Summary To date hands-on examination and treatment techniques have been the most accurate way of understanding the musculoskeletal workings of the spine, and the likely clinical diagnosis of pathology seen there. The underlying biomechanics are an integrated complex of physiology, biochemistry and anatomy, at each of the spinal levels, typified on examination by a characteristic pattern of movement in the three classic planes, ie sagittal, frontal and horizontal. With normal activity, combined movements among all three planes of movement also occur, depending on the structure and function between motion segment levels, up and down the spine. Changes in these ‘normal’ patterns occur when abnormal pathology is present, typified by the signs and symptoms expressed. The most important of these are the altered physiological and accessory movements demonstrated by the ‘regularity’ or ‘irregularity’ of movement patterns, for any given pathology. Regularity or irregularity of the combined movement pattern depends on the relationship between the primary movement and the overall abnormal pattern. This may be interpreted as an I or H configuration for ease of notation. The primary movement is that direction of movement, in one of the three planes, which is the most symptomatic. Depending on the area of symptoms and assuming that the symptoms do not cross the midline, ‘regularity’ may be expressed as a regular stretch or compression pattern. The outcome of the treatment and its expediency can be greatly influenced by accurate assessment of this movement relationship, between the normal and pathological state and thus by the correct choice of the combined movement technique; which can be performed as a physiological technique, an accessory technique, or both together. It also gives a greater appreciation of the likely causative structure at fault, from its anatomical location in the motion segment. This can be seen from the superimposed I or H pattern. This may aid in a clearer prediction of treatment results and prognosis. Undoubtedly this form of examination and treatment progresses the former maze of techniques and examination procedures into a much clearer guide for treatment when dealing with the conservative management of spinal pathology. It also allows some greater insight into the ways of forming and understanding a clinical diagnosis with such often difficult conditions, and is an essential progression of manipulation in the treatment and understanding of such spinal conditions.