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Chapter Four

c0020 The principles of combinedmovement assessment

Chris McCarthy

C H A PT E R C O N T E N T S

u0010 Subjective examination . . . . . . . . . . . . . . . 52u0015 Physical examination . . . . . . . . . . . . . . . . 54

u0020 Observation . . . . . . . . . . . . . . . . . . . 54

u0025 Functional demonstration . . . . . . . . . . . 54

u0030 Active movements . . . . . . . . . . . . . . . 56

u0035 Degree of symptom reproduction deemedacceptable . . . . . . . . . . . . . . . . . . . . 57

u0040 Prime movement and prime combination . 57

u0045 Muscle assessment . . . . . . . . . . . . . . 59

u0050 Passive movement and mini-treatments . 59

u0055 Assessing for the suitability of manipulativethrust techniques . . . . . . . . . . . . . . . . 60

u0060 Cervical spine case study . . . . . . . . . . . . . 62

u0065 Lumbar spine case study . . . . . . . . . . . . . 65

p0070 The purpose of clinical examination is not simply togather as much information as is possible in thetime available. Often the inexperienced cliniciancan spend an entire examination gathering data withlittle evaluation of its clinical relevance. As manualtherapists we provide our patients with incrediblysensitive examinations. The volume and sophistica-tion of our examination procedures is immense.However, we may occasionally fail to grasp theproblem of specificity. We must find a balancebetween gathering enough information to prioritizethe patient’s most significant dysfunction whilst

not being distracted by the less relevant dysfunc-tions we discover.p0075 We are essentially searching for the patient’s

‘predominant dysfunction or fault’ in order to directour intervention towards it. The process of ranking

the importance of our findings requires that we

test the hypothesis of ‘predominant dysfunction’throughout our interaction with our patients. Inshort, during the examination of patients we areconsidering if our hypothesis will guide treatmentmore effectively than the next most likely hypothe-sis. In addition, during treatment we should becontinually considering if our chosen interventionis in fact more effective than the next most likelyintervention. This process of analytical assessmentis not new and was advocated by Maitland (1986)and Grieve (1988, 1991) over 30 years ago.

p0080Simply gathering huge quantities of informationthat is neither discriminatory nor influential in man-agement represents a failure in our duty of care to

our patients. The purpose of clinical examinationis to evaluate valid information that will facilitatethe prioritization of likely diagnoses and strategiesof management. In other words, our duty to ourpatients is to ensure we are identifying their pre-dominant dysfunction/fault and to continuallyensure that we are providing the most effectivemanagement strategy at the time. Ensuring weadhere to this principle will ensure we are facilitat-ing recovery as quickly as possible. It could beargued that the primary objective of manual therapyis to facilitate recovery as quickly as possible. Onthe whole, the conservative management of mostmusculoskeletal dysfunctions will facilitate recov-

ery. Manual therapy’s role is in the acceleration of this process. Thus, ensuring our treatment choiceis making more difference, more quickly than thenext most likely choice of treatment is a crucialresponsibility.

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s0010Subjective examination

p0085 During theinitial consultationthe therapistwill beginto form an impression of the patient based on verbal

and non-verbal communication. Expert cliniciansform an impression regarding diagnosis, managementand expectations of the patient very quickly. Mixedmethods of clinical reasoning are utilized in this pro-cess as outlined in Chapter 3.

p0090 The diverse nature of musculoskeletal dysfunctionrarely allows the definitive identification of definitivepatterns of presentation. The clinician is frequentlyrequired to make reasoned judgements as to the pre-dominant dysfunction from several alternatives.Some of the typical judgements required are listedbelow. This is by no means an exhaustive list. Theprocess of establishing that one treatment approachis superior to another begins during the initial consul-

tation with the patient. Early in the initial interviewwith a patient, the therapist should look for answersto the following questions.

s0030 Is this patient’s presentation suitable for amanual therapy approach?

u0070 • Is this patient presentation sounding like I shouldexplore further with an assessment of biomechanical dysfunction?

u0075 • Does this patient’s presentation suggest that amore psychosocial approach may elicit effectivetreatment strategies?

s0035 Which patterns of presentation does this presentation match with?

u0080 • Does the presentation fit a pattern of presentation I have encountered before?

u0085 • If so, what is it that makes this patient’spresentation fit this pattern better than the nextmost likely pattern?

u0090 • What questions and tests do I need to use to testthis hypothesis?

s0040 Does the functional fault have a directionalquality?

u0095 • In what combination of positions are symptomsreproduced?

u0100 • In what combination of positions are symptomsreduced?

s0045 What is the likely source of the directional fault?

u0105 • Does the presentation have predominantlyarthrogenic features?

u0110• Does the presentation have predominantlymyogenic features?

u0115• Does the presentation have predominantlyneurodynamic features?

s0050 Is this predominantly a control orimpairment fault?

u0120• Does the presentation suggest a dysfunction incontrol of movement?

u0125• Does the presentation suggest a dysfunctionassociated with limitation (or impairment) of movement?

s0055 Is it acceptable to reproduce symptoms – arethey ‘severe’?

u0130• Is the faulty position producing severe pain?

u0135• Is positioning in the faulty position likelyto cause alatent or long-term exacerbation of symptoms?

u0140• Is there a position that will allow examination

and treatment whilst avoiding unacceptablesymptom reproduction?

u0145• Is it likely that caution needs to be taken due to apatho-anatomical reason that would make theuse of combined movement theory (CMT)unwise? See the contraindications to manualtherapy in the box below.

s0060What is the predominant pain mechanism?

u0150• Is the patient’s predominant pain mechanism:nociceptive, peripheral neurogenic, centralsensitivity, autonomic or affective?

b0010

p0215 A proforma planning sheet can be found on the CD. See

Figure 4.1.

p0370Prior to the conduct of a physical examinationusing the CMT approach the patient should beinformed of your plans and the risks and benefitsof the approach against other approaches.

p0375By examining the expectations of the patientthe suitability of utilizing a CMT approach can beestablished. If the patient’s expectations of treat-ment are radically different to the therapist’s, a

discussion of future management should ensue. A detailed biomechanical assessment of spinal dys-function may be unwarranted if the patient isexpecting and consenting only to generic adviceand exercise.

S E C T I O N O N E Combined Movement Theory

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Clinical pointb0015

b0015 Contraindications to spinal passive movementthat takes a joint to the end of passive range or

thrust techniques

s0065 Bone

p0220 Any pathology that has led to significant bone weakening:

u0155 • Tumour, e.g. metastatic deposits

u0160 • Infection, e.g. tuberculosis

u0165 • Metabolic, e.g. osteomalacia

u0170 • Congenital, e.g. dysplasias

u0175 • Iatrogenic, e.g. long-term corticosteroid medication

u0180 • Inflammatory, e.g. severe rheumatoid arthritis

u0185 • Traumatic, e.g. fracture

s0070 Neurological

u0190 • Spinal cord compression

u0195 • Cauda equina compressionu0200 • Nerve root compression with increasing

neurological deficit

s0075 Vascular

u0205 • Aortic aneurysm

u0210 • Bleeding into joints, e.g. severe haemophilia

u0215 • Cervical artery dysfunction (Kerry et al , 2008a, 2008b)

s0080 Relative contraindications

p0300 Special consideration should be given prior to the use

of spinal manipulative thrust techniques in the following

circumstances:

u0220 • Adverse reactions to previous manual therapy

u0225 • Disc herniation or prolapse

u0230 • Inflammatory arthritides

u0235 • Pregnancy

u0240 • Spondylolysis

u0245 • Spondylolisthesis

u0250 • Osteoporosis

u0255 • Anticoagulant or long-term corticosteroid use

u0260 • Advanced degenerative joint disease and spondylosis

u0265 • Psychological dependence upon spinal manipulative

thrust techniques

u0270 • Ligamentous laxity

u0275 • Arterial calcification

u0280 • Hypertension(diastolic>95) in cervicalmanual therapy

(See Gibbons & Tehan, 2001a,b; Grieve, 1991.)

s0085 Is the patient suitable for a biomechanicalassessment of their movement fault?

p0380 Patient presentations suggestive of a predominantmechanical influence on symptoms are suitable fordetailed biomechanical assessment and treatment.

Presentations that do not feature mechanical/move-ment influences on symptomology suggest thatspecific positions and movements may not be the pre-dominant influences to be addressed during examina-

tion and treatment. Thus, patients who have constantsymptoms, regardless of positioning, will be unlikelyto benefit from management with a positional bias.Patients with central sensitization or inflammatoryneurogenic pathology (‘irritable’ patients (Maitland,1985) have no mechanical predominance.

s0090 How acceptable is it to reproduce symptoms? p0385Patients, seeking manual therapy, present with pain

and largely judge their improvement by an ameliora-tion of their pain. In the process of assessing theeffect of testing and treatment, changes in pain areassessed. However, in cases where pain is severe, itis unacceptable to reproduce pain and inappropriateto treat an underlying mechanical dysfunction whilst

reproducing pain. Thus, prior to any physical testingthe therapist must be clear regarding the degree towhich pain is to be reproduced during their interac-tion with the patient. In certain presentations itmay be deemed acceptable to fully reproduce theminor discomfort the patient is seeking help for, inorder to fully relieve it. However, in situations wherepain is severe this is unacceptable. Using positionsthat can reduce the likelihood of reproducing severepain is one of the key advantages of CMT.

b0020Clinical relevance

p0390If it is not acceptable to reproduce symptoms, the

condition is severe. If it is acceptable it is not. Use anominal (yes/no) approach to this decision and your

clinical reasoning will be decisive and more reasonable.

s0095What is the functional demonstration of the positional fault?

p0395Patient presentations, suggestive of the suitability of aCMT approach, have symptoms predominantly influ-enced by specific positions or movements. Patientscan often demonstrate these movements or positionsand reproduce themin the course of replicatinga func-tional activity. For example, patients with anteriorstretch patterns of the mid cervical spine often relatesymptom reproduction with activities inducingipsilat-

eral lateral flexion and rotation, e.g. reversing the car.The monitoring of change in the functionaldemonstra-tion, during examination and treatment is a crucialmonitor of treatment effectiveness. Again, theconcept of a functional demonstration is a long-

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established tenet of the Maitland concept (Maitland,1986) and at the heart of CMT.

s0100 What is the region of the spine that is likely tobe faulty?

p0400 The biomechanical interpretation of patient presen-tation can allow the therapist to judge the locationof regions of dysfunction. Careful questioning canelicit functional activities that influence specificregions of the spine. For example, the influence of breathing on thoracic movement can provide valu-able inference towards spinal or rib dysfunctions.

s0105 What is the predominant hypothesis for thesource and mechanism of symptom productionand the next most likely hypothesis that will betested against it?

p0405 It is crucial to form hypotheses regarding the under-lying source and mechanism of symptom productionas you recognize presentation patterns. As a pattern

of presentation begins to emerge the use of follow-upquestions will establish a good fit with this pattern.Having identified a match with a recognizable pattern,the manual therapist should test the assumption thatthis hypothesis is predominant by comparing thematch with thenext most likely pattern. For example,having established that a patient’s presentationmatched an ‘arthrogenic’ presentation, one wouldexpect the presentation to be less well matched witha ‘myogenic’ presentation. In order to facilitate thisprocess it can be useful to develop a library of ‘stock’questions and tests for common presentations.

p0410 The use of these strategies will facilitate thetherapist’s reasoning regarding the appropriateness

of using CMT, the most likely hypotheses foraetiology of symptoms, the extent and direction of movements to be included in the examination andmost importantly the starting positions in whichassessment and treatment will be undertaken.

p0415 Figure 4.1 shows a suggested planning sheet for usein clinical reasoning during the CMT examination.

s0110Physical examination

p0420 The objective examination will follow the subjectiveexamination and is conducted in light of the consid-erations and clinical reasoning process outlined in

this book. The object of the physical examinationis not to form a long list of impairments with littleevidence of their relative contribution tothe patient’s dysfunction. The physical examinationshould allow the hypotheses, generated following

the subjective examination, to be tested. Thus, theexamination should be structured to allow this pro-cess to occur. In order to assess the influence of thetesting procedures themselves on a patient’s dys-

function the physical examination should be splitinto components.p0425The order in which components of the examina-

tion are conducted will be guided by the subjectiveexamination. A clinician may hypothesize that thepredominant mechanism of symptom production isrelated to a restriction in articular mobility ratherthan, e.g. a restriction in overlying muscle mobility.In this case, the examination would be structured toexamine the articular system, assess its influence onthe fault, and then assess the muscular influenceand reassess that system’s influence on the fault.In this way, in addition to gathering informationfrom each component of the examination the rela-

tive influence of the components can be evaluated. p0430Each component begins with an assessment of movement fault (using the patient’s functional dem-onstration), testing procedures and a subsequent reas-sessment of functional demonstration. See Figure 4.2.

s0115Observation

p0435Observation of staticposture cangive valuable insightinto the likely mechanical presentation of symptomswith movement.A numberof static features will helpin theinterpretationof activemovement. A deep skincrease may suggest hypermobility at the level whilstflat sections with reduced muscle bulk may suggest

hypomobility. Defined muscle borders may indicatehypertonicity whilst unilateral atrophy may indicatelocal neuropraxia or trophic change. See Figure 4.3.

s0120Functional demonstration

p0440The functional demonstration is the term given tothe combination of plane movements that thepatient has identified to take them into their mostaggravating position. This position identifies themovement fault, whilst the quality, range and speedof movement from neutral into this position andreturn, should be analyzed in depth. The combina-tion of physiological movements that constitute

the functional demonstration will provide invaluableinformation about the starting position that shouldbe adopted for passive movement assessment andtreatment. In addition, the three-dimensional com-ponents of this position will identify the movements


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List your hypotheses for the nature of the condition.

......................................................................................................................................................................................................

............................................................................................................................................................................................................................................................................................................................................................................................................

Which two hypotheses will you test against each other in the initial physical examination?

Primary ........................................................................................................................................................................................

Secondary ...................................................................................................................................................................................

Is the nature of the condition severe?

Yes No

Is the nature of the condition irritable?

Yes No

To what point are you allowing movement to occur?

Before painTo painTo end

What is your functional demonstration/re-test marker?

......................................................................................................................................................................................................

What is the primary pain mechanism of this patient’s condition?

NociceptivePeripheral neurogenicCentralAutonomicAffective

To what extent will you perform a neurological exam?

None requiredLocal peripheralLower motor neuron, upper motor neuron, limbsLower motor neuron, upper motor neuron, limbs and cranial

What is the weighting of the following components of the problem?

%Arthrogenic

Myogenic

Neurogenic

Inflammagenic

Psychogenic

Sociogenic

Pathogenic

Viscerogenic

Osteogenic

Likely first treatment:

In: ...................................................................................................................................................................................................

Will: ...................................................................................................................................................................................................

Comments/cautions:

.............................................................................................................................................................................................................

.............................................................................................................................................................................................................

OBJECTIVE EX AMINATION PLAN

0

50

100

Arthrogenic

Radar plot

MyogenicOsteogenic

NeurogenicViscerogenic

InflammagenicPathogenic

PsychogenicSociogenic

Figure 4.1 f0010 Clinical reasoning form.


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that should be examined in isolation. Change inthe range of movement and pain experienced inthe functional demonstration position will mostaccurately reflect overall improvement in thepatient’s impairment.

s0125 Active movements

p0445 Active movements should be carefully controlled bythe therapist. It is important that the patient movesto a point in range that is appropriatefor their severityand nature. Simply asking a patient to extend their

back will not give adequate guidance about howacceptable it is to reproduce their pain. A patient with very severe pain may be eager to please the therapistand extend beyond the onset of pain causing anexacerbation, or alternatively, may be fearful of

PAIVMS

Mini-treatmentReassess functional

demonstration

PPIVMS


demonstration

Functional demonstration

‘Posterior stretch’

Second hypothesis

‘Myogenic’

Observation

‘Hypertonic musclesipsilaterally’

Active movement

Passive movement

Starting positionPalpation

Muscle stretch


demonstration

Muscle contraction


demonstration

First hypothesis

‘Arthrogenic’

Observation

‘Hypomobile mid cx’

Active movement

Prime movementPrime combination

Passive movement

In the correct starting positionPalpation

Figure 4.2 f0015 A flow chart showing

the suggested compartmentalization

of the physical examination.

The functional demonstration is at

the head of the differentiation. Twocommon differentiations are

displayed: primary arthrogenic versus

primary myogenic.

Figure 4.3 f0020 Active extension, right rotation, showing

hypomobility of L5, L4, with movement (and skin crease)

at L3. IN: standing; DID: active extension of lumbar spine.

Segmental restriction of L4/L5 demonstrated.


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movement and not move to the point that reproducessymptoms. Variability on interpretation of incom-plete commands will lead to difficulties with the reli-ability of testing. Thus, clear commands regarding

how far to move in relation to reproduction of symp-toms should be included in the commands. A decisionabout how acceptable it is to reproduce symptomswill need to have been made prior to undertaking thissection of the examination.

s0130 Degree of symptom reproductiondeemed acceptable

p0450 Having agreed on this the therapist must use clearcommands to instruct the movement conducted:

u0285 • If the agreed degree of symptom reproduction isnil, then at the completion of a combination of

movements, the therapist’s command shouldstate clearly ‘stop before the pain starts’.

u0290 • If the agreed degree of symptom reproduction isfull, then at the completion of a combination of movements, the therapist’s command should be‘move as far as you possibly can’.

u0295 • If the agreed degree of symptom reproduction ispartial then at the completion of a combinationof movements, the therapist’s command shouldbe ‘stop when the pain starts’.

p0470 Good control of symptom reproduction will enablethe combination of movements needed to fullyassess the patient’s movement dysfunction. Disre-gard of this important control will lead to situations

where the patient’s symptoms are exacerbated orunder-evaluated.

b0025 Clinical point

p0475 If the patient has severe pain at rest the examination will

be aimed at finding the movement and position that

most reduces pain and it will typically involve finding

starting positions for assessment and treatment in the

quadrant opposite to the dysfunctional quadrant.

s0135 Prime movement and primecombination

p0480 Whilst observing active movements, particular atten-tion should be paid to ensuring that the patient movesareas of the spine that are impaired. Very often apatient will have developed hypermobility above a

hypomobile section of the spine. The patient can findit difficult to move the hypomobile segments as theymove at areas presenting the least resistance to move-ment and move only at the hyper-mobile segments.

This can lead to a situation where symptoms are notreproduced as the symptomatic levels are not beingtested, during the test movement. False negativescan occur unless this error in clinical reasoning is con-sidered. Consequently, it is important to guidepatients to move at regions you consider likely to besymptomatic during active movement testing. SeeFigures 4.4, 4.5 and 4.6.

p0485The active movement examination is structuredto examine the movements most relevant for thepatient’s impairment. The functional demonstrationwill have provided the examiner with evidence thatcertain movements are more important in reprodu-cing the dysfunction than others. The functional

demonstration position will justify a detailed exam-ination of the three movements that constitute it.The next stage in examining the biomechanical fea-tures of the impairment is to examine each of thethree components of the position to establish which

Figure 4.4 f0025 Active movement of the lumbar spine. Here,

movement of the stiff L4/L5, L5/S1 segment is facilitated

by fixing the sacrum with one hand whilst guiding

movement to the low lumbar spine. IN: Standing, bed

edge support, lumbar extension; DID: active right lateral

flexion, range assessment. Note the wide stance required

to ensure balance.


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two movements are the most important, and withinthese two movements, which is of primary impor-tance or ‘prime movement’.

p0490 The primary movement has an importance withinCMT in both the classification of syndromes and inselection of starting positions for treatment. Themovement itself is defined as being the movementthat either reproduces the patient’s signs and/orsymptoms most completely (when it is appropriate

to do so) or most completely relieves symptoms whenthe condition is too severe to reproduce symptoms.

p0495 Having established the prime movement in oneplane it should be explored by repeating the move-ment when combined with another movement, in

another plane, which will move one side of themotion segment in the same direction.

p0500In a simplified model of spinal biomechanics exten-sion, ipsilateral rotation and ipsilateral lateral flexionwill cause the superior joint facet to move down theinferior segment’s joint facet (see Fig. 4.7). Flexion,contralateral flexion and contralateral rotation willcause the superior facet to move up the inferior seg-ment’s joint facet. For example, right rotation is thepatient’s prime movement, reproducing right-sidedneck pain. Exploring this movement by examiningright rotation in extension and extension in right rota-tion will elicit which combination is the primary com-bination. The prime combination will closely resemblethe patient’s functional demonstration.

p0505The primary combination holds a crucial place inCMT as it is the starting position where passivemovement assessment is conducted. By positioningthe spine in the position of dysfunction the additionof passive movements will be more influential inreproducing symptoms and more likely to altermovement dysfunction than if conducted in a neutralposition. Passive movement conducted in neutral willrarely be sufficient to reproduce symptoms ade-quately. When performedin a position related to dys-function, the application of passive movement ormuscle contraction will provide valuable informationon, notonly thequality and control of movement, butalso the effect of the test on the dysfunction.

p0510Finding the primary combination is the processby which the clinician can be sure that passive

movement testing will be the most informativeand that treatment in this position will have thequickest effect on dysfunction. A two-dimensionalequivalent would be the need to assess and treat apatient with a 10 loss of elbow extension at this

Figure 4.6 f0035 Active, guided low cervical flexion. IN: sitting,

cervical flexion; DID: active assisted left rotation of the low

cervical spine. The patient is given feedback on where to

move.

Right rotationNeutral ExtensionRight rotation

Sensitized nociceptors C6C5

Figure 4.7 f0040 The illustration shows the selective tension

of articular and peri-articular tissue with progressive

addition of three planes of movement. A progressive

increase in anterior stretch is observed with the addition

of extension to right rotation (right rotation being coupled

with right lateral flexion).Figure 4.5 f0030 Active movement of the low thoracic spine.

Here, movement of the stiff T10/T11 segment is facilitated

by fixing the lumbar spine with one hand whilst guiding

movement to the low thoracic spine. IN: sitting, lumbar

neutral; DID: active left rotation, low thoracic range

assessment.


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position, not at 90 of elbow flexion (the equivalentof assessing in neutral).

s0140

Muscle assessment

p0515 The assessment of muscular influences on the spinaldysfunction should involve an assessment of muscu-laractivity (tone)in theprimary combination startingposition. The degree and location of hypertonicitycan be readily palpated in local, deep paraspinal mus-cles and the overlaying, superficial, musculature (seeFigs 4.8 and 4.9). At this point an assessment for trig-ger points (Travell & Simmons, 1998) can be

conducted, followed by an assessment of extensibil-ity (Chaitow, 2006) of the superficial phasic musclesthat have a tendency to become hypertonic in thepresence of spinal pain. See Table 4.1.

p0520During this process, hypertonic muscles are pas-sively lengthened either locally, globally or both anda temporary reflexogenic reduction in muscular activ-ity can be induced. Consequently, these tests areeffectively mini-treatments of the muscular system.

p0525The effect of this mini-treatment on the patient’sfunctionaldemonstration can be immediately assessed.In this way the relative contribution of the myogenicsystem can be assessed against the arthrogenic systemby mini-treating first one system and then another.See Figures 4.10 and 4.11.

s0145Passive movement andmini-treatments

p0530Having established the optimal position to inducepassive movement at the motion segments movingdysfunctionally, an assessment is made to determinewhich passive movement will be the most effective

Figure 4.8 f0045 Palpation of anterior paraspinal muscles,

fascia and neurovasular structures. IN: supine, neutral;

DID: palpation of anterior low cervical musculature.

Special care must be taken to ensure that the flat of the

thumb is used – to avoid painful pressure.

Figure 4.9 f0050 Palpation of upper thoracic soft tissue tone.

IN: prone, neutral; DID: soft tissue tension palpation,

upper thoracic spine. Firm pressure will be needed to pick

and work through the superficial musculature. Bands of

resistance to movement will be palpated.

Table 4.1 t0010Listing the musculature that becomes over

or under-active in common spinal pain syndromes

(Chaitow, 2006)

Short/facilitated/overrecruited

Long/inhibited/underrecruited

Occipital extensors Upper cervical flexors (rectus

capitis anterior)

Sternocleidomastoid Deep cervical flexors (longus colli)

Scalenes Low cervical extensors

(iliocostalis)

Upper trapezius Lower/middle fibres of trapezius

Levator scapulae Subscapularis

Rhomboids Serratus anterior

Pectoralis minor

Pectoralis major

Latissimus dorsi

Iliopsoas Gluteal muscles

Tensor fascia latae Abdominal muscles

Quadratus lumborum


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at reducing the dysfunction. This will involve decid-ing between accessory and physiological passivemovement and between particular combinations of both. One method of deciding between two likelytreatment options is to compare the immediateeffectiveness of using the treatments. Even a short

period of treatment, if applied in the correct start-ing position, will have an immediate effect on move-ment dysfunction. The patient will be able todiscriminate between the treatment effects and tellyou which treatment to use!

p0535Mini-treatment requires a degree of skill to per-form. Whilst the treatment is of a short duration,in order to fit into the assessment process withoutbecoming too time consuming, it must be enough

of a ‘dose’ of treatment to evoke a change in muscleactivity and/or joint mobility. Thus, the examinerneeds the palpatory skill to be able to tell whenthese features have subtly changed. With practicethe skilled manual therapist can be as confident indiscriminating this change in mobility as they havein their ability to discriminate between a normal orhypomobile joint on initial assessment.

p0540If we really are striving to provide treatment thatis the most efficacious option we must prove thatthe specific treatment we are proposing is indeedmore effective at reducing the dysfunction thanthe next most likely option. Testing one treatmentagainst another is something we do whilst treating

patients, however, the incorporation of this princi-ple during the assessment process is of particularimportance with the CMT approach.

s0150 Assessing for the suitability of manipulative thrust techniques

p0545Local movement impairment, specific to one or twospinal segments, can present with hypomobility inthe contralateral side glide that accompanies ipsilat-eral lateral flexion and rotation. Acute musclespasm or long-standing movement impairment canlead to a perceptible change in the passive range of contralateral side glide during ipsilateral lateral flex-ion. When visualizing the quality of resistance topassive movement the movement diagram, devel-oped by Maitland (1986) is useful. When passivelyinducing lateral flexion at one spinal segment a per-ception of the profile of resistance to movement canbe drawn. Profiles of resistance that are short inrange represent a ‘crisp’ end feel, whilst a long rangeof resistance profile will feel ‘bouncy’. Finally amovement that has no range of resistance andcomes to a complete stop immediately resistanceis felt, will feel ‘solid’. See Figure 4.12. Segmentsthat do not have this ‘crisp’ profile do not generallycavitate in response to a high velocity thrust.

p0550Thus, unless the therapist assesses lateral flexion

and its associated contralateral side glide the ratio-nale for choosing a manipulation technique over amobilization technique is less clear. The assessmentof accessory glides does not afford the informationto make this judgement. The assessment of

Figure 4.11 f0060 Post-isometric relaxation technique for the

right, anterior paraspinal muscles. IN: supine, neutral

extension;DID: isometric contraction resisting extension and

right rotation. The patient performs an isometric contraction

in response to AP pressure. Contraction of the right anterior

musculature is produced. See video clip number 4

Figure 4.10 f0055 Post-isometric relaxation technique for the

right, posterior paraspinals. IN: sitting, thoracic flexion;

DID: isometric contraction resisting left rotation of T1 on

T2. The patient is told to ‘Don’t let me win’ as the neck is

moved towards more flexion and rotation. The patient will

contract the extensors and right rotators. An isometric

contraction can be held for 6–10 seconds.


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b0030b0030 CERVICAL SPINECASESTUDY

s0155 INITIAL INTERVIEW

s0160 Symptomology

p0560 A 22-year-old female sought treatment for pain in the right

cervical spine and right shoulder. The pain was located in the

lower cervical spine and referred into the right shoulder

across the right supra-scapula fossa (Fig. 4.17). The pain was

not radicular in quality but severe (8/10). There was no

suggestion of an upper motor neuron lesion and no indication

of other red flags. There were no features suggestive of

segmental cervical instability or shoulder derangement. There

was no history of cervical locking, catching or weakness. There was no headache.

s0165 Relevant history

p0565 Symptoms developed over a 6-day period following a mild,

rear shunt whiplash injury, a week previously.

s0170 Behaviour of symptoms

p0570 Pain was reproduced with low cervical flexion and left lateral

flexion. Sitting with the neck in this position reproduced

symptoms within 2 minutes. The symptoms were eased

immediately, by positioning the lower cervical spine in

extension and right lateral flexion. No latent painwas exhibited.

s0175 Diurnal pattern

p0575 There was no stiffness in the cervical spine in the morning.

Shoulder pain developed in the evening. Sleep was not

disturbed.

s0180 Special questions

p0580 The patient’s general health was good. There was no

weight loss, no dizziness, no dysphagia, no dysarthria,

no diplopia, no raised blood pressure, and no symptoms of

cervical artery dysfunction. Radiographs of the cervical

spine were normal. The patient was not currently taking

any anticoagulant or steroid therapy and had received no

benefit from anti-inflammatory medication. There was no

history of locking, clunking or giving way of the shoulder,

with no history of trauma.

p0585See the completed planning sheet in Figure 4.18.

Figure 4.15 f0080 Assessment of the contralateral glide

associated with ipsilateral flexion of the low lumbar spine.

IN: left side-lying, flexion; DID: right lateral flexion with left

side glide at the motion segment. As the lumbar spine is

laterally flexed, firm pressure is applied towards the bed.

Figure 4.16 f0085 Assessment of resistance profile of

contralateral glide in a combined position used to induce

cavitation. IN: flexion, left lateral flexion, right rotation; DID:

right rotation combined with contralateral glide

downwards. The combined starting position for a Grade

IV À rotation, thrust technique.

Figure 4.17 f0090Cervical spine case study – pain chart.


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1. .......................... Posterior facet capsule sprain .........................................................................................................................

2. .......................... Posterior paraspinal strain ..............................................................................................................................3. .......................... Posterior annular disc sprain ...........................................................................................................................


Primary ................. Articular predominance ..................................................................................................................................

Secondary ............ Myogenic predominance .................................................................................................................................


Yes No


Yes No


Before painTo painTo limit

What is the functional demonstration/primary re-test marker?

.............................. Flexion contralateral, lateral fl exion quadrant ...............................................................................................






%Arthrogenic 50

Myogenic 40

Neurogenic 1

Inflammagenic 2

Psychogenic 1

Sociogenic 1

Pathogenic 1

Viscerogenic 1

Osteogenic 3


In: Extension, right lateral flexion quadrant .....................................................................................................................................

Will: Anterior capsular stretch, large amplitude movement, in resistance (Grade III) ........................................................................

Comments/cautions:

Pain relief approach, progressing to a stretch of the tissues driving the nociceptive pattern of presentation ...................................

.................................................................................................................................................................................................................


0

50

100

Arthrogenic

Radar plot

MyogenicOsteogenic




Figure 4.18 f0095 Objective examination plan for the cervical spine.


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s0185PHYSICAL EXAMINATION

s0190Observation

p0590 There was no atrophy of the cervical musculature. There

was an i ncr ease in muscle tone of the right

sternocleidomastoid, upper fibres of trapezius and levator

scapula and right scalenes.

s0195 Active movement

p0595Pain was reproduced earliest in range with left lateral

flexion. Restriction to flexion was apparent at the C5/C6

level. Pain was reproduced further into range with flexion

than with left lateral flexion. Restriction to movement

was most obvious in the mid cervical region. See

Figure 4.19.

Prime movement = left lateral flexionPrime combination = left lateral flexionfollowed by flexion. 3/4 full range

Right-sidedcervical andshoulder painSevere

Figure 4.19 f0100 Box diagram showing the prime

combination for the patient.

PAIVMS

Mini-treatment

Effect on functionaldemonstration

40%

PPIVMS

Mini-treatment


10%


Flexion, left lat flex

Second hypothesis

Posterior musculature

strain

Observation

Muscle atrophyHypertrophy

Hypotonicity

Hypertonicity

Active movement

Control and timing of

muscles during movement

Passive movement

Starting position

Palpation

Local stretch

Mini-treatmentEffect on functional

demonstration0%

Muscle contraction

Mini-treatment


10%

First hypothesis

Posterior facet capsule

sprain

Observation

Postural positioningmalalignment

Active movement

Prime movement

Prime combination

Passive movement

Starting position

Palpation

The technique that alters movement and muscle tone most

with mini-treatment is the initial treatment choice

Figure 4.20 f0105Flow chart of differential

examination for the cervical spine.


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s0200 Passive physiological intervertebral movement(PPIVMS)

p0600 Due to the severity, the examination was undertaken in right

lateral flexion and extension (posterior structures off stretch)

to establish the movement that most reduced pain anddysfunction. Right lateral flexion induced the greatest

increase in movement and reduction in muscle tone.

A short passive treatment, using this right lateral flexion of

C5 on C6 reduced the pain produced by the functional

demonstration by 10%.

s0205 Passive accessory intervertebral movement(PAIVMS)

p0610 Due to the severity, examination was undertaken in right

lateral flexion and extension (posterior structures off stretch)

to establish the movement that most reduced pain and

dysfunction. Anterior pressure (AP) on C5 induced the

greatest increase in movement and reduction in muscle

tone (greater than induced by AP movement of C4 or C6).

A short passive treatment, using this accessory movement

reduced the pain produced by the functional demonstration

by 40%.

s0210Muscular assessment

p0620In right lateral flexion and extension due to severity of

pain, palpation of musculature revealed hypertonicity of

deep paraspinals (C4 to C6) and hypertonicity of the

region’s phasic muscles. No trigger points were detected.

Palpation and length assessment of the levator scapulae,

scalenes, upper fibres of trapezius and sternocleidomastoid

did not alter the functional demonstration.

p0630See Figure 4.20.

b0035b0035 LUMBAR SPINECASESTUDY

s0215 INITIAL INTERVIEW

s0220 Symptomology

p0635 A 45-year-old male sought treatment for pain in the right

back and buttock (Fig. 4.21). The pain was not radicular in

quality and not severe (4/10). There was no suggestion of

an upper motor neuron lesion and no indication of other

red flags. There were no features suggestive of segmental

lumbar instability or disc derangement. There was no

history of lumbar locking, catching or weakness and there

was no cauda equina syndrome.

s0225Relevant history

p0640Symptoms developed over a 6-month-period with no

history of trauma.

s0230Behaviour of symptoms

p0645Pain was reproduced with low lumbar extension and right

lateral flexion (whilst arching his back to put on his coat).

Standing reproduced symptoms within 20 minutes.

Walking reproduced symptoms in 30 minutes. The

symptoms were eased, immediately, by positioning the

back in flexion, either by sitting or leaning over in standing.Pain was also eased by crossing the right leg over the left,

in sitting. No latent pain was exhibited. Pain was also

experienced whilst turning over in bed.

s0235Diurnal pattern

p0650 There was less than 30 minutes of stiffness in the back in

the morning. Buttock pain developed in the evening. Sleep

was not disturbed.

s0240Special questions

p0655His general health was good. There was no weight loss, no

night sweats or fever, no constant night pain (worse than

during the day), no raised blood pressure, no symptoms

of vascular stenosis or peripheral vascular disease. No

history of cancer. The patient was not currently taking anyanticoagulant or steroid therapy and had received no

benefit from anti-inflammatory medication.

p0660See the completed planning sheet in Figure 4.22.Figure 4.21 f0110 Lumbar spine case study – pain chart.


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1. .......................... Superior facet capsule source .........................................................................................................................

2. .......................... Sacro-iliac joint source ...................................................................................................................................3. .......................... Anterior paraspinal muscle source .................................................................................................................


Primary ................. Lumbar articular drive (75%) ........................................................................................................................

Secondary ............ Sacro-iliac articular drive (25%) ...................................................................................................................


Yes No


Yes No


Before painTo painTo limit

What is the functional demonstration/primary re-test marker?

..............................Extension, ipsilateral lateral flexion quadrant ...............................................................................................






%Arthrogenic 70

Myogenic 20

Neurogenic 1

Inflammagenic 4

Psychogenic 1

Sociogenic 1

Pathogenic 1

Viscerogenic 1

Osteogenic 1


In: Extension, right lateral flexion quadrant ....................................................................................................................................

Will: Superior capsular stretch, large amplitude movement, in resistance (Grade III) ........................................................................

Comments/cautions:

Pain relieving mobilization, combined with a stretch of the tissues driving the nociceptive pattern of presentation

................................................................................................................................................................................................................

0

50

100

Arthrogenic

Radar plot

MyogenicOsteogenic





Figure 4.22 f0115 Objective examination plan for the lumbar spine.


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s0245 PHYSICAL EXAMINATION

s0250 Observation

p0665 There was no atrophy of the lumbar musculature. There

was an increase in muscle tone of the right erectore

spinae, quadratus lumborum and piriformis.

s0255 Active movement

p0670 Pain was reproduced earliest in range with right

lateral flexion. Restriction to extension was apparent at

the L4/L5 level. Pain was reproduced further into range

with extension than with right lateral flexion. See

Figure 4.23.

s0260 Passive physiological intervertebral movement(PPIVMS)

p0675 Right lateral flexion, in extension of L4 on L5, induced

the greatest increase in movement and reduction in

muscle tone, when compared with movement at L3/L4

and L5/S1.

A short passive treatment, using this right lateral flexion of

L4 on L5 reduced the pain produced by the functional

demonstration by 50%.

s0265 Passive accessory intervertebral movement(PAIVMS)

p0685 In right lateral flexion and extension, posterior pressure

(unilateral posterior-anterior angled caudad) on L4 induced

the greatest increase in movement and reduction in muscle

tone, when compared to the same accessory movement

applied to L3 or L5.

A short passive treatment, using this accessory movement


by 20%.

s0270Passive movement of the sacroiliac joint (SIJ)

p0695In right lateral flexion and extension PA pressure on the right

apex of the sacrum (encouraging nutation) reproduced

symptoms and was the most restricted sacral glide, whencompared to the response of moving the other three corners

of the sacrum.

A short passive treatment, using this passive movement


by 10%.

p0705See Figure 4.24.

PAIVMS


demonstration20%

PPIVMS


demonstration50%


Extension, right lat flex

Second hypothesis

Restricted nutation of the

right SIJ

Observation


Active movement

SamePrime movement

Prime combination

Passive movement

SameStarting position

Palpation

SIJ passive movement


demonstration10%

First hypothesis

Superior facet capsule

sprain

Observation


Active movement

Prime movementPrime combination

Passive movement

Starting positionPalpation

The technique that most alters movement and pain

response with mini-treatment is the initial treatment choice

Figure 4.24 f0125Flow chart of differential examination for the

lumbar spine.

Prime movement = right lateral flexionPrime combination = right lateral flexion

followed by extension. 3/4 full range

Right-sidedlumbar andbuttock painNot severe

Figure 4.23 f0120 Box diagram showing the prime

combination for the patient.


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References

Chaitow, L., 2006. Muscle energytechniques. Elsevier Health Sciences,Oxford.

Gibbons, P., Tehan, P., 2001a. Patientpositioning and spinal locking forlumbar spine rotation manipulation.Man. Ther. 6 (3), 130–138.

Gibbons, P., Tehan, P., 2001b. Spinalmanipulation: indications, risks andbenefits. Journal of Bodywork &Movement Therapies 5 (2), 110–119.

Grieve, G.P., 1988. Common vertebral joint problems. ChurchillLivingstone, New York,pp. 525–526.

Grieve, G.P., 1991. Mobilization of thespine. A Primary handbook of Clinical Method. ChurchillLivingstone, Edinburgh.

Kerry, R., Taylor, A.J., Mitchell, J., et al.,2008a. Manual therapy and cervicalarterial dysfunction, directions for thefuture: a clinical perspective. TheJournal of Manual & ManipulativeTherapy 16 (1), 39–48.

Kerry, R., Taylor, A.J., Mitchell, J., et al.,2008b. Cervical arterial dysfunctionand manual therapy: a criticalliterature review to inform

professional practice. Man. Ther. 13(4), 278–288.

Maitland, G., 1986. Vertebralmanipulation. Elsevier HealthSciences, Sydney.

Travell, Simmons, 1998. TravellSimons’ myofascial pain anddysfunction: the trigger pointmanual, second ed. Lippincott Williams & Wilkins, San Francisco.


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