Chapter Seven Principles and progression of combined movements
Whilst the use of the IN and DID system will encourage the consideration of starting positions, the use of box diagrams is an excellent method of conveying combined movement theory (CMT) positioning. The box diagram conveys considerable amounts of information with the simple addition of two lines to a box framework (Fig. 7.1). The frame of the box diagram represents the normal range of movement in sagittal (vertical line), coronal and axial planes (horizontal line). Flexion, extension and lateral flexion movements are denoted using straight lines, and rotation by an arc. The box diagram is drawn to represent the movement pattern associated with a dysfunction. It should be accompanied by shading to identify the predominant side of pain. This process identifies the quadrant of dysfunction (the corner of possible three-dimensional movement that is painful or restricted).
In addition to the above, a judgement on severity of pain (severe or not) should be placed next to the box. The diagram signifies to another CMT therapist that a process has been undertaken in order to draw the box diagram. The significant features of the box diagram follow:
• Patients finding it difficult to move towards the side of pain have anterior stretch dysfunction whilst pain produced by movement away from the side of pain is a posterior stretch dysfunction. This information ensures that the three movements that stretch either the anterior or posterior structures are examined and ranked for importance.
In order to describe the reasoning process of CMT treatment we will use the cervical spine case study from Chapter 4. Take a minute to familiarize yourself again with the presentation which is detailed below.
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. The pain was not radicular in quality but severe at rest and with movement (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.
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 pain was exhibited.
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, and no history of trauma.
Pain 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 is most obvious in the mid cervical region (see Fig. 7.3).
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. Right lateral flexion induced the greatest increase in movement and reduction in muscle tone.
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).
In right lateral flexion and extension due to severity of pain, palpation of musculature reveals hypertonicity of deep paraspinals (C4 to C6) and hypertonicity of the region’s phasic muscles. No trigger points were detected.
The starting position for this technique allows the production of specific passive movement on the side and on the level of pain generation. The starting position and movement induced do not stretch the posterior aspect of the motion segment. A neurophysiologically-mediated alteration in the perception of nociceptive pain will occur (Wright, 1995). This phenomenon is rapid acting and within seconds the therapist will be able to detect a reduction in paraspinal hypertonicity and a concurrent increase in compliance to passive movement. This had occurred after 1 minute of mobilization and thus the technique was stopped, to allow reassessment of the patient’s demonstration of dysfunction.