Transmisión vertical

Cervical spine case study . . . 102 Integration of manipulation . . . 106 Integration and progression of muscle

tonicity techniques . . . 106

Notation

Whilst the use of the IN and DID system will encour- age the consideration of starting positions, the use of box diagrams is an excellent method of conveying com- bined movement theory (CMT) positioning. The box diagram conveys considerable amounts of information with the simple addition of two lines to a box frame- work (Fig. 7.1). The frame of the box diagram re- presents 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 thera- pist that a process has been undertaken in order to

draw the box diagram. The significant features of the box diagram follow:

• The direction of movement that reproduces pain suggests whether the pain is an anterior or posterior stretch pattern.

• 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.

• The presence of two lines on the box diagram signifies that the movement not featuring was the least provocative.

• The bolder of the two arrows signifies that this is the most provocative movement, or ‘prime movement’.

• A two-headed arrow simply emphasizes that this was the second movement of the primary combination, whilst a one-headed arrow shows that it was the first.

• The order of the primary combination signifies that this order has been established by comparing both combinations and ranking them.

Treatment progression

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.

CERVICAL SPINE CASE STUDY

INITIAL INTERVIEW

Symptomology

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.

RELEVANT HISTORY

Symptoms developed over a 6-day period following a mild, rear shunt whiplash injury, a week ago.

BEHAVIOUR OF SYMPTOMS

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.

DIURNAL PATTERN

There was no stiffness in the cervical spine in the morning. Shoulder pain developed in the evening. Sleep was not disturbed.

SPECIAL QUESTIONS

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.

PHYSICAL EXAMINATION

Observation

There was no atrophy of the cervical musculature. There was an increase in muscle tone of the right sternocleidomastoid, upper fibres of trapezuis and levator scapula and right scalenes.

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).

Passive physiological intervertebral movement (PPIVM)

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.

See the completed planning sheet in Figure 7.2.

Right-sided movement Flexion

Extension

= Extension to half expected range ‘prime movement’

= Extension, left lateral flexion ‘prime combination’ Key Left-sided movement Low neck severe

List your hypotheses for the nature of the condition.

1. ... Posterior facet capsule sprain ... 2. ... Posterior paraspinal strain ... 3. ... Posterior annular disc sprain ...

Which two hypotheses will you test against each other in the initial physical examination?

Primary ... Articular predominance ... Secondary ... Myogenic predominance ...

Is the nature of the condition severe?

Yes No

Is the nature of the condition irritable?

Yes No

To what point are you allowing movement to occur?

Before pain To pain To limit

What is the functional demonstration/primary re-test marker?

... Flexion contralateral, lateral flexion quadrant ...

What is the primary pain mechanism of this patient’s condition?

Nociceptive Peripheral neurogenic Central

Autonomic Affective

To what extent will you perform a neurological exam?

None required Local peripheral

Lower motor neuron, upper motor neuron, limbs

Lower motor neuron, upper motor neuron, limbs and cranial

What is the weighting of the following components of the problem?

% Arthrogenic 50 Myogenic 40 Neurogenic 1 Inflammagenic 2 Psychogenic 1 Sociogenic 1 Pathogenic 1 Viscerogenic 1 Osteogenic 3

Likely first treatment:

In: Extension, right lateral flexion quadrant ... Will: Anterior capsular stretch, large amplitude movement, in resistance (Grade III) ...

Comments/cautions:

Pain relief approach, progressing to a stretch of the tissues driving the nociceptive pattern of presentation ... ...

OBJECTIVE EXAMINATION PLAN

0 50 100 Arthrogenic Radar plot Myogenic Osteogenic Neurogenic Viscerogenic Inflammagenic Pathogenic Psychogenic Sociogenic

A short passive treatment, using this right lateral flexion of C5 on C6 reduced the pain produced by the functional demonstration by 10%.

Passive accessory intervertebral movement (PAIVM)

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).

A short passive treatment, using this accessory movement reduced the pain produced by the functional demonstration by 40%.

Muscular assessment

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.

Palpation and length assessment of levator scapulae, scalenes, upper fibres of trapezius and sternocleidomastoid did not alter the functional demonstration.

The most appropriate treatment to induce great- est change in dysfunction was established to be:

Rx1 IN: right lateral flexion, extension DID: unilateral AP glide of C5 on C6, Grade III, 1 1 minute

OUTCOME: 40% reduction in pain