Chapter One Introduction to combined movement theory
To move is to change place, position or posture. Thus, the positions at the initiation and cessation of movement are integral to the analysis of movement. The spinal positions we adopt to allow full function are three-dimensional and continuously adapting to the functional demands placed on us. Naturally, the spinal system cannot always immediately accommodate to these demands and consequently short- and long-term impairment can result. In a system that continuously changes position and demands the acquisition of new and challenging positions the integrated control of movement can be compromised. Combined movement theory (CMT) offers the investigator a framework to examine the influence of starting and finishing positions on movement impairment and use these positions to intervene therapeutically.
Spinal dysfunction is a complex situation that must be considered in a biopsychosocial context. Our spines are continuously moving from one starting position of movement to another. The point at which this process becomes dysfunctional is dependent on the schema of the individual. The psychological perspective of the individual and societal influences have a huge bearing on just when function is considered to have become dysfunctional. For some, the spine has become dysfunctional only as they await the anaesthesia prior to surgery and others when they develop an inkling that ‘something is not quite right in their back’. Thus, the presentation of spinal dysfunction is incredibly variable. Within this group of presentations are patterns of dysfunction that have become recognizable to healthcare practitioners. With the development of taxonomy of spinal dysfunctions, specific therapeutic interventions such as manual therapy have been developed; however there is no panacea for spinal dysfunction. There will never be one intervention that optimally matches all spinal dysfunctions. Thus, the search for efficacious interventions for specific presentations of dysfunction is the greatest test of our ingenuity in the short and long term.
Patients are people undergoing treatment for a problem they are perceiving. Patients do not generally attend for treatment for a problem they are not perceiving. Thus, all patients have a perception that something is problematical. If we accept this stance then we must assess patients from a biopsychosocial perspective. Each patient will present with a biopsychosocial profile that will need to be interpreted to allow the successful tailoring of intervention to optimally influence the patient’s perception of their problem. In other words, we cannot afford to look at a patient from only one perspective. Tailoring an approach to management that only considers the biomedical or psychosocial factors influencing the patient’s perception of their problem is not appropriate. For example, a patient with specific low back pain, for example a fractured coccyx, will be approached in a manner that matches their schema of the problem. Thus, whilst all patients with such a fracture would benefit from education and advice on the prognosis, timescales and options for management, the addition of a rehabilitation programme will depend on the psychological profile of the patient. Some patients would require a formal rehabilitation programme whilst others will manage by themselves. Some patients might develop compensatory, mechanical low back pain whilst others might not need this complication addressed formally. The strength of our examination to predict likely outcomes, discriminate different conditions and to correlate with objective tests of dysfunction is vital for our practice.
There are some presentations of spinal dysfunction that suggest a mechanically-focused intervention may be the optimal strategy for treatment. There are some spinal presentations that suggest the dysfunction has a strong relationship to the positions the spine is held or moved into. There are some presentations of dysfunction that appear to be more dominantly influenced by mechanical factors than the psychosocial influences underpinning them. Indeed, some presentations of spinal dysfunction lead individuals to consult manual therapists for their assessment and treatment rather than a psychologist, cognitive behavioural therapist or faith healer. The quest to identify who is most suited to manual therapy as opposed to other conservative therapies is currently being undertaken by clinicians and researchers around the world; however, we are at the beginning of this journey with its end being some way over the horizon.
In the muddy waters of spinal pain it is clear that when it appears appropriate to intervene with therapeutic spinal movement, be it with muscle contractions, passive mobilization or manipulative thrust techniques, the starting and ending positions of these movements are crucial. The underlying hypotheses of these interventions is that the position in which these movements are undertaken has a superior effect on reducing dysfunction than inducing movement in a random fashion. Thus if we believe that, for certain presentations of spinal pain, the painful position of the spine is related to the patient’s dysfunction, then interventions that take this relationship into consideration may be more effective than invoking random movement or generic exercise.
This simple assumption leads the quest for appropriate treatment into the realm of specific assessment and induction of spinal motion in spinal dysfunction. Thus, the examination and treatment of spinal dysfunction in presentations where positions and postures are important in its aetiology and maintenance must include a three-dimensional assessment of motion. In addition, therapeutic strategies must include a consideration for starting and finishing positions. CMT fulfils these requirements and thus has considerable clinical utility. It is a system of examination that emphasizes the expansion of the musculoskeletal examination to fully evaluate the active and passive combinations of physiological and accessory movement of the vertebral column and offers the investigator greater scope for identification and treatment of dysfunction.
The concept of ‘combined movements’ examination and treatment was developed by Dr Brian Edwards, a specialist manipulative physiotherapist from Perth, Western Australia. The work of Brian Edwards (1987) was incorporated into the seminal writings of Geoff Maitland and is seen as an important corollary of the ‘Maitland Concept’ (Maitland, 1986). Having been taught the principles of CMT by Dr Edwards and subsequently corresponded with him over its development I hope this book provides you with a reference that shows that CMT has developed into a comprehensive approach to the management of specific types of spinal dysfunction.
CMT encourages the consideration of starting positions in the choice of therapeutic treatments. Whilst even the most ardent follower of the CMT concept may occasionally treat the patient in a relatively neutral position, the vast majority of treatments require the careful consideration of the position the treatment is conducted in. The consideration of starting positions starts during the patient interview, continues through the initial examination and throughout the progression of treatment. Home exercise and discharge programmes will continue to emphasize the value of the positions to the patient.
The simple addition of ‘In’ and ‘Did’ into the process of note-taking during treatment will encourage a consideration of the starting position in practice. This attention to the recording of position and treatment technique has been recently recommended by the fellows of the American Academy of Orthopaedic Manual Physical Therapists (2006).