRUSH-PILE

 LIGHTING THE FARTHER SIDE OF
THE PILE

TURNING THE RED-HOT VESSEL

NYASA WOMAN MAKING POTS AT MASASI

Pottery is an art which must always and everywhere excite the
interest of the student, just because it is so intimately connected with
the development of human culture, and because its relics are one of
the principal factors in the reconstruction of our own condition in
prehistoric times. I shall always remember with pleasure the two or
three afternoons at Masasi when Salim Matola’s mother, a slightly-
built, graceful, pleasant-looking woman, explained to me with
touching patience, by means of concrete illustrations, the ceramic art
of her people. The only implements for this primitive process were a
lump of clay in her left hand, and in the right a calabash containing
the following valuables: the fragment of a maize-cob stripped of all
its grains, a smooth, oval pebble, about the size of a pigeon’s egg, a
few chips of gourd-shell, a bamboo splinter about the length of one’s
hand, a small shell, and a bunch of some herb resembling spinach.
 Nothing more. The woman scraped with the
shell a round, shallow hole in the soft, fine
sand of the soil, and, when an active young
girl had filled the calabash with water for her,
she began to knead the clay. As if by magic it
gradually assumed the shape of a rough but
already well-shaped vessel, which only wanted
a little touching up with the instruments
before mentioned. I looked out with the
MAKUA WOMAN closest attention for any indication of the use
MAKING A POT. of the potter’s wheel, in however rudimentary
SHOWS THE a form, but no—hapana (there is none). The
BEGINNINGS OF THE embryo pot stood firmly in its little
POTTER’S WHEEL
depression, and the woman walked round it in
a stooping posture, whether she was removing
small stones or similar foreign bodies with the maize-cob, smoothing
the inner or outer surface with the splinter of bamboo, or later, after
letting it dry for a day, pricking in the ornamentation with a pointed
bit of gourd-shell, or working out the bottom, or cutting the edge
with a sharp bamboo knife, or giving the last touches to the finished
vessel. This occupation of the women is infinitely toilsome, but it is
without doubt an accurate reproduction of the process in use among
our ancestors of the Neolithic and Bronze ages.
There is no doubt that the invention of pottery, an item in human
progress whose importance cannot be over-estimated, is due to
women. Rough, coarse and unfeeling, the men of the horde range
over the countryside. When the united cunning of the hunters has
succeeded in killing the game; not one of them thinks of carrying
home the spoil. A bright fire, kindled by a vigorous wielding of the
drill, is crackling beside them; the animal has been cleaned and cut
up secundum artem, and, after a slight singeing, will soon disappear
under their sharp teeth; no one all this time giving a single thought
to wife or child.
To what shifts, on the other hand, the primitive wife, and still more
the primitive mother, was put! Not even prehistoric stomachs could
endure an unvarying diet of raw food. Something or other suggested
the beneficial effect of hot water on the majority of approved but
indigestible dishes. Perhaps a neighbour had tried holding the hard
roots or tubers over the fire in a calabash filled with water—or maybe
an ostrich-egg-shell, or a hastily improvised vessel of bark. They
became much softer and more palatable than they had previously
been; but, unfortunately, the vessel could not stand the fire and got
charred on the outside. That can be remedied, thought our
ancestress, and plastered a layer of wet clay round a similar vessel.
This is an improvement; the cooking utensil remains uninjured, but
the heat of the fire has shrunk it, so that it is loose in its shell. The
next step is to detach it, so, with a firm grip and a jerk, shell and
kernel are separated, and pottery is invented. Perhaps, however, the
discovery which led to an intelligent use of the burnt-clay shell, was
made in a slightly different way. Ostrich-eggs and calabashes are not
to be found in every part of the world, but everywhere mankind has
arrived at the art of making baskets out of pliant materials, such as
bark, bast, strips of palm-leaf, supple twigs, etc. Our inventor has no
water-tight vessel provided by nature. “Never mind, let us line the
basket with clay.” This answers the purpose, but alas! the basket gets
burnt over the blazing fire, the woman watches the process of
cooking with increasing uneasiness, fearing a leak, but no leak
appears. The food, done to a turn, is eaten with peculiar relish; and
the cooking-vessel is examined, half in curiosity, half in satisfaction
at the result. The plastic clay is now hard as stone, and at the same
time looks exceedingly well, for the neat plaiting of the burnt basket
is traced all over it in a pretty pattern. Thus, simultaneously with
pottery, its ornamentation was invented.
Primitive woman has another claim to respect. It was the man,
roving abroad, who invented the art of producing fire at will, but the
woman, unable to imitate him in this, has been a Vestal from the
earliest times. Nothing gives so much trouble as the keeping alight of
the smouldering brand, and, above all, when all the men are absent
from the camp. Heavy rain-clouds gather, already the first large
drops are falling, the first gusts of the storm rage over the plain. The
little flame, a greater anxiety to the woman than her own children,
flickers unsteadily in the blast. What is to be done? A sudden thought
occurs to her, and in an instant she has constructed a primitive hut
out of strips of bark, to protect the flame against rain and wind.
This, or something very like it, was the way in which the principle
of the house was discovered; and even the most hardened misogynist
cannot fairly refuse a woman the credit of it. The protection of the
hearth-fire from the weather is the germ from which the human
dwelling was evolved. Men had little, if any share, in this forward
step, and that only at a late stage. Even at the present day, the
plastering of the housewall with clay and the manufacture of pottery
are exclusively the women’s business. These are two very significant
survivals. Our European kitchen-garden, too, is originally a woman’s
invention, and the hoe, the primitive instrument of agriculture, is,
characteristically enough, still used in this department. But the
noblest achievement which we owe to the other sex is unquestionably
the art of cookery. Roasting alone—the oldest process—is one for
which men took the hint (a very obvious one) from nature. It must
have been suggested by the scorched carcase of some animal
overtaken by the destructive forest-fires. But boiling—the process of
improving organic substances by the help of water heated to boiling-
point—is a much later discovery. It is so recent that it has not even
yet penetrated to all parts of the world. The Polynesians understand
how to steam food, that is, to cook it, neatly wrapped in leaves, in a
hole in the earth between hot stones, the air being excluded, and
(sometimes) a few drops of water sprinkled on the stones; but they
do not understand boiling.
To come back from this digression, we find that the slender Nyasa
woman has, after once more carefully examining the finished pot,
put it aside in the shade to dry. On the following day she sends me
word by her son, Salim Matola, who is always on hand, that she is
going to do the burning, and, on coming out of my house, I find her
already hard at work. She has spread on the ground a layer of very
dry sticks, about as thick as one’s thumb, has laid the pot (now of a
yellowish-grey colour) on them, and is piling brushwood round it.
My faithful Pesa mbili, the mnyampara, who has been standing by,
most obligingly, with a lighted stick, now hands it to her. Both of
them, blowing steadily, light the pile on the lee side, and, when the
flame begins to catch, on the weather side also. Soon the whole is in a
blaze, but the dry fuel is quickly consumed and the fire dies down, so
that we see the red-hot vessel rising from the ashes. The woman
turns it continually with a long stick, sometimes one way and
sometimes another, so that it may be evenly heated all over. In
twenty minutes she rolls it out of the ash-heap, takes up the bundle
of spinach, which has been lying for two days in a jar of water, and
sprinkles the red-hot clay with it. The places where the drops fall are
marked by black spots on the uniform reddish-brown surface. With a
sigh of relief, and with visible satisfaction, the woman rises to an
erect position; she is standing just in a line between me and the fire,
from which a cloud of smoke is just rising: I press the ball of my
camera, the shutter clicks—the apotheosis is achieved! Like a
priestess, representative of her inventive sex, the graceful woman
stands: at her feet the hearth-fire she has given us beside her the
invention she has devised for us, in the background the home she has
built for us.
At Newala, also, I have had the manufacture of pottery carried on
in my presence. Technically the process is better than that already
described, for here we find the beginnings of the potter’s wheel,
which does not seem to exist in the plains; at least I have seen
nothing of the sort. The artist, a frightfully stupid Makua woman, did
not make a depression in the ground to receive the pot she was about
to shape, but used instead a large potsherd. Otherwise, she went to
work in much the same way as Salim’s mother, except that she saved
herself the trouble of walking round and round her work by squatting
at her ease and letting the pot and potsherd rotate round her; this is
surely the first step towards a machine. But it does not follow that
the pot was improved by the process. It is true that it was beautifully
rounded and presented a very creditable appearance when finished,
but the numerous large and small vessels which I have seen, and, in
part, collected, in the “less advanced” districts, are no less so. We
moderns imagine that instruments of precision are necessary to
produce excellent results. Go to the prehistoric collections of our
museums and look at the pots, urns and bowls of our ancestors in the
dim ages of the past, and you will at once perceive your error.
MAKING LONGITUDINAL CUT IN
BARK

DRAWING THE BARK OFF THE LOG

REMOVING THE OUTER BARK

 BEATING THE BARK

WORKING THE BARK-CLOTH AFTER BEATING, TO MAKE IT

SOFT

MANUFACTURE OF BARK-CLOTH AT NEWALA

To-day, nearly the whole population of German East Africa is
clothed in imported calico. This was not always the case; even now in
some parts of the north dressed skins are still the prevailing wear,
and in the north-western districts—east and north of Lake
Tanganyika—lies a zone where bark-cloth has not yet been
superseded. Probably not many generations have passed since such
bark fabrics and kilts of skins were the only clothing even in the
south. Even to-day, large quantities of this bright-red or drab
material are still to be found; but if we wish to see it, we must look in
the granaries and on the drying stages inside the native huts, where
it serves less ambitious uses as wrappings for those seeds and fruits
which require to be packed with special care. The salt produced at
Masasi, too, is packed for transport to a distance in large sheets of
bark-cloth. Wherever I found it in any degree possible, I studied the
process of making this cloth. The native requisitioned for the
purpose arrived, carrying a log between two and three yards long and
as thick as his thigh, and nothing else except a curiously-shaped
mallet and the usual long, sharp and pointed knife which all men and
boys wear in a belt at their backs without a sheath—horribile dictu!
[51]
Silently he squats down before me, and with two rapid cuts has
drawn a couple of circles round the log some two yards apart, and
slits the bark lengthwise between them with the point of his knife.
With evident care, he then scrapes off the outer rind all round the
log, so that in a quarter of an hour the inner red layer of the bark
shows up brightly-coloured between the two untouched ends. With
some trouble and much caution, he now loosens the bark at one end,
and opens the cylinder. He then stands up, takes hold of the free
edge with both hands, and turning it inside out, slowly but steadily
pulls it off in one piece. Now comes the troublesome work of
scraping all superfluous particles of outer bark from the outside of
the long, narrow piece of material, while the inner side is carefully
scrutinised for defective spots. At last it is ready for beating. Having
signalled to a friend, who immediately places a bowl of water beside
him, the artificer damps his sheet of bark all over, seizes his mallet,
lays one end of the stuff on the smoothest spot of the log, and
hammers away slowly but continuously. “Very simple!” I think to
myself. “Why, I could do that, too!”—but I am forced to change my
opinions a little later on; for the beating is quite an art, if the fabric is
not to be beaten to pieces. To prevent the breaking of the fibres, the
stuff is several times folded across, so as to interpose several
thicknesses between the mallet and the block. At last the required
state is reached, and the fundi seizes the sheet, still folded, by both
ends, and wrings it out, or calls an assistant to take one end while he
holds the other. The cloth produced in this way is not nearly so fine
and uniform in texture as the famous Uganda bark-cloth, but it is
quite soft, and, above all, cheap.
Now, too, I examine the mallet. My craftsman has been using the
simpler but better form of this implement, a conical block of some
hard wood, its base—the striking surface—being scored across and
across with more or less deeply-cut grooves, and the handle stuck
into a hole in the middle. The other and earlier form of mallet is
shaped in the same way, but the head is fastened by an ingenious
network of bark strips into the split bamboo serving as a handle. The
observation so often made, that ancient customs persist longest in
connection with religious ceremonies and in the life of children, here
finds confirmation. As we shall soon see, bark-cloth is still worn
during the unyago,[52] having been prepared with special solemn
ceremonies; and many a mother, if she has no other garment handy,
will still put her little one into a kilt of bark-cloth, which, after all,
looks better, besides being more in keeping with its African
surroundings, than the ridiculous bit of print from Ulaya.
MAKUA WOMEN