Chapter Four The principles of combined movement assessment
The purpose of clinical examination is not simply to gather as much information as is possible in the time available. Often the inexperienced clinician can spend an entire examination gathering data with little evaluation of its clinical relevance. As manual therapists we provide our patients with incredibly sensitive examinations. The volume and sophistication of our examination procedures is immense. However, we may occasionally fail to grasp the problem of specificity. We must find a balance between gathering enough information to prioritize the patient’s most significant dysfunction whilst not being distracted by the less relevant dysfunctions we discover.
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.
Simply gathering huge quantities of information that is neither discriminatory nor influential in management represents a failure in our duty of care to our patients. The purpose of clinical examination is to evaluate valid information that will facilitate the prioritization of likely diagnoses and strategies of management. In other words, our duty to our patients is to ensure we are identifying their predominant dysfunction/fault and to continually ensure that we are providing the most effective management strategy at the time. Ensuring we adhere to this principle will ensure we are facilitating recovery as quickly as possible. It could be argued that the primary objective of manual therapy is to facilitate recovery as quickly as possible. On the whole, the conservative management of most musculoskeletal dysfunctions will facilitate recovery. Manual therapy’s role is in the acceleration of this process. Thus, ensuring our treatment choice is making more difference, more quickly than the next most likely choice of treatment is a crucial responsibility.
During the initial consultation the therapist will begin to form an impression of the patient based on verbal and non-verbal communication. Expert clinicians form an impression regarding diagnosis, management and expectations of the patient very quickly. Mixed methods of clinical reasoning are utilized in this process as outlined in Chapter 3.
The diverse nature of musculoskeletal dysfunction rarely allows the definitive identification of definitive patterns of presentation. The clinician is frequently required to make reasoned judgements as to the predominant dysfunction from several alternatives. Some of the typical judgements required are listed below. This is by no means an exhaustive list. The process of establishing that one treatment approach is superior to another begins during the initial consultation with the patient. Early in the initial interview with a patient, the therapist should look for answers to the following questions.
• 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.
By examining the expectations of the patient the suitability of utilizing a CMT approach can be established. If the patient’s expectations of treatment are radically different to the therapist’s, a discussion of future management should ensue. A detailed biomechanical assessment of spinal dysfunction may be unwarranted if the patient is expecting and consenting only to generic advice and exercise.
Patient presentations suggestive of a predominant mechanical influence on symptoms are suitable for detailed biomechanical assessment and treatment. Presentations that do not feature mechanical/movement influences on symptomology suggest that specific positions and movements may not be the predominant influences to be addressed during examination and treatment. Thus, patients who have constant symptoms, regardless of positioning, will be unlikely to benefit from management with a positional bias. Patients with central sensitization or inflammatory neurogenic pathology (‘irritable’ patients (Maitland, 1985) have no mechanical predominance.
Patients, seeking manual therapy, present with pain and largely judge their improvement by an amelioration of their pain. In the process of assessing the effect of testing and treatment, changes in pain are assessed. However, in cases where pain is severe, it is unacceptable to reproduce pain and inappropriate to treat an underlying mechanical dysfunction whilst reproducing pain. Thus, prior to any physical testing the therapist must be clear regarding the degree to which pain is to be reproduced during their interaction with the patient. In certain presentations it may be deemed acceptable to fully reproduce the minor discomfort the patient is seeking help for, in order to fully relieve it. However, in situations where pain is severe this is unacceptable. Using positions that can reduce the likelihood of reproducing severe pain is one of the key advantages of CMT.
Patient presentations, suggestive of the suitability of a CMT approach, have symptoms predominantly influenced by specific positions or movements. Patients can often demonstrate these movements or positions and reproduce them in the course of replicating a functional activity. For example, patients with anterior stretch patterns of the mid cervical spine often relate symptom reproduction with activities inducing ipsilateral lateral flexion and rotation, e.g. reversing the car. The monitoring of change in the functional demonstration, during examination and treatment is a crucial monitor of treatment effectiveness. Again, the concept of a functional demonstration is a long-established tenet of the Maitland concept (Maitland, 1986) and at the heart of CMT.
The biomechanical interpretation of patient presentation can allow the therapist to judge the location of regions of dysfunction. Careful questioning can elicit functional activities that influence specific regions of the spine. For example, the influence of breathing on thoracic movement can provide valuable inference towards spinal or rib dysfunctions.
What is the predominant hypothesis for the source and mechanism of symptom production and the next most likely hypothesis that will be tested against it?
It is crucial to form hypotheses regarding the underlying source and mechanism of symptom production as you recognize presentation patterns. As a pattern of presentation begins to emerge the use of follow-up questions will establish a good fit with this pattern. Having identified a match with a recognizable pattern, the manual therapist should test the assumption that this hypothesis is predominant by comparing the match with the next most likely pattern. For example, having established that a patient’s presentation matched an ‘arthrogenic’ presentation, one would expect the presentation to be less well matched with a ‘myogenic’ presentation. In order to facilitate this process it can be useful to develop a library of ‘stock’ questions and tests for common presentations.
The use of these strategies will facilitate the therapist’s reasoning regarding the appropriateness of using CMT, the most likely hypotheses for aetiology of symptoms, the extent and direction of movements to be included in the examination and most importantly the starting positions in which assessment and treatment will be undertaken.
The objective examination will follow the subjective examination and is conducted in light of the considerations and clinical reasoning process outlined in this book. The object of the physical examination is not to form a long list of impairments with little evidence of their relative contribution to the patient’s dysfunction. The physical examination should allow the hypotheses, generated following the subjective examination, to be tested. Thus, the examination should be structured to allow this process to occur. In order to assess the influence of the testing procedures themselves on a patient’s dysfunction the physical examination should be split into components.
The order in which components of the examination are conducted will be guided by the subjective examination. A clinician may hypothesize that the predominant mechanism of symptom production is related to a restriction in articular mobility rather than, e.g. a restriction in overlying muscle mobility. In this case, the examination would be structured to examine the articular system, assess its influence on the fault, and then assess the muscular influence and reassess that system’s influence on the fault. In this way, in addition to gathering information from each component of the examination the relative influence of the components can be evaluated.
Each component begins with an assessment of movement fault (using the patient’s functional demonstration), testing procedures and a subsequent reassessment of functional demonstration. See Figure 4.2.
Figure 4.2 • A flow chart showing the suggested compartmentalization of the physical examination. The functional demonstration is at the head of the differentiation. Two common differentiations are displayed: primary arthrogenic versus primary myogenic.