Treatment of Thoracic/Lumbar Spine Dysfunction with Combined Movement Theory: Mobilisation & Manipulation

Tutor: Christopher McCarthy PhD, PGD Manipulative Therapy, PGD Biomechanics, MMACP, MCSP
Duration: 2 day(s)

Course Description:

Full course outline (PDF) click here

Spinal manipulative thrust technique (SMTT) has been used by physiotherapists and other manual therapy professions for many years (1). Seminal authors in the field of musculoskeletal therapy including Cyriax, Grieve and Maitland have described spinal manipulative thrusts and recommended their consideration in the management of spinal dysfunction. At post-graduate level SMTT continues to be requested and taught and there appears to be no decline in the popularity of these techniques despite the scarcity of evidence to support their continued use.

Passive movement of the vertebral column is used commonly in the management of spinal dysfunction. One of the most popular paradigms of passive movement treatment in spinal dysfunction is the Maitland Concept and the corollary of this, Combined Movement Theory (CMT). The aims of this course are to introduce the fundamental similarities in approach between SMTT and CMT and introduce a process of SMTT selection based upon CMT. It is envisaged that adopting this rational of SMTT selection will provide the participant with a method of applying SMTT that integrates the two concepts.

Aims of the Course

An Exploration of the Combined Movement Approach:

This course aims to provide participants with an opportunity to explore the treatment of spinal dysfunction using the Combined movement concept of treatment advocated by Brian Edwards. This concept offers participants a rational way to select patient presentations suited to this method of treatment and a clinically reasonable way of incorporating manipulative thrust and end of range mobilization techniques into a passive movement treatment approach. The philosophy of the course is to facilitate the learning of participants by encouraging self directed exploration of the issues and avoidance of a didactic teaching style.

Selection of Type and Position of Treatment:

This course does not set out to provide participants with a handful of manipulative thrust techniques rather encourages participants to develop skills in the selection of mobilisation and manipulation techniques in the appropriate clinical scenarios. An important tenant of this course is the emphasis on CMT being a component of a holistic approach to spinal dysfunction and not that this approach is the panacea to all spinal pain.

The Development of Practical Handling Ability:

The course contains a large component of practical skill development however this element is grounded in the theoretical background of analytical assessment, validity of technique and risk /benefit. Before participants begin palpating the rational behind techniques are discussed.

Development of Clinical Reasoning Skills:

Participants may not have successfully performed a manipulative thrust at the end of the two days but will know when, where and how to achieve it. More importantly they will know why they would consider this approach and what they should expect from it.

Learning Outcomes of the Course

On completion of the two, two-day course participants will be able to;

Clinically reason what patient presentation type should be suited to the CMT approach.
Have developed the skills to determine primary movement patterns suggesting source structures and corresponding starting positions for treatment.
Developed skill in palpating the cervical spine anteriorly, and the rest of the spine posteriorly. The participant will be able to palpate muscle spasm and passive joint restriction.
Clinically reason the decision of when to mobilise and when to manipulate a spinal joint. Appreciate the complexities of the issues surrounding pre-manipulative screening and the risk/benefits of end of range mobilisation and SMTT’s.
Appreciate the evidence base behind mobilisation and manipulation in the treatment of spinal dysfunction.
Clinically reason progression and regression of treatment and be conversant with the notation of treatment.

Structure of The Course With Examples Of Teaching Strategies

Introduction to CMT and SMTT (Lecture format)

The course begins with a formal lecture encouraging interactive discussion regarding the effects, effectiveness and applicability of SMTT. The lecture introduces the evidence on effectiveness of SMTT in light of the evidence of it's effects. This approach allows participants to interpret the strengths and weaknesses of the available literature in the filed. During this lecture the importance of developing palpatory skill is highlighted and discussion of the issues encouraged.

Introduction to Examination Principles.

Participants are given a case presentation and interactively develop an approach to examination. Basing the practical examination on a clinical presentation facilitates the reasoning behind the structure of the differential examination and emphasizes the flexibility of the approach. Practical techniques that will be explored will include, Anterior palpation of the cervical spine with discussion of the applied anatomy. Combined PPIVM’s and PAIVMS and discussion of the validity of the appreciation of “end feel”.

The progressive development of combined starting positions.

Participants will be guided through a process of developing skill in appreciating the feel of progressively more combined and complex starting positions for treatment. An understanding of the underlying structures being placed under tension will be emphasized throughout this process.

Development of the ability to judge the suitability of manipulation.

The strongest indicator for whether a manipulative or mobilisation technique is utilized is the quality of the “end feel”. Participants will be able to make a confident assessment of this before the end of the course.

Prior to SMTT’s the risk / benefit and VBI issues are discussed. This lecture (at the start of the second day) encourages an open debate regarding the risks and benefits of SMTT in the cervical spine and covers the issues of VBI testing, guidelines and contraindications. Participants will be given case study clinical presentations and asked to discuss there views on suitability for SMTT / end of range mobilisation.

End of range mobilisation / SMTT techniques

Having developed confidence in being able to identify whether a joint is “suitable” for a SMTT participants are encouraged to work with their models to identify levels that may be manipulated. Agreement between the models and operators is encouraged throughout this process. Prior to SMTT techniques models are screened for potential VBI and a process of consent is established.

SMTT’s will only be conducted under the agreement of both operator and model that the joint feels suitably positioned to thrust and that the technique will only be conducted under the supervision of the tutor. Post SMTT the reassessment of the joint’s end feel and change in local paraspinal muscle tone is emphasized. Participants will be able to feel the immediate changes that are produced by the technique and thus will develop a better understanding of when these changes are indicated.

Discussion of the reasoning behind starting positions and the progression and regression of treatment.

Participants are presented with case presentations and in small groups reason the starting positions for treatment and the progression and regression of a treatment programme. Included in this are discussions on home exercise procedures.

Summative discussion collating / reiterating and synthesizing what has been covered in the weekend.

Group discussion is encouraged to ensure that the key themes of the weekend are reiterated and that participants feel confident to utilise the principles of the CMT approach into their clinical practice.

Thus, the courses strategies for learning include:

Interactive lectures / group discussion
Case scenarios – discussed in small groups and presented with intergroup discussion
Problem solving in small groups – debate on clinical decision making
Practical sessions emphasizing continual feedback from participants and tutor.

Who Can Attend:

This course is suitable for all HPC registered manual therapists (physiotherapists) and osteopaths & chiropractors.