To B or not to B ? A new digital movement diagram

When choosing a topic for this blog post, I had several ideas in mind. In the end, I decided to revisit an old project that I hadn’t been able to bring to life for a long time. Trying again, I finally found the solution. All that was left to do was build the tool—a custom website created from scratch and its linked software application: movementdiagram.com—before sitting down to write these few lines.

The Legacy of Geoffrey Maitland

One of the greatest strengths of the Maitland Concept® lies in its unmatched ability to model and map clinical complexity. Rather than reducing the physical examination to a rigid medical diagnosis, Geoffrey Maitland created a true visual and conceptual language to capture the patient's dynamic reality through an open-minded approach. He developed an arsenal of clinical representation tools built upon several essential conceptual pillars:

• The Brick Wall: A brilliant metacognitive model that separates the theoretical/pathological side (often uncertain anatomical hypotheses) from the clinical/functional side (observable signs and symptoms). It enables clinicians to treat what they actually evaluate without falling into the trap of a biased structural diagnosis.

• Clinical Categories: A rigorous framework for clinical reasoning (pain mechanisms, irritability, dominant presentation, red/yellow flags) that guides decision-making.

• Mobilization Grades (I to IV): A universal system for dosing the force, amplitude, and rhythm of passive mobilizations.

• The MOVEMENT DIAGRAM***

• …

Movement Diagram vs. Numeric Rating Scale

The Maitland movement diagram and the Numeric Rating Scale (NRS) do not measure the same thing: the NRS is a unidimensional measure of pain intensity as perceived by the patient, whereas the Maitland diagram is a three-dimensional, dynamic tool for clinical reasoning.

Why the Maitland Diagram Is More Powerful

The Numeric Rating Scale indicates how much pain a patient feels (e.g., 6/10), but it offers no mechanical information to the examiner. The Maitland diagram surpasses the NRS because it maps the relationship between three cardinal factors throughout the passive range of motion (PROM):

• Pain (P): Its onset, intensity, and limit.

• Tissue Resistance (R): Its onset, progression, and end-feel.

• Protective Muscle Spasm (S): Its reactivity and dominance.

By overlaying these variables on an amplitude axis (A-B) and an intensity axis (A-C), clinicians can identify the primary limiting factor (e.g., does pain occur before or after tissue resistance?).

To B or Not to B?

Asking this question—which carries two distinct meanings—is essential:

1. When I assess a passive movement, where do the Pain, Resistance, and Spasm parameters fall along the range of motion relative to point B?

2. When I want to treat these limitations effectively, which parameters should move toward point B?

A clinician working alone in their clinic must constantly make decisions: What should I do with these thresholds of pain, resistance, and spasm? What seems "abnormal"? What must I respect? How do I make sense of the overall clinical presentation?

This reasoning process is emphasized in orthopedic manipulative therapy courses, most notably within the Maitland Concept®, which offers the movement diagram as an analytical and decision-making tool. Granted, this tool is not perfect (see the blog post by our colleague Rolf Walter from September 9, 2018, on imta.ch), but as mentioned earlier, it strives to reflect reality.

Much like physicists writing equations to grasp the physical reality of an apple falling from a tree, a orbiting planet, or a liquefying gas, therapists use a mental or drawn movement diagram to better understand what is happening under their hands.

A Recognizable Melody

When analyzing a movement diagram, precision is desirable, but it is not everything. What matters most is recognizing the melody. Indeed, if we compare the different parameters to musical notes and chords, two things become strikingly clear:

1. Differentiating two melodies despite shared notes is remarkably easy (whether comparing two different patients or tracking the progression of a single patient).

2. The same melody can be played differently by transposing it into a higher or lower key, yet it remains instantly recognizable.

The diagram becomes the synthetic sheet music of manual therapy. By reading the behavior of these notes throughout the range of motion, therapists no longer passively endure the consultation: they listen, adapt their technique in real time, and reassess immediately after their intervention.

Diagrams and Therapeutic Strategy

This is where things get more challenging, and where being able to justify clinical choices becomes crucial (as reflected in clinical reasoning forms). While neuroscience research helps us better understand pain and what might be happening inside our patient's "black box," it remains a complex endeavor.

To extend the musical analogy: we must realize that some patients need slow ballads, others need rock 'n' roll, and some require heavy metal—and this musical style must adapt as the patient evolves (as seen in frozen shoulder cases, for instance). 

A Digital Tool to Explore

Instructors, course participants, and clinicians are all invited to try out movementdiagram.com and share it across their networks. This digital diagram tool is already capable of reproducing nearly every diagram found in the Maitland Concept® literature, though it remains a work in progress open to further refinement.

I hope you find it useful, and I look forward to hearing your feedback and suggestions!

Pierre Fisette

MovementDiagram https://movementdiagram.com/

Tutorial : https://youtu.be/n2-ByrggAyg?si=TCLIBK5eW8T_gp0F

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