tion of the development of pain the­ories and mechanisms, including the gate theory and that of central mod­ulation of pain, with clinical applica­tions. The chapter discusses the phe­nomena of referred and projected pain, and mechanisms for pain perception. References are extensive and the rec­ommended reading is up-to-date.

Chapter Four, "Assessment of Musculoskeletal Disorders," presents a systematic, thorough outline for tak­ing a history and evaluating a patient (formatted in part after Cyriax). This evaluation sequence is subsequently applied to each peripheral joint as it is discussed in later chapters. The pro­posed method will serve well as a guide for the general therapist, but would not be as useful for the hand specialist.

Chapter Six describes and illus­trates peripheral-joint mobilization techniques, specifying that this is sim­ply a form of passive movement (re­member that a detailed rationale for joint mobilization was given in an ear­lier chapter). The authors include an interesting history of joint manipula­tion from the time of the "bone set­ters" to the present, drawing the con­clusion that the physical therapist is the logical practitioner to be treating manipulatively.

An excellent chapter is devoted to automobilization techniques in the ex­tremities. These techniques are not de­scribed as they apply to the finger joint, and I question whether this is even a practical consideration. The illustra­tions and descriptions are given for the shoulder only; I have personally found these a very useful addition to the shoulder patient's home program.

A short chapter on friction mas­sage and a rather lengthy chapter on relaxation follow. As hand therapists we must, of course, be cognizant of the fact that relaxation may indeed en­hance progress. But in this day of spe­cialization, training in the techniques covered here may well fall into anoth­er's realm of expertise.

Part Two presents the clinical ap­plication of the foregOing material to specific peripheral joints. For each re­gion the following areas are covered: review of functional anatomy and bio- ' mechanics, history and examination, lesions common to the region, and suggestions for management of spe­cific lesions. The section on the shoul­der and shoulder girdle describes the biomechanics of the region; the lesions discussed are impingement syn-

132 JOURNAL OF HAND THERAPY

drome, adhesive capsulitis, and acute bursitis. In the chapter on the wrist and hand complex, the greatest em­phasis is placed on joint and ligamen­tous architecture. The extensor mech­anism is described, as are the modes of prehension and grip. The common lesions discussed are, of course, all nonsurgical in scope: carpal tunnel syndrome, Colles' fracture, de Quer­vain's disease, scaphoid fracture, and osteoarthritis of the thumb. These may be the hand and wrist cases seen most often in the general physical therapy department, but they undoubtedly comprise a much smaller part of the hand therapist's practice.

This is not a reference text for the hand! It is, however, a valuable library addition for therapists who, in their practices, treat numbers of nonsurgi­cal hand patients with accompanying disorders of the elbow and shoulder. It is also a good review and update for those of us who make use of trans­cutaneous electrical nerve stimulation and other pain-decreasing modalities, as well as joint mobilization, in our treatment.

Virginia Feiler, RPT

Differential Diagnosis in Physical Therapy: Musculoskeletal and Sys­temic Conditions. By Catherine Cavallaro Goodman and Teresa E. Kelly Snyder. Philadelphia, W.B. Saunders, 1990. 407 pp. $33.95.

Catherine Goodman, MBA, PT, and Teresa Snyder, RN, MN, have ad­dressed a new need in this text. The need is one felt by independent phys­ical or occupational therapy practition­ers. Currently, 24 states permit direct patient access to physical therapists without the traditionally requir,ed physician referral. Conducting such an open practice thrusts a greatly ex­panded responsibility upon the inde­pendent therapist. It becomes the therapist's critical duty to thoroughly screen each patient, not to make a de­finitive medical diagnosis, but to rule out any medical condition that may be contributing to the patient's present­ing complaint. This onus is indeed a heavy one.

A superficial reader might at first regard the work as a Reader's Digest version of how to be a doctor in 400 pages. However, such a cynical char-

acterization is not justified. A closer reading reveals a conscientious effort to present a complicated topic in a practical format. .

The purpose of Differential Diag­Ilosis in Physical Therapy is clearly spelled out in the introduction: to proVide in­dependent therapists with a guide to recognizing the existence of nonmus­culoskeletal illnesses that may mimic or exacerbate musculoskeletal com­plaints. It is the goal of the authors to instruct the reader in a systematic ap­proach to investigating and ruling out medical problems that, prior to inde­pendent practice, were routinely the exclusive province of the referring physician.

To an extent, the text succeeds. The initial section, devoted to history taking and interviewing, is one of the most valuable contributions. A well­organized approach is described that, if diligently followed, should lead one toward the source of a presenting complaint. An additional strong point is Goodman and Snyder'S emphasis on the absolute need for an independ­ent practitioner to maintain a low threshold for making a referral to a physician for a more comprehensive evaluation of a suspected underlying medical condition. This admonition is made repeatedly, as it should be.

In each subsequent chapter, the underlying principle running throughout is that each body system has potential to give rise to symptoms, especially pain, and particularly back pain, perceived as musculoskeletal complaints. The book is organized by­chapters discussing signs and symp­toms of individual systems (for ex­ample, cardiovascular signs and symptoms or gastrointestinal signs and symptoms). In each case, major phys­iologic principles are presented along with common problems.

In any survey text of this type, the author must make the difficult de­cision about how much depth and de­tail are appropriate, as each chapter could be expanded to the size of a tome or reduced to a scanty outline. In this regard the writers have offered an adequate rendering.

Differential Diagnosis is readable but falls short of compelling. There is little specific material to recommend it to the hand therapy community. Those treating the entire upper quarter may­find the message more useful.

Kenneth Flowers, RPT