Combined Movement Theory is the development of Dr Brian Edward’s “Combined Movements” to rationally incorporate Spinal Manipulation Techniques, Muscle Energy Techniques and new methods of Mobilisation. The concept promotes rational Manual Therapy for Spinal Dysfunction.

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. 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.

Read more about Combined Movement Theory here…

Dr Chris McCarthy is a Physiotherapist and Spinal Fellow at Imperial College Healthcare NHS Trust, St Mary’s Hospital Paddington, London. After qualifying as a Physiotherapist in 1989 he undertook post-graduate training in Biomechnics and Manipulative therapy at Strathclyde and Coventry Universities before undertaking a PhD degree in rehabilitation within the faculty of Medicine at Manchester University. He was awarded a “Young Investigator of the Year” award in 2001, for his PhD studies, by the British Society of Rheumatologists.

Following Post-doctoral studies, investigating the sub-classification of non-specific low back pain, he became an Assistant Professor of Rehabilitation within the Clinical Trials Unit of the Medical School of Warwick University attracting over a million pound of funding in two years. More recently he has joined Imperial College healthcare as a clinician and researcher.

He has taught internationally on Manual Therapy, specifically on Combined Movement Theory, and lectures on six of the Masters courses in Manual Therapy in the UK. He is a member of the international advisory board for Manual Therapy journal and regularly reviews and publishes papers in the academic field of Manual Therapy.

Read more about Dr Chris McCarthy here….

This book expands on the widely used concept of combined movements and incorporates both grade IV- manipulative thrust techniques and muscle energy / proprioceptive neuromuscular facilitation techniques. The book is the first to include chapters on cervical artery dysfunction (VBI) and upper cervical instability with clinical chapters on the regional management of spinal dysfunction. The first section of the book discusses the underlying theoretical concepts underpinning combined movements theory and manipulation, with the second section offering a comprehensive manual of tests and treatments for each region of the spine. Revision multiple choice tests are at the ends of the theoretical chapters.

A chapter on home exercise is included along with a DVD of video clips and clinical reasoning form. The book will provide readers with a comprehensive resource to start using combined movements theory immediately and is a real substitute to attending a course on the method. The book is an update, expansion and development of the Manual of Combined Movements published by Brian Edwards.

Features

• DVD with over 60 video clips of tests and techniques
• Chapter on premanipulative – premobilisation screening and Cervical Artery Dysfunction
• Chapter on Upper Cervical Instability and assessment
• Update on the biomechanics of each region of the spine
• Multiple choice tests
• Integration of mobilisation, manipulation and muscle energy techniques

Contributions by

• Roger Kerry, Associate Professor, University of Nottingham
• Gail Forrester, Senior Lecturer, Coventry University
• Louise Potter, Registered Osteopath, University of Leicester
• Ioannis Paneris, Extended Scope Practitioner, Manchester

Read more about the book here…

What are the valid clinical tests for diagnosis of a lumbar disc prolapse? A patient is referred with a suspected disc prolapse. You wish to know which are the best clinical questions/ tests to confirm the diagnosis.

Search Strategy

Medline 1966-09 using the PubMed Clinical queries database was searched using the following terms (Broad Therapy Filter = ((clinical[Abstract] AND trial[Abstract]) OR clinical trials[disc prolapse, disc herneation and clinical tests, examination] OR clinical trial[Journal] OR random*[Abstract] OR random allocation[disc prolapse, disc pain,] OR therapeutic use[surgery, conservative management]). In addition the BestBETS database was searched using similar terms. Finally, the PEDrO (Physiotherapy best evidence) database was searched, as above, with only papers already rated as 7/10 on the quality score being selected for inclusion.

Search Outcome

Altogether 1000 abstracts were identified from the combined searches, after duplicates had been
removed. Abstracts were screened in teams of two. Full papers were obtained for those papers
that answered, or potentially answered the three part search question. This resulted in 4 papers
being obtained. These papers were rated for quality and risk of bias using a standard proforma
(See appendix 1) with papers scoring over 5/10 being summarised in Table 1. This process
resulted in four papers being rated as good quality and directly answering the PICO question

Comments

The reviews included some studies of poor methodological quality and sometimes with
no gold standard documented. This does reduce the validity of the results. The high LR
of the CSLR in the Vroomen et al systematic review (1999) has not been reproduced in
subsequent studies.

Clinical Bottom Line

Crossed straight leg raise is the most useful clinical test in the diagnosis of a Lumbar disc
prolapse. Slump test and paresis is moderately helpful in diagnosis. In terms of subjective
features pain that is worse in the leg than the back may help predict the presence of a disc
prolapse.

Research Currently being undertaken at the University of Birmingham suggests the examination of the cervical spine using CMT is reliable.

Ioannis Stamos MMACP is a Post-graduate manipulative Physiotherapists currently completing his Masters degree at the University of Birmingham. He has undertaken a thorough evaluation of the reliability of the Combined Movement Theory clinical examination in the cervical spine. His inter-tester reliability of the active assessment of cervical spine patients has demonstrated excellent agreement between examiners. Watch this space for more detail.

Clearly, good reliability (low levels of measurement error) is a prerequisite for valid testing and so this work is encouraging for those already using combined movement assessment in the cervical spine. Ioannis’s work adds to the work from 1999, demonstrating excellent reliability in the lumbar spine (see the abstract below). This just leaves the thoracic and upper cervical spines for someone to take on. Let me know if you are a capable researcher looking for a project supervisor!

Barrett CJ, Singer KP, Day R. Assessment of combined movements of the lumbar spine in asymptomatic and low back pain subjects using a three-dimensional electromagnetic tracking system. Man Ther. 1999 May;4(2):94-9.

Combined movement examination (CM) is used by physiotherapists to assess and treat patients with low back pain (LBP). However, this method has not been subjected to quantitative assessment. The purpose of this study was to discover if CM of the lumbar spine could be measured with acceptable intra-examiner reliability and to make a preliminary investigation of the effect of LBP on the results of CM. Combined movement examination of the human thoracolumbar spine was measured using a three-dimensional electromagnetic goniometer (3SPACE Fastrak Polhemus, Colchester, Vermont, USA). 1. Intra-examiner reliability of CM was evaluated using a test-retest design; examination was repeated in 23 subjects without LBP and 16 with LBP. 2. A sample of 31 subjects without LBP and 23 subjects with LBP underwent CM, which involved measuring right and left sideflexion in the flexed, neutral and extended position. Pearson’s r and the intraclass correlation coefficient for all variables ranged from 0.79 to 0.93 (P < 0.05). A MANOVA test (P < 0.05), comparing the combined effects of the two variables for each position, was used to test for a difference between the positions attained by the subjects with LBP and those without. Generally LBP subjects showed smaller ranges of movement than those without LBP. Each position was recorded as a degree of rotation around the x-axis (flexion/extension) and around the y-axis (left and right sideflexion). CM can be carried out with acceptable intra-examiner reliability; preliminary evidence is presented concerning the effectiveness of CM in identifying reduced spinal movement in LBP subjects.