Combined Movement & Its Assessment - “Brain Edward”

 Combined Movement & Its Assessment 

By

“Brain Edward” 

INTRODUCTION

The concept of the combined movement theory was developed by – “Brain Edward” who is the author of the “Manual of combined movement”

DEFINITION- movement imparted on the spine as directed under the control of the therapist.

• There is little use of the combined movements in the past.

• Common examples are- Spurling’s maneuver and Quadrant test.

• Combined movements are extremely useful in the management of musculoskeletal disorders of the spine.

• Majority of an individual’s normal daily activity involves complex movement through the range of cardinal planes rather than simple movements such as flexion, extension, rotation, and side flexion. e.g.- simple activity such as looking over the shoulder to reverse the car involves a combination of movements – cervical rotation, lateral flexion, extension, lifting items into the car involves- lumber flexion, side flexion, and rotation.

• So according to Edward we should examine the patient through a similar combination of planes of movement to determine the true nature of patient dysfunction.

• In clinical practice there are many situations where movement in the cardinal planes is not provocative enough to reproduce the patient’s symptoms. This is common where the patient’s disorder is less severe and more of a nuisance problem. These patients can be difficult to treat because the therapist has little information to prescribe treatment and also nothing to re-evaluate for treatment effect. Hence combined movements can be used as a more provocative procedure to increase the stress on the spine to “chase the symptoms”. The therapist is then able to logically progress treatment using the combined movement theory and has a reassessment sign for treatment effect

• Combined movements will vary the mechanical stresses placed on the innervated structure of the spine (which includes the facet joint, disc, spinal ligament, muscle, dura, and nerve). Hence it is possible to vary the patient’s symptoms both in intensity (strong pain- mild pain) and in distribution (local pain- referred pain) . For patients with severe pain and with disorders of a more serious nature it is possible to minimize the stress on the painful structures by using combined movement theory.

• It is apparent in clinical practice that end range Mobilization techniques are more effective than early range movements. Combined movement theory permits the use of an end-range treatment technique throughout a treatment.

• Combine movement theory attempts to incorporate the biomechanics of the IV motion segment in examination and treatment.

 

DIFFERENCE BETWEEN COMBINED AND COUPLED MOVEMENT

COUPLED MOVEMENT
• An involuntary movement that occurs in an unintended or unexpected direction during the execution of the desired movement.
• Occurs naturally during all spinal movement
• Occur under involuntary control.

COMBINED MOVEMENT
• Are movements imparted on the spine as directed under the control of the therapist.
• Combined movements don’t occur naturally.
• Occur under voluntary control.

MOVEMENT PATTERNS
• The movement of the vertebral column is complex. The articulations are such that each vertebral segment when moved involves the movement of three different joints -2 zygoapophyseal joints and a disc.

• The shape of the articulation, and the amount and type of movement which is possible at each level is affected by the soft tissue structure between the bony articulation and the structure within neural foramina and vertebral canal.

• The movements of the vertebral column do not occur in isolation but in a combined manner. Roland 1966, and Loebi1973, found that axial rotation of the lumber spine was to the left when the subject bent to the left and to the right when the subject bent to the right. In the case of coupled movement to the lumbar spine, the direction of the axial rotation may vary as stated by Pearcy and Tibrewal in 1984 and Stoddard in 1983 states that the direction of rotation during lateral flexion in the lumber and the thoracic spine will vary according to whether the lateral flexion is performed with the whole spine in flexion or extension. They suggested that the rotation is to the same side if the lateral flexion is performed in flexion, but on the opposite side when the movement is performed in extension. The direction of movement appears to be the same regardless of whether the movement of lateral flexion is performed in flexion or extension.

EXAMINATION OF ROTATORY AND LATERAL FLEXION MOVEMENTS

• Invarying position of flexion and extension will help in establishing `the type of movement response present. Combing movement gives an indication as to the way of signs and symptoms change when the same movement is performed in flexion and extension.

• E.g. of combination of 2 movements is- The amount of rotation that is possible between the cervical 2nd and 3rd vertebra will vary depending on the amount of flexion or extension when movement is performed.

• E.g. of a combination of 3 movements is- lateral flexion and rotation can be carried out either in flexion or extension. It is also imp to realize that the sequence of performing the movement may be varied and produce a different symptomatic response. This is because the movement which is performed first can reduce the available range of the 2nd movement and obviously the 3rd movement is restricted even further. So when using this combination of movement as examining movement care must be taken to ensure that each position is maintained while performing the next movements.

Various possible variations of sequence can be seen in this e.g. of flexion, lateral flexion, and rotation to the left of the cervical spine are-
1)Flexion, lateral flexion to the left, rotation to the left.
2)Flexion, rotation to the left, lateral flexion to the left.
3)Lateral flexion to the left, flexion, and rotation to the left.
4)Lateral flexion to the left, rotation to the left, flexion.
5)Rotation to the left, flexion, lateral flexion to the left.
6)Rotation to the left, lateral flexion to the left, flexion.

Different movements of the spine- those in flexion, lateral flexion, and rotation can cause similar stretching and compressing movements on the side of IV joint.

Combining movements of examination can therefore increase or decrease the compressive or stretching effects on the IV segment.- This result in recognizing movement response in the patients with mechanical disorder of movement?
These are

- Regular
- Irregular

REGULAR RESPONSE

These are responses in which similar movements at the IV joint produce the same symptoms whenever the movement is performed.
Tend to be single-structure and non-traumatic
E.g. discogenic; stretch/compressive pattern
facet joint; compressive
capsular; stretch
• Regular pattern is divided into -Compressing
-Stretching
• Compressing-If the patient's symptoms are produced on the side to which the movement is directed then the response is a compressing response. i.e. the compressing movement produces the response.

e.g. - Right cervical rotation produces right suprascapular pain. This pain is worsen when the movement is performed in extension and is eased when performed in flexion.

- Right lateral flexion in the lumbar spine produces right buttock pain. This is made worse when the movement is performed in the extension and eased when performed in flexion.

• Stretching response- if the symptoms are present on the opposite side from that to which the movement is directed.

e.g. - right lateral flexion in the cervical produces left suprascapular pain. This pain is accentuated when the same movement is performed in flexion and eased when performed in extension.
- Right lateral flexion in the lumbar spine produced left buttock pain. This is accentuated when the movement of right lateral flexion in performed in flexion and eased when performed in extension.

• Combination of movement will increase or decrease the compression or stretch in a given area. this will predict by using the following pattern.

• In flexion all the structure anterior to line X( the axis about which the movement occurs) will be compressed and all the structure posterior to line Y will be stretched. In extension, the reverse will be true. In side flexion, to the left side, the structure on the right side will be stretched.

• When the two movements are combined such as flexion and side flexion to the right all the structures in quadrant 1 will be compressed maximally and all the structures in quadrant 3 stretch maximally. Quadrants 2 and 4 will have a combination of stretch and compression which will have no combined effect.

IRREGULAR RESPONSE

All responses which are not regular, fall into the category of irregular responses. With the irregular responses, there is not the same consistency of symptoms and stretching and compressing movement do not follow any recognizable response. There is random reproduction of symptoms despite combining movement with similar mechanical effects.

e.g. 1- right rotation of the cervical spine produces right suprascapular pain (a compressing test movement). This pain is made worse when right rotation is performed in flexion stretching movement) and eased when the movement is performed in extension (a compressive movement).

e.g. 2- an extension of the lumbar spine increases right buttock pain. When right lateral flexion is combined with this movement, the pain is decreased, but when left lateral flexion is combined with extension, the pain increased.

• Irregular pattern – tends to be multi-structural and traumatic( e.g. following motor vehicle accident) e.g. combination of disc, capsular, ligamentous, and intervertebral foramina.
• Irregular or inconsistent patterns are common where there is instability.


ESTABLISHING THE MOVEMENT PATTERN

1) SUBJECTIVE EXAMINATION

This part of the examination follows the principles described by Maitland. In this pattern recognition is encouraged. Particular emphasis is placed on determining a subjective directional-related pattern of symptoms reproduction. In other words, find the movement direction (eg flexion) or activities ( e.g. flexion activity such as putting shoes on) that most aggravate the patient's symptoms. This will enable the Physical examination to be more precise and ensure that the patient's problem is going to be addressed.
It is most important to determine the SEVERITY, IRRITIBILITY, NATURE (SIN) of the patient presenting disorder. This information enables the therapist to examine and treat the patient without increasing symptoms when the patient has high SIN and make sure that more aggressive treatment is given when the patient has low SIN. In combined movement theory, the SIN will determine the extent and vigorous of the physical examination as well as starting position of the treatment.

2) PHYSICAL EXAMINATION

Examination of the plane's active movement will determine the primary movement. This is the active movement that is most significant in reproducing the patient's symptoms. This is important as it helps in determining the order in which combined movement testing is applied. The secondary movement is the additional movement that is added to the primary movement in the primary position.

The primary combination is that movement combination which is most comparable to the patient's symptoms. This is the movement combination that brings on the patient's symptoms more than any other movement combination.

The primary position is that point in the range at which symptoms first begin. It is essential to take the primary movement to the onset or increase( in resting pain) and ensure
that primary movement is not altered when the secondary movement is added.

3) SEQUENCE OF TESTING

( Depending on the SIN of the presenting disorder). But in cases where the SIN is not a concern then the following testing procedure will be undertaken.
a) Primary movement, must be active.
b) Just after the onset of the pain (p1) add the secondary movement which should be active-assisted.
c) Determine the symptom response.
d) It is very important to give clear instructions to the patients, particularly with respect to the response to the secondary movement. Is the patient's pain “ better, worse, or the same”. It is important to make sure that the primary movement is maintained while performing the secondary movement otherwise the interpretation of the patient's response will be invalid.
e) It is also important to determine which pain is provoked by the combined movement, whether is it the patient's pain they complain of or it is a new pain that they have never experienced before.

HOW TO RECORD THE INFORMATION

1)Suppose the patient has right-sided low back pain which is indicated by the shading in the right lower quadrant.
2) The primary movement is an extension which is indicated by the thick arrow pointing towards the extension. The length of the arrow indicates the range of movement available. The full range would be to the perimeter of the box.
3) The double-headed arrow is the secondary movement and again the length of the arrow indicates the available range of motion.
4) The two arrows together indicate the primary combination.
Regular compressive pattern

PALPATION IN THE COMBINED MOVEMENT

Palpation in the combined position can be used to confirm or refute a hypothesized combined movement pattern.
The therapist would undertake the routine palpation of the cervical or the lumbar spine.
A common technique employed in the combined movement examination of the cervical and lumbar spine includes central, unilateral PA, and transverse pressure AP is used in the cervical spine.
Recording palpation finding in combined positions

>The arrow on the left indicates a posterior-anterior pressure.
> L1-5 indicate the L1 to the L5 spinous process.
> Lines under each level indicate the amount of stiffness present at each level.
no lines- no stiffness normal
accessory glide
3 lines- maximum stiffness
2 lines- moderate stiffness
1 line- minimal stiffness.

The spiral line under the stiffness indicates pain.
no spiral – no pain.
a small spiral – mild pain
longer spiral- moderate pain
longest spiral- severe pain on
accessory glide

SELECTION OF TECHNIQUE
v Depend on all the factors including, irritability, severity, nature of the disorder( SIN).
v The lower the SIN the closer the treatment technique to the primary combination.
v The higher the SIN the further away the treatment technique from the primary combination. In general, it is better to use a position that does not incorporate the primary movement. Primary movement can be added at later stages.

Patient category
Once the primary movement and primary movement combination have been established, the next point is to establish the category of the patient. It is established after the full examination procedure, and it is useful in assisting with the selection of the initial direction of the treatment techniques or position of the patient at the beginning of the treatment program.
Three categories are recognized and they are-
>ACUTE
> SUBACUTE
> CHRONIC

ACUTE CATEGORY-
a) Less than 48hrs onset.
b) Primary movement is less than half range.
c) Pain score is usually greater than 5 on a visual analog scale (VAS) of 1-10.
d) May be irregular or regular movement response.
e) On the movement diagram, pain, resistance, and spasm are present and tend to start before half range is reached. Usually limited by pain.
f) Symptoms are usually local but can be referred to.

SUBACUTE CATEGORY-
a) Onset is longer than 48hrs but less than 6 weeks.
b) Primary movement is equal to, or greater than 6 weeks.
c) Pain score is equal to, or less than, 5 on VAS.
d) Regular movement response may be dominant, but an irregular movement response can still be present.
e) Movement diagram resistance starts before half range is reached, pain and spasm are usually Present, but are minor. Limited by resistance.
f) Symptoms may be local or referred.

CHRONIC CATEGORY-
a) Onset is longer than 6 weeks.
b) Primary movement is greater than half range.
c) Pain score is less than 5 on VAS.
d) Regular response usually dominates.
e) Movement diagram show resistance starting early in the range. The pain graph is low. The limitation is always resistance.
f) Symptoms are local or referred.

 

SELECTION OF INITIAL TREATMENT TECHNIQUE AND PROGRESSION OF TREATMENT

ACUTE CATEGORY-

In the acute category with regular or compressive movement, the direction of the initial procedure is always towards the opposite quadrant.
E.g.- a patient presenting with left buttock pain, with regular compressive movement response. Left lateral flexion is the primary movement, restricted to the one-quarter range. Left lateral flexion in extension is the primary combination restricted to the one-eighth range. the first tech chosen is RLF in flexion shown by three-headed arrows.

PROGRESSION

ROUTE 1
( R ) LF In F
( R ) LF In E
( L ) LF In E

ROUTE 2
( R ) LF In F
( L ) LF In F
( L ) LF In E

Route 1 is probably a less painful direction as it more gradual approach to the primary combination.

Regular stretch responses for an acute category- patient complains of left buttock pain. Flexion is the primary movement, and RLF performed in flexion is the primary combination. Symptoms are produced in the C quadrant. The starting position is LLF In E.

PROGRESSION

ROUTE 1
( L ) LF In E
( L ) LF In F
( R ) LF In F

ROUTE 2
( L ) LF In E
( R ) LF In E
( R ) LF In F

Route 2 is less painful.
In the category of subacute and chronic regular stretch and compressive movement responses, the same principles can be used. The starting point may be closer to the primary combination, except where distal symptoms and neurological signs are present. In these cases, it is always best to start in the opposite direction and use the same progression as for the acute category.

SUBACUTE CATEGORY

REGULAR COMPRESSIVE MOVEMENT RESPONSE

Symptoms fall into the C quadrant. The extension is the primary movement, and LLF in extension is a primary combination.
PROGRESSION

ROUTE 1
( R ) LF In N
( R ) LF In E
( L ) LF In E

ROUTE 2
( L ) LF In F
( L ) LF In N
( L ) LF In E

route 1 is less painful.

REGULAR STRETCH PATTERN

For left buttock pain. Symptom fall in quadrant C. flexion is the primary movement and right lateral flexion in flexion is the primary combination.

PROGRESSION

ROUTE 1
( L ) LF In N
( L ) LF In F
( R ) LF In F

ROUTE 2
( R ) LF In E
( R ) LF In N
( R ) LF In F
Route 2 is less painful.

CHRONIC CATEGORY
REGULAR COMPRESSIVE MOVEMENT RESPONSES

Pain in the left buttock. Primary movement is an extension. And primary combination is left lateral flexion in extension.

PROGRESSION

ROUTE 1
( L ) LF In N
( L ) LF In E

ROUTE 2
( R ) LF In N
( R ) LF In E
( L ) LF In E

Route 2 is less painful.
REGULAR STRETCH RESPONSES

Flexion is the primary movement and right lateral flexion with flexion is the primary combination.

PROGRESSION

ROUTE 1
( R ) LF In n
( R ) LF In F

ROUTE 2
( L ) LF In N
( L ) LF In F
( R ) LF In F

Route 2 is less painful.
IRREGULAR MOVEMENT RESPONSES

acute left buttock pain, irregular movement responses. Pain is produced in the C quadrant.
An extension is the primary movement and right lateral flexion in extension is the primary combination. So quadrant A is probably the best starting point because the movement can be directed away from the primary combination.

PROGRESSION

(L ) LF In F
(L ) LF In N
(L ) LF In E
(R ) LF In E

Note: Evaluation and Treatment of Vertebral Motion Segment Dysfunction. (Functional Assessment & Treatment of Spine related dysfunction) is my one more Blog for Spine realted Dysfunction Treatment. 

https://hemalphysio.blogspot.com/2019/08/evaluation-and-treatment-of-vertebral.html 

Referance:

Manual of Combined Movements: Brain C. Edwards. Second Edition.

Dr.Hemal Patel (PT) (M.P.T)

Assistant Professor 

Ashok & Rita Patel Institute of Physiotherapy

Constitute of CHARUSAT