Chapter Four The principles of combined movement assessment
We are essentially searching for the patient’s ‘predominant dysfunction or fault’ in order to direct our 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. In short, during the examination of patients we are considering if our hypothesis will guide treatment more effectively than the next most likely hypothesis. In addition, during treatment we should be continually considering if our chosen intervention is in fact more effective than the next most likely intervention. This process of analytical assessment is not new and was advocated by Maitland (1986) and Grieve (1988, 1991) over 30 years ago.
Subjective examination
Is it acceptable to reproduce symptoms – are they ‘severe’?
• Is the faulty position producing severe pain?
• Is positioning in the faulty position likely to cause a latent or long-term exacerbation of symptoms?
• Is there a position that will allow examination and treatment whilst avoiding unacceptable symptom reproduction?
• Is it likely that caution needs to be taken due to a patho-anatomical reason that would make the use of combined movement theory (CMT) unwise? See the contraindications to manual therapy in the box below.
What is the predominant pain mechanism?
• Is the patient’s predominant pain mechanism: nociceptive, peripheral neurogenic, central sensitivity, autonomic or affective?
Clinical point Contraindications to spinal passive movement that takes a joint to the end of passive range or thrust techniques
Relative contraindications
(See Gibbons & Tehan, 2001a,b; Grieve, 1991.)