There was not much going on our Blog recently, but here we have the long-awaited food for thought!
Rolf has faced us with some very important questions, going much in depth to the topic of Movement Diagram – an issue closely connected with the manual therapy world.
He makes us look at it from many different angles and invites for discussions… so, here I go!
I’m in turn a great fan of the Movement Diagram – in its modern understanding, as we present it during Maitland Concept courses!
As the very definition, which Rolf cited, says – it is only(?) a teaching aid (a good one though:), intended to help therapists (at their beginnings of the adventure with manual examination) try and focus on many factors at the same time: range, pain, resistance, spasm and “analyse the manner in which these factors interact to affect the movement”. Of course, faced with the current science we know clearly, that in certain cases these factors may, or may not be interrelated! (eg. in the presence of some processing issues).
So, I’ll try to answer some of Rolf’s intriguing questions in my own understanding:)
*Would I do the Movement Diagram for each of my patients, even in the light of current neuroscience?
Well, why not?! Surely, not on the piece of paper (although at my beginnings I’d used tones of paper trying to come to terms with this issue), but in my head I do it almost automatically. Why? To check if “the features fit” – if I get what I expected, or if I can get anything informative from the interdependencies or the lack of them! It’s always better to analyse, than assume:)
*How would we express in the Movement Diagram some important issues, clearly influencing our treatment parameters, like activity levels, individual reactions related to loading, immunological/metabolic/hormonal informations about the patient, their psychological health?
Well, we could try, but then our diagram could look somewhat like this…
Luckily – no need to do it! We don’t have to put all the factors inside, but simply put the Movement Diagram in relation to all the aforementioned factors!
*Can the movement diagram be used in a clinical decision making process?
Yes, as an additional information to what we already know about the patient!
*Can it decide on where to treat, how to treat, in which directions to treat?
No, it’s not the diagram that decides, but it’s us, using all sorts of data we managed to collect. Movement Diagram is just one of them:)
*…and can it help in making decisions on how to dose the treatment?
Yes, it can give us some hints, so “help” is the right word here:)
Then Rolf explains: “Movement diagram features are maybe part of a decision making process but it’s elements (…) have to be put into a larger bio-psycho-social model.” I totally agree! I think, as physiotherapists, we all implicitly work according to this model during our meetings with patients (majority of us chose this profession, simply because we like people and we care about them!). However, it’s a pretty big issue on the courses of Maitland Concept, to make this approach more explicit.
…and there’s some more!
*Does the most painful or most restricted joint needs to be treated?
Sometimes yes, sometimes no.
Geoff Maitland himself stated, that “a stiff joint does not necessarily cause pain”  . Increased stiffness (eg. on one spinal level) may in fact be a normal variant (alternating tropism) and bear no relationship to the patient’s presenting symptoms.
It’s also clear, that in case of a very painful joint (or the structures around it), we may choose to treat some neighbouring or distant places.
The answer to the question above lies again in the clinical reasoning process – for this we use categories of hypotheses, we decide on clinical group, pain mechanisms… we use all sort of available puzzles to decide on how we would like to handle each patient. Therefore we need to collect so many information, before we even touch our patient! It’s not like in the old school manual therapy settings, where the patients had nothing to say (poor guys) – there was only MC Manual Therapist and his all-knowing hands.
Nowadays we know from numerous studies (mentioned also by Rolf), that the reliability of clinicians’ assessment of stiffness and movement assessment is poor. However, in the Maitland Concept, before we do this palpation or palpation of movement, we already have some hypotheses about the individual. If we know what we’re looking for, it’s easier to find it and confirm the hypothesis… or reject it! Using our hands as the only tool will always fail. Thanks God for our heads;)
Not to forget, there actually are some studies that demonstrate increased resistance being associated with symptomatic levels [2,3]
Rolf mentioned also various studies analysing the inter-therapist reliability in the performance of grades of mobilisation as well as in finding R1. Are we consistent? The studies show clearly: not really. Should we now be in a dark despair? Not at all!
One of the possible explanations for the poor reliability of therapists to detect resistance during spinal joint accessory movement may relate to the very concept of R1. There’s an ongoing discussion on it’s definition. Does it start at the first contact with patient’s tissues, or is it the first firm resistance, perceived by the therapist? If we adopt the second option (as we do in the Maitland Concept), is it then a point on the line, or rather set of points? (Petty and Maher concluded in their study, that there’s no clear transition point between the toe and the linear regions of the force-displacement curve on the Movement Diagram, rather there are a range of points, which might be considered to reflect a change in gradient.) 
The second trouble with checking the reliability of finding R1 is the issue of measurement. The studies which have tested therapist reliability of finding R1 have used force as a measurement (both on living subjects, as well as on some various, sometimes elaborate devices). [4,5,6,7,8]
However, if the studies considered R1 as a point, and in fact it’s a range of points (a section of the curve), then the therapists would have been considered to be reliable.  Yeah!!!!!
(Rothstein (1985)  comments, that a science is only as good as the measurement on which it is based.:)
Also the studies, which show poor inter-tester reliability of the grades of movement, are based on force measurements, which is equally not optimal. Some other researchers in their studies, however, do not support the use of a single amount of force for a specific grade of movement. Rather the need to vary forces between individuals is supported. 
Recognising the ranges for various grades of mobilisation helps to clarify parameters that can serve as reference for clinical practice.
But wait! There are also studies that claim, that students instructed in in Maitland’s grades can identify the grades visually and kinaesthetically when demonstrated on a chosen in the study technique, and can also perform grades within this technique with 90% accuracy level.  This looks much better fur us as therapists, doesn’t it? 😉
What is more, when it comes to the reliability of pain provocation tests, in research the situation looks much more promising! Matyas & Bach  in their research – in contrast to poor reliability for tests of spinal compliance, concluded that tests of pain had good to excellent reliability. Also other researchers [13,14] found, that tests which relied solely on patient response (such as pain and tenderness) are reliable.
Rolf has shown results of one meta-analysis which show, that “as little as 3% of pain relief can be attributed to the actual MT treatment and the rest can be attributed to natural history, patient motivation and expectations maximized by re-assurance”. (the 3% concerned actually acute pain; in chronic patients situation looks slightly better, giving 32% of attribution to MT in pain relief). The other study mentioned by Rolf shown, that patients, who got a “simple re-assuring sentence had the greatest level of satisfaction with their treatment”. But hey! Isn’t the modern definition of Manual Therapy connected among others with explanation for the patient or active approach? We do it all! Maitland himself would always put a lot of attention to the appropriate communication with the patient (which we still highlight during the courses), which is also a part of manual therapy. Therefore I think it’s not to be separated. We do it all simultaneously – treating on different levels! If we then add all the percentages, the result starts giving much more comfort, than this frightening 3% (is it really possible to measure it, anyway?)!
The same study says: “Treatments serve to motivate, reassure, and calibrate patient expectations – features that might reduce medicalization and augment self-care. Exercise with authoritative support is an effective strategy for acute and chronic low back pain.”
Here we are! Bio-psycho-social model at work:)
And sure, as Rolf underlined, the Movement Diagram consists (actually ONLY) of “subjective” factors – pain (patient’s perception), stiffness (therapist’s perception). So I wouldn’t call it a “NAIL” anyhow! However, we often have no better data to operate on, so we have to squeeze out as much as possible from available sources. And exactly for this reason I personally find Movement Diagram (with all its undeniable limitations!) a cool thing, especially as a teaching aid. Without it, the considerations on the super-multifactorial influences on patient’s presentation could have been too abstract to comprehend for the newcomers to manual examination in particular! So, maybe it looks quite scary on the first look, but we truly can get used to integrating it into our reasoning as an additional tool:)
Rolf’s Blog reveals what I like in the IMTA so much – constant search for better tools, constant inquiry in the knowledge we share and the critical look on our own program, constant improvement according to the latest evidence… Maitland Concept is even today revolutionary: open, flexible, modern! I love it!
Thank you Rolf for this very interesting Blog contribution and for your relevant comments and observations!
 Maitland G (1986): Vertebral Manipulation. (5th ed.) London: Butterworths.
 Gay RE, Ilharreborde B, Zhao K, Zhao C, An KN. Sagittal plane motion in the human lumbar spine: comparison of the in vitro quasistatic neutral zone and dynamic motion parameters. Clin Biomech (Bristol, Avon). 2006;21:914–9
 Petty NJ, Maher C, Latimer J, Lee M. Manual examination of accessory movements — seeking R1. Man Ther. 2002;7:39–43
 Hazle CR, Nitz A, A simulated passive intervertebral motion task: observations of performance in a cross-sectional study, J Man Manip Ther. 2012 Aug; 20(3): 121–129.
 Cook CE. Effectiveness of Visual Perceptual Learning on Inter-Therapist Reliability of Lumbar Spine Mobilization, The Internet Journal of Allied Health Sciences and Practice. July 2003. Volume 1 Number 2.
 Chang JY, Chang GL, Chang Chien CJ, et al. Effectiveness of two forms of feedback on training of a joint mobilization skill by using a joint translation simulator. Phys Ther. 2007;87:418–430.
 Sheaves EG, Sodgrass SJ, Rivett DA, Learning Lumbar Spine Mobilization: The Effects of Frequency and Self-Control of Feedback. J Orthop Sports Phys Ther 2012;42(2):114-124, Epub 25 October 2011.
 Chester R, Watson MJ, A newly developed spinal simulator. Manual Therapy (2000) 5(4), 234–242
 Rothstein J, .Campbell.S, Echternach J, Jette A, Knecht H, and Rose S (1991): Standards for tests and.measurements in physical therapy practice. Physical Therapy 71: 589-622.
 Talbott NR, Witt DW, In vivo measurements of humeral movement during posterior glenohumeral mobilizations. J Man Manip Ther. 2016 Dec; 24(5): 269–276.
 Rollins CA, Robinson JL, Evaluation of Undergraduate Physical Therapy Students’ Comprehension of Maitland’s Grades (I-IV) for Posterior Mobilization of the Glenohumeral Joint. J Orthop Sports Phys There 1980.1:214-221.
 Matyas T, Bach T (1985): The reliability of selected techniques in clinical arthrometrics. Australian Journal of Physiotherapy 31: 175199.
 KeatingJ, Bergman T,Jacobs G, Bradley D,Finer A and Larson K. (1990): Inter-examiner reliability of eight evaluative dimensions of lumbar segmental abnormality. Journal of Manipulative andPhysiologicalTherapeutics1 J: 463-470.
 Patter N, Rothstein J (1985): Intertester reliability for selected clinical tests of the sacroiliac joint. Physical Therapy 65: 16711675.