Therapeutic effectiveness of a Society of

Musculoskeletal Medicine (SOMM) approach

to mobilization versus a Maitland approach
in the treatment of neck pain: A comparative
pilot study
Jennifer Hall 1 , Angela Clough 2, Michael Traynor 3
1

BMI Healthcare, The Priory & Edgbaston Hospitals, Birmingham, UK, 2Department of Sport, Health and
Exercise Science, The University of Hull, Yorkshire, UK, 3School of Health and Education, Middlesex University,
Highgate Hill, London, UK
Objective: A pilot trial to compare a Society of Musculoskeletal Medicine (SOMM) approach to mobilization
with a Maitland approach in neck pain patients.
Method: Participants were adults with neck pain (central, bilateral, or unilateral neck or scapula pain, without
neurology). Five participants were randomly assigned to a SOMM approach or a Maitland approach of
manual therapy. All received four weekly treatments and proven adjunct therapies. Pain (visual analogue
scale) and function (neck disability index) were assessed before each treatment and after the fourth.
Results: Irrespective of approach all subjects demonstrated a reduction in pain (to a clinically important level)
and an increase in function. The low power of this pilot did not permit differences between groups to be
tested.
Discussion: It would be feasible to investigate these promising trends with a future trial, providing two main
limitations are addressed; firstly, recruitment and secondly, the consent process.
Keywords: Neck pain, Mobilisation, Orthopaedic medicine, Maitland, Pilot study

Introduction
Neck pain affects 54% of the population at some point
during their lives.1 It is a major cause of morbidity and
is costly in terms of visits to healthcare providers and
loss of productive capacity.2
Physiotherapists often use manual therapy in the
management of neck pain. Manipulation and mobilization are both forms of manual therapy that differ in
locus of control, amplitude, and velocity.3 Both are
equally efficacious.4 Manipulation is a small amplitude,
high-velocity thrust at the end of range and is technically out of the control of the patient. It may be associated with a risk of cerebrovascular event, albeit one that
cannot be quantified from the existing literature.5,6
Contemporary research has focused on the comparison of individual mobilization techniques,
asking which is best? This question is largely
Correspondence to: Jennifer Hall, BMI Healthcare, The Priory & Edgbaston
Hospitals, Birmingham, B5 7UG, UK.
Email: jennifer.hall2@bmihealthcare.co.uk

52

unanswered7 and has been criticized as not being a

true reflection of clinical practice, where a progression
of several mobilisation techniques is commonly used.
This progression, or selection of techniques has been
termed an approach.8 A recent Cochrane review
suggested future research compare the most viable
approaches.4
Physiotherapy practice in the United Kingdom
(UK) has two main approaches: Maitland and
Society of Musculoskeletal Medicine (SOMM), previously The Society of Orthopaedic Medicine.9 The
former was developed by Geoffrey Maitland, an
Australian physiotherapist whose assessment focus is
on the intervertebral levels, (specifically the facet
joints) and the identification of the symptomatic
level.3 Treatment is then targeted at the symptomatic
level. Maitland offers an empirical guideline, a
sequence of independent treatment techniques based
on the distribution of patient symptoms, suggesting
the technique applicable in each case.3 The clinician

W. S. Maney & Son Ltd and the British Institute of Musculoskeletal Medicine 2013
DOI 10.1179/1753615413Y.0000000017

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Therapeutic effectiveness of a SOMM approach to mobilization versus a Maitland approach in the treatment of neck pain

decides (based on clinical presentation) the grade at

which to deliver the technique from five distinct
grades. From here on in, this approach will be referred
to as the Maitland approach. Traditionally the
Manipulation
Association
of
Chartered
Physiotherapists (MACP), one of the largest professional bodies in postgraduate education in the
UK, based its curriculum on this approach.9
The SOMM approach is based on the work of
James Cyriax, an English orthopaedic physician who
was interested in patients with pain of a musculoskeletal origin that did not require surgery.10 In contrast to
the former approach, assessment considers systematically applied selective tension, active and passive physiological movements, and when indicated resisted
movement,11 but not level identification specifically.
In cases pertaining to the spine (that are not the
result of arthritis) the traditional model is of disc displacement as the pain generator.11 Treatment is targeted at the cervical spine as a whole. Three grades
of movement are available with traction used in conjunction and discreetly.11 From here on in this
approach will be referred to as the Society of
Musculoskeletal Medicine (SOMM approach).
The Society of Musculoskeletal Medicine (formerly
called The Society of Orthopaedic Medicine) is a
recognised provider of postgraduate education and
has based its curriculum on the work of Cyriax.11
To date, no studies have directly compared the two
approaches of SOMM and Maitland and only a
paucity of well designed trials have compared mobilisation techniques.
In view of this uncertainty and lack of evidence for
each approach, this pilot study was designed to
compare the effectiveness of a SOMM approach to
mobilisation versus a Maitland approach. The null
hypothesis being tested was that there is no significant
difference in pain and function between persons with
neck pain after treatment with a SOMM approach
to mobilisation compared to persons treated with a
Maitland approach.

Method
A quasi-experiment with a between subjects design
was used to examine the effects of mobilisation
approaches on pain intensity and function over 1
month. A quasi-experiment allows examination of
causality in a clinical setting not conducive to controls.12 A purposive sample was tested in a partially
manipulated setting with the inclusion of postural
and exercise advice, both proven co-interventions.7

Setting
Patients were recruited from two private musculoskeletal clinics where the researcher is employed.

Participants
Inclusion Criteria: to be eligible for the trial patients
(1870 years) had to be suffering with symptoms
located as either central, bilateral or unilateral neck,
or scapula pain for at least 1 week.
Exclusion Criteria: patients were excluded if they (1)
did not give informed consent, (2) had red flags for a
serious spinal condition (e.g. tumour, infection, osteoporosis, and fracture), (3) had pain distribution outside
the described area, (4) were in hyperacute pain, (5) displayed a capsular pattern (equal limitation of side
flexion and rotation, some loss of extension and
usually full flexion, (6) had undergone cervical spine
surgery, (7) had a positive neurological examination
(diminished upper reflexes, sensation, or strength),
(8) were taking anticoagulant medication or had a
blood clotting disorder, (9) were diagnosed with
inflammatory arthritis, (10) were taking long-term
steroids, (11) had suffered an upper motor neuron
lesion, or (12) recent trauma, or (13) drop attacks,
(14) were at risk of upper cervical instability as associated with Downs syndrome and rheumatoid arthritis,
(15) had symptoms that had progressively worsened
over 3 months, (16) were pregnant, (17) had dizziness
associated with vertebrobasilar insufficiency/carotid
artery dysfunction, and (18) or presented with nonmechanical features to pain/suspicious features such
as: pain not altered by posture or activity, side
flexion away from pain as the only painful movement,
T1 weakness, history of tumour (breast, bronchus, or
prostrate), arm pain under the age of 35 years,
double root palsy.3,11

Sampling approach

Figure 1

Block randomisation sequences.

After attaining written consent, subjects were randomly allocated to one of the two treatment
approaches using block randomisation. A randomisation list was constructed by randomly choosing
from a list of potential blocks.13 Blocks of four gave
six possible sequences of allocation. Each block comprised of the number of treatments, twice, as is
common practice. Each block was numbered 16
(Fig. 1).

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The order of the blocks was determined by an

independent party using a random numbers table.14
A pin was placed into the random numbers table
by an independent party. From the number identified, working towards the right, numbers from 1
to 6 were recorded in the order that they arose.15
Each number, 16 corresponded to an allocation
sequence block. The allocation sequence was then
constructed by noting down the blocks that correspond to the sequence of numbers, determined by
the random numbers table. This allocation sequence
was transferred to postcards (each card had an O
(SOMM approach) or M (Maitland approach)
marked on) that were placed into numbered opaque
envelopes and aligned in order by the experimenter.
The allocation sequence was ensured by the treating
therapist picking the consecutive numbered, opaque
envelope. Subjects remained blind to treatment
allocation.

information sheet and given a copy of the consent

form for their own reference.
The treatment approach allocation was then
obtained by the treating physiotherapist who asked a
member of the administration team to open the
opaque envelope from the sequenced envelopes and
read the treatment allocation. The therapist then
returned to the patient and followed the indicated
approach as detailed for their four weekly sessions
(where needed).

SOMM approach
Mobilisation techniques were applied by the treating
physiotherapist in accordance with an Orthopaedic
Medicine approach for Clinical Model II; central,
bilateral or unilateral neck, or scapula pain.11
The grade of mobilisation applied was determined
by the treating physiotherapist. Two grades of mobilisation exist and are defined as; Grade A, a passive,
active, or active/assisted mobilisation performed
within the mid existing range and Grade B, movement applied to the end of range.11 Both grades are
used with the purpose of pain relief and in addition
Grade B is used to improve function.

Procedure
This study was conducted by two physiotherapists, one
of which (the author) also conducted data collection
and analysis. Both physiotherapists (2.5 and 6 years
qualified) undergraduate education was based on
Maitland philosophy. Post graduation both physiotherapists attained the Society of Orthopaedic
Medicines Part A qualification pertaining to neck
and upper limb (recognised by the Chartered Society
of Physiotherapy and the International Federation of
Manipulative Therapists). Patients are referred to the
clinic via consultant, general practitioner, or self-referral. Upon entering the department, patients identified
as having neck pain (all patients are categorised by
region of pain by the administration team as standard
practice), were given a pre-treatment neck disability
index (NDI) questionnaire (standard practice) and
an information sheet regarding the trial by a member
of the administration team. The information sheet
had been tested for clarity prior to the trial and was
Fog Scored 8.68, comparable with a popular novel
(http://www.nres.nspa.nhs.uk/rec-community/gui
dance). Dependant on time of patient arrival, 5
minutes or more was allotted for this process.
Patients were then met by one of the two treating
physiotherapists and taken to a treatment room. A
subjective history was taken, including a pre-treatment visual analogue scale (VAS), followed by an
objective examination (observation, neurological,
and movement examination only). Patients who met
the inclusion criteria were invited to participate and
where willing, the information sheet was discussed
and any questions answered. If happy to proceed,
the patient and treating physiotherapist signed the
consent sheets. Patients were requested to keep the

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Maitland approach
The subjects cervical spines were assessed by the treating therapist for segmental mobility using passive
physiological accessory vertebral mobilisations.
Painful or hypomobile levels were identified and
noted mentally (standard practice), together with the
grade of mobilisation deemed appropriate for treatment. Four grades of mobilisation have been defined
by Maitland:3 Grade I is a small amplitude movement
near the starting position of the range, Grade II is a
large amplitude movement which carries well into
range, it can occupy any part of the range that is free
of any stiffness or muscle spasm. Grade III is a
large amplitude movement but one that does move
into stiffness or muscle spasm, and Grade IV is a
small amplitude movement stretching into stiffness
or muscle-spasm.3 Depth of treatment was determined by pain, musclespasm, and any other physical
restriction to movement as identified in the assessment
of the cervical spine.3
Technique of mobilisation was then applied according to Maitlands recommended approach, based on
the distribution of subject symptoms being unilateral
or bilateral. The technique of traction was excluded
as it is recommended that a halter is used and this is
not equipment held within the clinics.
Before each of the four weekly treatment sessions,
subjects completed a VAS. Following the fourth
session, a post-treatment NDI and VAS was completed prior to leaving the treatment room. In addition
to being treated in accordance with the treatment

Hall et al.

Therapeutic effectiveness of a SOMM approach to mobilization versus a Maitland approach in the treatment of neck pain

approach, subjects received postural and exercise

advice as deemed appropriate by the treating therapist.
Postural and exercise advice are proven conservative
interventions for neck pain.7

Data collection
Outcome measures
Pain intensity was measured via VAS a 100 mm line
with 0 at one end representing no pain and 10 at
the other representing pain as bad as it possibly
could be. The VAS is a reliable and valid measure of
pain intensity.16 Patients were asked to place a perpendicular mark on the line corresponding to the intensity
of their symptoms. This was then measured to the
nearest millimetre. A change in pain intensity of
>20 mm was accepted as clinically important.17
Function was measured via the NDI, the standard
measure within the clinics. The NDI is scored from 0
to 50, higher scores representing greater disability.
Actual scores are divided by the total possible score
and multiplied by 100 to be expressed as a percentage.
The NDI is a reliable and valid assessment of disability in patients with neck pain.18
Data analysis pilot study
This was a pilot study of inherently low power.
Subjects pre-treatment data were checked to see if
assumptions of parametric data were met via visual
checking of frequency distribution. The data recorded
pre-treatment were not found to be parametric and so
subjects clinical and demographic data (sex, age, duration of symptoms, VAS, and NDI) pre-treatment were
compared between groups using MannWhitney tests.
Due to the lack of subjects and incomplete followup (one subject in the SOMM approach) it was not
possible to run inferential statistics on post-treatment
data. Where possible, data were analysed by descriptive statistics and where this was not possible the
results were conveyed by the actual observed values.
For each treatment approach, the means and standard
deviations (where able) were calculated for the change
scores from pre- to post-treatment for each outcome
measure.
Intention to treat analysis was not possible due to
the small numbers that completed the trial, as
inclusion would have distorted the results and this is
acknowledged as a limitation.
Ethical considerations
Ethical approval was granted by the Middlesex
University Health Studies Ethical Sub-Committee.
Approval to conduct the research within the two
private musculoskeletal clinics was provided by the
Physiotherapy Manager of both sites. All subjects provided written informed consent. This process was
facilitated by patients being given information sheets
regarding the study and time to read them, prior to

meeting the physiotherapists. Additionally, time was

allowed for the information sheets to be discussed
and any questions answered. Confidentiality and
anonymity was maintained by the numerical coding
of subject data prior to analysis. All patient notes
and un-coded data were stored in secure filing as per
standard department practice.

Results
The results of this pilot study were limited by the extremely small sample size and incomplete follow-up.
Consequently, examination of differences between
the two approaches via inferential statistics was not
possible. The results will be presented descriptively
where possible, or by presentation of the observed
values. The implications of the findings for the main
trial will be discussed.
Due to one group having two patients at the start
and only one at first follow-up; the missing case was
removed from the post-treatment data values when
presented descriptively so as not to exaggerate or
underestimate the limited findings. In the main study,
analysis would be by intention to treat as a greater
sample would enable this.

Sample description
Five patients (two males and three females; 2742 years
old; mean 34; SD 6.40) participated in this study, three
were randomised to the Maitland Approach and two to
the SOMM approach. One participant from the
SOMM group was lost to follow-up. The duration of
symptoms at presentation ranged from 3 to 19 weeks.
All patients had symptoms located in a right, unilateral
distribution, with one also having centrally located
symptoms. None of the patients reported adverse
effects from mobilisation. T-tests found that no significant differences were found between groups (P > 0.05)
for patients demographic and clinical data at baseline,
as shown in Table 1.

Post-treatment findings
Irrespective of treatment approach, all patients exhibited a reduction in pain and an increase in function as
indicated by their post-treatment VAS and NDI scores,
Table 1 Means (standard deviations) of patients
demographic and clinical data of each group at baseline

Variables
Sex (male/
female)
Age (years)
Symptom
duration
(weeks)
Pre-NDI (%)
Pre-VAS (mm)

Orthopaedic
approach (n = 2)
1/1
36 (4.243)
9 (4.243)

24 (11.314)
51.5 (21.920)

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Maitland
approach (n = 3) P-value
1/2
32.67 (8.145)
11.33 (8.021)

0.564
0.767

23.33 (4.163)
42.33 (16.623)

1.000
0.564

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underpinning these guidelines. In the cervical and

lumbar spine the need to adopt the recommended preferred technique has been challenged, as pain has
been shown to reduce regardless of whether the preferred or any other mobilisation technique is
employed.1921 Additionally, current literature does
not support the symptomatic joint level identification
fundamental to the Maitland approach as pain has
been found to reduce whether mobilisations are
directed at a symptomatic or an asymptomatic
level.22,23
It is apparent from mobilisation literature that
despite heterogeneity regarding methodology, patient
outcomes improve following mobilisation.4 Although
no conclusions can be drawn from the presented
data, trends shown are similar to those in the
literature.4
The pilot study shows several limitations. First, low
recruitment meant between group differences could
not be examined and so no conclusive results can be
drawn. Secondly, no control group was possible as
the study was conducted within private practice and
to deny treatment would have been unethical;
however, current work in this field does not include
control groups.4 Thirdly, it was felt that the consent
process should be adapted to allow more time and
independent consideration over participation: on
occasions, the administration team forgot to give
patients the information to read. Reading time then
ate into treatment time. In a future trial, patients
time to read could be separated from treatment time
by either posting the information to be read prior to
a patients first attendance or by extending patient
appointment times. Fourthly, regarding blinding,
while the treating therapist could not be blinded to
the approach given, the scale of the study did not
permit blinding of the analyst; a larger scale and
employing a statistician would permit this. Fifthly,
we recognise that the congruent therapies were not
standardised: it has been shown that mobilisation,4
postural advice, and exercises7 work independently.
Thus our study design limited the ability to determine
the effects of each mobilisation approach. To overcome this flaw an improved trial design might incorporate the use of a standard advice sheet on posture
given to all participants and an agreement between
the treating therapists on a standard set of exercises.
Conducting the pilot trial has fulfilled its purpose in
testing the feasibility for a definitive trial and allowing
identification of adaptations to improve its conduct.
Based on standard values; statistical significance (P
level) 0.05, power 0.8, a minimum of 28 participants
per group are required.20 It is estimated that if this
design were used but the number of physiotherapists
participating was extended to 6, it would take 3.1
years to achieve the number of subjects identified.

Table 2 Observed values for outcome measure before and

after treatment

Orthopaedic case 1
Maitland case 1
Maitland case 2
Maitland case 3

Pre Rx
NDI
(%)

Post Rx
NDI (%)

Pre Rx
VAS
(mm)

Post Rx
VAS
(mm)

32
22
28
20

6
14
1
8

67
60
40
27

3
29
0
0

respectively. The observed values for each outcome

measure are shown in Table 2.
The means and standard deviations (where possible)
of the change scores of each outcome measure for both
groups are shown in Table 3.
A clinically important (>20 mm) reduction in pain
was seen within both groups. It was not possible to
run accurate parametric or non-parametric tests on
such a small sample and so between group differences
are not presented for this pilot study.

Discussion
The purpose of this study was to conduct a pilot for a
future trial that can test the null hypotheses; that there
is no significant difference in pain or function between
patients with neck pain treated with an SOMM
approach to mobilisation compared to a Maitland
approach. The literature search conducted did not
find any study that compared mobilisation
approaches.
The results of this pilot study exhibit positive effects
on pain and function immediately after treatment, irrespective of treatment approach employed, and cumulatively over a 1-month period in patients with
central, bilateral or unilateral neck, or scapula pain.
The low power of this pilot study did not permit
differences between groups to be tested, but within
both groups a clinically important reduction in pain
and an increase in function were shown. It remains
possible that these findings are the result of chance.
In contrast to the Maitland approach, the SOMM
approach, does not include symptomatic joint level
identification, but targets the cervical spine as a
whole. According to Maitland, the preferred mobilisation technique (determined by symptom distribution)
is targeted at the symptomatic level, previously
identified by joint identification testing. The current
literature does not support the decision making
Table 3 Means (standard deviations) of change scores
between pre-treatment and post-treatment for each outcome
measure

56

Outcome
measure

SOMM approach
(n = 1)

Maitland approach
(n = 3)

VAS (mm)
NDI (%)

64
26

32.667 (6.658)
15.667 (10.012)

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The data collection period might be reduced by the

inclusion of more physiotherapists.

10

Conclusion

11

This pilot study has shown the methodology is largely

suitable for the population and no adverse events were
reported. The main limitations were low recruitment
and timing of the consent process which can be overcome with necessary changes in the planning of a
larger study.

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