Manipulation of the Spine, Thorax and Pelvis: An Osteopathic Perspective Second Edition

Peter Gibbons Philip Tehan Foreword by Philip EGreenman CHURCHILL UvrNGSTONE EUEVlER Manipulation of the Spine, Thora...

Author: Peter Gibbons MB BS DO DM-Smed MHSc | Philip Tehan DO DipPhysio MHSc

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Peter Gibbons Philip Tehan Foreword by Philip EGreenman

CHURCHILL UvrNGSTONE EUEVlER

Manipulation of the Spine, Thorax and Pelvis An Osteopathic Perspective With accompanying CD-ROM

SECOND EDITION

Peter Gibbons MB BS 00 DM-SMed MHSc Associate Professor. Osteopathic Medidne. Victoria University, Melbourne. Australia

Philip Tehan 00 DipPhysk> MHSc Senior lecturer, Osteopathic Medidne. School of Health Sciences. Victoria University, Melbourne. Australia

Foreword by

Philip E. Greenman 00 FAAO Emeritus Professor, Department of Osteopathic Manipulative Medicine;

Emeritus Professor. Department of Physical Medicine and Rehabilitation, Michigan State University College of Osteopathic Medicine. Michigan. USA

Photographs by Tim Turner

ELSEVIER

•

EOIN8UAGH LONDON

NEW YORK OXFORD PHIlADElPHIA ST lOUIS SYDNEY TOAOHTO 2OOl5

CHURCHILL UVINGSTONE El..SEVIE.R

C Hatcourt Pub6shers limited 2000

C 2006. Elsevier Sclt!nce Umited. All rights ff!§ef'ied. The rights of P1!ter Gbbons and Philip Tehan to be idefltifled )'mmetry, range of motion and tissue texture changes).3.22.n Pain provocation and reproduction of famiJiar l>)'mptoms should also be used to localize somatic dysfunction. The presence

of somatic dysfunction and/or pathology should be determined not only by physical examination but also by information gained from a thorough patient history and patient feedback during assessment. l11is depth of diagnoslic deliberation is essential if one is to select which case may or may not be amenable to treatment and \vhich treatment approach might be the most effective while offering the patient a reason€
Somatic dysfunction is identified by the S-T-A-R-T of diagnosis lBox A.2.2l Box A.2.2 Diagnosis of somatic dysfunction

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relates to symptom reproduction • T relates to tissue tenderness • A relates to asymmetry • R relates to range or motion

• T relates to tissue text...-e changes

S

relates to symptom reproduction

While somalic dysfunction can be al>)'mplomatic, it commonly exists within the context. of a patient presenting with symptoms. Pain provocation and the reponing of reproduction of familiar symptoms are therefore essential components of the physical examination. T

relates to tissue tenderness

Undue tissue tenderness is often present and must be differentiated from reproduction of the patient's familiar pain.

A

relates to asymmetry

DiCiovanna links the criteria of asymmetry to a positional focus stating that the 'position of the vertebra or olher bone is

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Osteopathic philosophy and technique asymmetrical'?2 Creenman broadens the concept of a~)ymmeuy by including functional in addition to strudural ~ymmetry.:U

R relates to range of motion Alteration in range of motion can apply to a single joint, several joints or a region of the musculoskeletal system. the abnormality may be either restrided or increased mobility and includes assessment of quality of movement and 'end feel:

T relates to tissue texture changes The identification of tissue texture changt'S is important in the diagnosis of somatic dysfunction. Palpable changes may be noted in superficial, illlennediate and deep tissues. It is important for clinicians to recognize normal from abnormal. The diagnosis of somatic dysfunction using the S-T-A-R:r approach should nOt be based upon a single finding but should be detennined b)' the clinician identifying a number of positive findinf.;) that are consistent with the patient's clinical presentation.

SOMATIC DYSFUNCTION AND OSTEOPATHIC MANIPULATIVE TECHNIQUES A palielll's overnll management requires the identification of broad thernpeutic objectives. The Quebec taskforcE?4 developed a Jist of objectives in the treatment of spinal disorders. Box A.2.3 is a modified list of these objectives. which takes accollnt of an osteopathic perspective. Patients should be made aware of the potential debilitation of excessivf' bed re;t, the dangers of OVf'r medication and thf' inadvisability of surgery without strong preoperative indications. Once a praaitioner has established therapeutic objectives. consideration must be given to the specific treatment of somatic dysfunruon. '111ere are many osteopathic approaches (Box A.2.4) that can be used.

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Box A.2.3 Therapeutic objectives in the treatment of spinal disorders • Promote rest fOt" the affected anatomic structures • Diminish musde spasm • Diminish inflammatton • Improve tissue fluid drainage • Reduce symptomatic pain • Increase musde strength • Increase range of motion • Increase endurance • Increase functional and physical WOfk capacity • Modify work and home environment • Alter mechanical structures by surgical intervention • Met" neorological structures by denervation • Modify social envil'Ol'Y1'lent • Provide treatment adapted to the psychological aspects d the probkom

Box A.2A Osteopathic manipulative techniques

• • • • • • • • • • • • •

• • •

Articulatory Balanced ligamentous tensKMl Chapman's reflexes Facilitated positional release Fascial ligamentous release Functional High-velocity low-amplitude thrust Integrated neuromuscular release and myofasdal release Lymphatic Muscle energy Myofasclal trigger point Osteopathy in the cranial field Progresslve inhibition of neuromuscular structures Soft tissue Strain and counterstrain Visceral

Ideally, osteopaths should embrace a range of different techniques and not f.wour anyone specific approach. In practice. the most commonly used osteopathic manipulative treatment

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HVLA thrust techniques - an osteopathic perspective

techniques are articulatory, high-velocity

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!O\...·amplitude (1IVlA) lhnlSl, rounterslrain, muscle energy, Ill}'ofascial/neuromuscular release and soft tissue techniques. u

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References

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Special Commill~ on Ostcopalhk Principles and Osu,;opathicTtxhnk. Kirksville College of Osteopathy and SuIgCl)'. An interpretaLion of the osteopathic ConCcpL Tentam'f': fonnulaLion of a leaching guide for farulty, hospital staff and studem bod}'. J Osteopathy 1953; 60:8-10. lhe Glossary Review Committee of the WucalionaJ Council on 05leop.nhk I'rinciples.. Glossary of osleopathic lerminology. In: Allen TW, ed. ADA Yearbook and Directory of Osleopathic Ph)"Sirians.. O1icago: American Osleopa1hk Association; L993:GlossaJ)'_ Kappler RE. PaJpatOly skills and. exercises for oodoping the sense of touch. In: Ward R. ro. Foundations for OstOOJl'lthic Mrokine. Philaddphia: Uppincou Williams & Wilkins; 2003: Ch. 38. lohnslon WI.. Elkiss MI- Marino RV, Blum CA. I"as&iw: gross ITlOI ion lesting: Part II. A study of il1terexarniner agrttmmL I Am Osteopath Assoc 1982; 81 (5):65-69. JohnSiOll WL I~I Me, BluTli GA.. Iiendm ,I... Neff I)R. Rosen ME. Passhl': gross motion 1e5ling: Part III. Examiner agreemenl on sdooro subjects.. J Am Osleopath Assoc 1982; 81 (S): 70-74. McConnell I)G, Heal Me, Dinnar U, et al. Low agreement of findings in neuromuscuJoskeletal vcamlnalions by a RIOtIP of osleopalhic physicians using Iheir own procedures. I Am Ostcopath Ass« 1980; 79(7):59-68. Beal Me.. Goodridge JP' lohnston WI. McConnell DC. 11llel"t.'Xaminer agrecmell1 on patiel\l imprOYellll':llt afler negOlialed selection of lestS. I Am OSleopalh Assoc 1980; 79(7): 45-53. Marcoue J, Normand M.. llIack P. 'nlf: kinemalics of motiOll palpalion and its effect 011 the lellability for cetVical spine rotation. , Manipulal.ive Physiol Ther 2002; 25(7):471. Van Duersen I1.JM, Pat.ijn I, Oc.kh1l)'SCtl AL \'ortman BJ. lhe value of some c!inicaltcsts of Ihe sacroiliac jOillL Man Moo 1990; 5:96-99. 1.ask1t M, Williams M.. The reliability of selected pain pt"O\"OGIlion IesU for sacroiliac joim palhoklgy. In: L.ttming A, Moone)' V, Dorman T, SnijdeB CI, cds. The Inlegr.uro I\.ll'lCtion of th(' Lumbar Spine and Sacroiliac loinl. Rotlerdam; EGO; 1995:465-498.

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Connella C l' posterior axis is the z-axis (Fig. A.3.I'). In biomechanical terms, flexion is anterior (sagittal) rotation of the superior vertebra around the x-axis, whiJe there is accompanying forward (sagittal) translation of the vertebral body along the z-axis. In extension, the opposite ocrurs and the superior vertebra rOtates posteriorly around the x-axis and translates posteriorly along the z-axis. In sidebending. there is bone rotation around the amero-posterior 7....axis, but sidebending is rarely a pure movement and is generally accompanied by vertebral rotation. The combination, and association, of one movement with others is termed 'coupled motion'. 1he concept of coupled mOtion is not recent. As early as 1905, Lovett~ published his observations of coupled motion of the spine.

COUPLED MOTION Coupled motion is described by White and PanjabiS as a 'phenomenon of consistent association of one motion (translation or rotat.ion) about an axis with another motion

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,.....

Figure A3.1 Axes of motion. (Reproduced with permission from Bogduk..l )

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about a second axis'. Bogduk and 1\....o mer describe coupled movements as 'movements that occur in an unintended or unexpected direaion during the execution of a desired motion'. Stokes eI. aI.' simply state coupling to be when 'a primary (or intentional) movement results in a joint also moving in other directions'. Where rotation occurs in a consistent manner as an accompaniment to sidebending it has been termed conjunct rotation. 7A Therefore. in rotation the venebra should rotate around the vertical y-axis but translation will be complex dependent upon the extent and direction of coupling movements. Coupling will cause shifting axes of motion. Creenman' maintains that rotation of the spinal column is ah\T3.}'S coupled with sidebending with the exception of the atlantoaxial joint. 11le coupled rotation can be in the same direction as sidebending (eg. sidebending righL rotation right) or in

opposite directions (eg. sidebe:nding right, rotation left). The osteopathic profession developed the convention of naming the coupled movements as Type I and T)els with 1.3-4 being a transition level. They concluded that the 'rotary coupling patterns in the lumbar spine are a funaion of the inte"rertebral level and posture'. At the upper lumbar levels, axial torque produced lateral bending to the opposite side whereas at the lower lumbar levels axial torque produced lateral bending to the same side. h was also noted 'that the spine does not exhibit mechanical reciprocity' for example at L4-5 applied left axial torque produced coupled left lateral bending but applied left lateral bending produced coupled right axial rotation. Panjabi et ars l ' finding that 3t 'Ll-3, coupled lateTal bending increased from about 0.5 0 in the fully extended posture to 1.5 0 in neutral and to about 2 0 in flexed posture;', conflicts with Fryette's third Law, whidl indicates that introduction of motion to a vertebral joint in one plane automatically reduces it.o; mobility in the other two planes. In lumbar flexion the coupled lateral bending increased by 0.5 0 from the neutral to the flexed position. A number of studies have indicated that coupled movement ocrors independently of muscular activit},.8.14,27 In 1977, Pope et al. 14 utilized a biplanar radiographic technique to evaluate spinal movements in intaa cadaveric and living human subjects. 'nley confinned that 'vertebral motion occurs as a coupling motion, and that axial rotation uniformly is associated with lateral bend'. FrymO}rer el al. n measured spinal mobility using orthogonal radiogrnphy on 20 male cadavers and nine male living subjects. They found that complex coupling doe; ocrur in the lumbar spine and demonstrated remarkably similar spinal behaviour between the two groups. 'I'hese studies indicate that coupling ocrurs independently of musOIlar aaivity.

Vicenzino and Twomey' used four human male post-mortem lumbar spines from Ll to the sacrum. \\lith ligaments intact and muscles removed to assess conjunct rotation of the spine \.men sidebending was introduced in both a flexed and extended position. 'Iltey found that in the flexed position, lateral flexion of the lumbar spine \vas associated with conjuna rotation to the same side:. lbis is consistent with Frycne's laws. However, in the extended position, lateral flexion was associated \\lith conjuna rotation to the opposite side. which supports Stoddard'sll radiographic observations of coupled motion in the extended position. These findings are not consistent with Fryetle's Laws, which predia sidebending and rotation to lhe same side as lhe facets are not 'idling' when in the extended position. Vicenzino and 1\vomey's' study reveals that the lS-$1 segmem is unique in that conjunct rotation was ah\l3)'S in the same direction as sideflexion, independent of flexion or extension positioning. This finding for the 15-51 segment was supported by Pearcy and Tibrewal u \.mo found that during axial rotation al I5-SI, lateral bending always ocOIrre:d in the same direction as the axial r()(ation. Vicenzino and Twomey' dr.l\v the conclusion that as both in l'itro and in vi.., studies hm.>e demonstrated conjunct rOlation, the non-contractile components of the Iwnbar spine may have primary responsibility for the direction of conjunct rotation and that neuromuscular aaivit}, may only modify the coupling. The impact of muscular anivily on coupled motion in both the normal and dysfunctional intervertebral joint requires further study. The presence of apophysial joint uopism might influence spinal motion and confound prediaive models of vertebral coupling. The incidence of facet uopism has been reported as 20% at all lumbar lE":\ocls but may increase to 30% at the 15-5I segment. l 'I'he incidence of facet tropism is also higher in patient populations attending manual medicine praaitioneT5. It has been

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estimated that as many as 90% of patients presenting with low back pain and sciatica have arlicular tropism with pain ocaming on the side of the more obliquety oriented facet. J Cyran and Hulton 28 subjeaed 23 cadaveric lumbar imer\'enebral joints to a combination of compressive and shear forces. \'lhen asymmetric facels were present, the vertebrae that have such facets rol'ated towards the side of the more oblique facet. They concluded anirular tropism could lead to lumbar instability manifesting itself as joint rotation toward the side of the more oblique facel. This was not a study of coupled motion and no dear comments can therefore be made ahom the influence of faro tropism on patterns of coupling but it does suggest that tropism can influence spinal mechaniex. Disc degeneration and spinal pathology presenting with pain and nerve root signs might also influence spinal coupling. In 1985, Pearcy er. al.·' undertook a lhree~ dimensional radiographic analysis of lumbar spinal movements. l1ley studied patients \vith back pain alone and patients with back pain plus nerve tension signs demonstrated by restriaed straight leg raise. Coupled movements were increased only in Lhose patients without nerve lension signs indicating the possibility of asymmetrical muscle aaion. II was concluded that "The disturoo.nce from the normal pattern of coupled movements in the group with back pain alone suggests that the ligaments or muscles were involved unilaterally and thus acted asymmetrically when the patient moved'. The faCI Lhal coupled movements wefe increased in the back pain group suggests that muscular aajvity, while not being essential for coupling. can influence the magnitude of coupled movement. The adion of the contmctile elements in normal, dysfunctional and pain states requires more study before any definite statements can be made relating to their effea upon coupled motion. Using peraltaneous tmnspedirular screws and optoelearonic camera measurement. Lund eI al. demonstrated that chronic low back pain patients had differ£l1t

coupling behaviour from that of the normal population.1'J It is evident that many faaon;,. such as facet tropism, vertebral I€:\rd, ilUervenebral disc height, back pain and spinal position, might influence the degree and direction of coupling. While it appears that Fryeue's Laws are open to Question and clinicians' concepts of lumbar mupling are inconsistent. Jll there are still only two possibilities for the coupling of sidebending and rotation, i.e. to the same or the opposite side. With this in mind. it appears reasonable to dassify spinal movement as TypE' I and Type 2 in relation to mupled sidebending and rotation. What is nOI dearly established is the influence of flexion and extension in relation to Type I and Type 2 mo\'emenl

CONCLUSION

Conclusions that can be drawn from the litefature are limited for a number of reasons. Cadaver studies exclude the effects of muscular activity and normal physiological loading; the studies were also often single segment analysis and generally of small sample size. Plain radiographic studies have inherent measuring difficulties assodated with extrapolating threedimensional movements from twodimensional films. The use of biplanar radiographic assessment improved the accuracy of measurement and allowed studies to be performed with muscular activity and In more normal physiological conditions; again, however, the groups studied were small. Notwithstanding these observations, there are a number of conclusions that can be drawn: ,. Coopled motion occurs in all regions of the spine. 2. Coupled motion occurs independently of muscular activity but muscular activity might influence the direction and magnitude of coupled movement

Kinematics and coupled motion of the spine

3. Coupling of sidebending and rotation in the lumbar spine is variable in degree and direction. 4. There are many variables that can influence the degree and direction or coupled movement and include pain. vertebralle\lel, posture and facet tropism. 5. There does not appear to be any simple and consistent relationship between conjunct rotation and intervertebral motion segment Ievd in the lumbar spine. Thefe is evidence to support L.ovett's initial observaUons and Fryctte's laws in relation to sidebending and rotation coupling in the cervical spine, i.e. sidebending and rotation ocror to the same side. However, the evidence in relation to lumbar spine coupling is inronsistent.-1.\17.l9 While Fryette's laws may be useful for predicting coupting behaviour in the cervical spine caution should be exercised for the thoracic and lumbar spine where modification orthe model may be necessary.

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References Fr)'eue H. PrindplO'i of ~teopathk Technic.

Newark. OH: Americall Academy of Osteopathy; 1954 (Re-prinl 1990). 2 Milchell 11... 'nle Mu:scle Energy Manual. F..a.sl L.111.~ing, MI: MET Press; 1995, 3 Bogtluk N, '1\'>'Ollll'Y I:/: Qinical Analomy of Ihe 1.111nbar SpiTle and Sacrunl, 3rd ron. Mcibolll1le: Churchill U",ingslone; 1997, 4 lovell RW, 'Ihe mechanism of the normal spine and ilS rclmiOIl 10 scoliosis. I:loslOn Mro SllIgJ 1905; 13:349-358, 5 White A. Panjabi M. Oinical Biomechanics of the Spine. 'ibrolllo: I..ippincolt Company; 1990. 6 Slokes I, Wilder 0, Iltymo)'er I, Pope M. Assc:ss.melll of palienls wilh low-back pain by biplanar radiographic measuremelll of illlct\'CJ1ebrai lTlOtion. Spine 1981; 6(3):233-240, 7 MacConaill M. The gromeuy and algebra of articular kinemalia. Bio Med Eng 1966; 5:205-211. 8 Vicel\?jno G, Twomey L Sideflexion indLKCd lumbar spine conjuncI rotation and ils

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innuencing factors. Ausl PhysiOlher 1993; 39(4):299-306. Creenman Pf_ l'linciple:s of Manual Mooicine, 3rd oon. Philadelphia. Pi\.: UppinCOIl Williams & Wilkins; 2003. Cibbons P. Tehan P Mu.sde energy concepl$ and coupled mocion of lhe ~in~ Man -I'het" 1998; 3(2):95-101 Brown L An illlroduction 10 the ueallnenl and examinalion of the spilM: by combined ITlO\'eIllCOIS. l'hysiother:apy 1988; 74(7):347-353. Brown L Treatmenl and examination of the spine by combined mO\'Unents - 2. Physk>thcrapy 1990; 76(2):666-674. Stoddard A. Manual of Osleopathic l"raclicr. London: Hutchinson MedKal l"ublkations; 1969. I"opt' "''I. Wilder D. Mallen It Frymo)"t'r J. EqlerimcotaJ measurenwnu of \'ft1cbr.tl motion under load. Onhop Oin NOM Am 1977; 8(1 ):155-161. IUrcy M.. 1ibrewal S. Axial rotation and laleral bending in the I"IOI"mailumbar spine measured by three-dimensional rndklgraphy. Spine 1984; 9(6):582-587. l"earry M, Portek I, Shtpherd I. -11M' effect of low back pain 011 lumbar spinal n)()\ocmenlS rT\t'a$ural by three-dimensional X-ray analysis. Spine 1985; 10(2):150-153. l>Jamonoon A. Gagnon M, Maurnis C. Applicalion of a S'ereoradiogrnphic method for the MUd)' ofinten-enebral moliOIl. Spine 1988; 13(9): 1027-1032. Mimur.t M. Moriya H, Watanabe T, Takahashi K. Yama~ua "''I. Tamaki '1: Three dimensional motion analysis of the cervical spine with special referenCE: to the axial rotalion. Spine 1989; 14(11):1135-1139. Panjabi M, Yamamoto I, Oxland T, Crisco J, How'does. poslure affect coupling in lhe lumbar spinel Spine 1989; 14(9): 1002-1011, Nager! H, Kubein-Meesenburg D, Fanghancl I. Elements of a general theoty of joints. Anal Anz 1992; 174(l):6(,-75, Bennett Sf_ Schenk It Simmon:o; E. Active range of motion ulilized in the cervical spine 10 perfonn daity functional tasks. J Spinal Disord Tech 2002; 15(4):307-311. Rr.welll~ Pearcy M. Un.s~YOrth A. Meawremem of the ranse and coupled lnQ\oemenlS ob5er.w in the lumbar spine. Br 1 Rheumatol 1993; 32(6):490-497. Cook C. Coupling behavior of the Iwnbar spine: A lilerature review. J Man Manipulative Ther 2003; 11(3):137-145.

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HVlA thrust techniques - an osteopathic perspective Schultz A. warwick D, Befkson M. Nacherru;on A. Mechanical properties of human lumbar spine motion segments - Part 1. J Biomechanical Eng 1979; 101:46-52. 25 McClashen J will be different depending on whether the patient's spine is placed in a flexed or a neutral/extended position. lhere is some evidence to suppon the view that.. in the flexed position, the coupling of sidebending and rotation is to the same side »'11 whereas in the neuual/extended position.. the coupling of sidebending and rOtation OCCUI1i to opposite sides. :JO.lI.ll1he model outlined in Table A.4.2 incorporates the available evidence and is useful in the teaching and application of HVI.J\ techniques. Because Ihe evidence for coupling behaviour is inconsistem, it must be undmtood that this is a model for facet apposition locking which cannot be relied upon in all circumstances.

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HVlA thrust techniques - an osteopathic perspective

Table A.4.2

Spinal level 14-12 11-5 Position of spine T4-L5

Flexion

Coupled motion

Facet apposition locking

Type 1 or type 2 Type 1 or type 2

Type 2 or type 1

Type 2

Type 1 - s1debending and

Type 2 or type 1

rotation to the opposite

side

NeutraVextension

Type 1

Type 2 - sidebending and rotation to the same side

For patient romfon and safety, the practitioner should limit the total amowlt of trunk rotation when using HVlA thrust techniques in the thoClcolumbar and lumbar spine. In most instances. this can be achieved using the facet apposition model and an understanding of neutral/extension and flexion positioning prior to the application of a HVL\ thrust technique These techniques can be applied in either a neutral/extension or in a flexed position.

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In the example of neutral/extension positioning (Fig. A.4.6), the practitioner uses spinal positioning and locking to limit the total range of trunk rotation. If the praaitioner introduces trunk flexion from below (Fig. A.4.7), or from above and below (Fig. A.4.8), an increased range of trunk rotation is then required to achieve the necessary joint locking prior to the application of an J IVIA thrust technique.

Spinal positioning and locking

Figure A.4.6 NeutraVextension positioning.

Figure A.4.8 Note further increased rotation necessary to achieve facet apposition locking with introduction of trunk flexion from both above and below.

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Figure A.4.7 Note increased rotation necessary to achieve facet apposition locking with introduction of trunk flexion from below.

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Neutral/extension positioning The patient's lumbar and thoeacic spine is positioned in a neutr.al/extended posture (Fig. A.4.9). Using the model outlined. the normal coupling behaviour of sidebe:nding and rotation in the neutral/extension position is type 1 movement Facet apposition locking will be: achieved b)' introducing a type: 2 movemenl, i.e. sidebending and rotation to the same side. The spine in the neutral/extension position is slung between the pelvis and

shoulder girdle and creates a long C curve with the trunk side:bending to the patient's right \.. . hen the patient lies on the left side. Trunk rotation to the right is introduced by gently pushing the patient's upper shoulder a\YaY from the ope-r.ator. Rotation and sidebending to Lhe same side achi(!\~ facet apposition locking in the neutrnl or extended position, in this instance with sidebending and rotation to the right (Fig. AA.l0).

Figure A.4.9 Neutral/extension positioning. ¢ Direction of body movement (patient).

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Figure A.4.10 NeutraVextension positioning. Type 2 locking. Rotation and sidebending to the same side. i.e. sidebending right and rotation right

__________;:s::;pinal positioning and I_OC_k_i_n;.g.....~" Flexion positioning '111e patient's lumbar and thoracic spine is positioned in a l1exed posture (Fig. A4.lt). '11(> normal coupling behaviour of sidebending and ralation in the flexed position is type 2 mO\.'CmenL Face! apposition locking will be achieved by introducing a type I movement, i.e. sidebending and rotation to opposite sides. To achieve facet apposition locking of the spine, in the flexed posture,. the trunk must be rotated and sidebent to opposite sides (Fig. A4.12). TI1e operator imroduCt'$ trunk sidebending to the left by placing a rolled lowel under the patient's thoracolumbar

spine. Trunk rotation to the right is introduced by gently pushing the patient's upper shoulder away from the operator (~1l!- M.12). Mall)' factors. such as facet lTopism, vertebral level. intervertebral disc height. back pain and spinal position, can affect coupling beha,'iour and there will be occasions when the model outlined needs to be modified to suit an individual patient. In such circumstances. the operator \\ ill need to adjust patient positioning to facilitate effective localiz.ation of forces To achieve this. the operator must develop the paJpatory skills necessary to sense appropriate pre·thrust tension and leverage prior to delivering the HVlA thrust.

Figure A.4.11 Flexion positioning. ¢ Direction of body movement (patient).

....

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F.igure A.~.12 Flexion positioning. Type 1 locking_ Rotation and sldebendtng to opposite sides. i.e. sidebending left and rotation right.

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HVlA thrust techniques - an osteopathic perspective

References Nyberg R. Manipulation: definition. types, application. In: Basmajian I, Nyberg R. eds. Ration.al Manuallherapia Baltilll()ll', MO: Williams & Wilkins; 1993:21-47. 2 Downing CII. Principles and l>rnctice of -ymptoms that might be suggestive: of VB!, a normal physical examination \'/Quld indude painfree range of motion testing of the cervical spine (Figs AS.3-A5.8). Such range of motion testing might include bOlh aClive and passive: movements, but would be performed with care and to the point of provocation of symptoms only.

(HVlA) thrust techniques

2.5-3 mm in adults and >4.5-5 mm in children indicatt'S atlanto-axial instability./f1 Cineradiography has also been shown to be a valuable adjunai\'e technique in the diagnosis of cavical instabilhy." ComputerizOO tomography (CD may have some advantages over plain radiograph~ with magnetic resonance imaging (MRJ) also offering benefits becall.Se of the ability to provide dired sagittal projection./f1 cr and MRI provide complementaJy information when combined with flexion and extension radiographs. 1100\YVt':T, caution should be used when using flexion and extension views in cases of acute cervical trauma."

The above symptoms and signs might also indicate the pre~ence ofVBI or spinal cord compression unrelated to upper cervical instability. As a result, it is necessary {a establish whether the symptoms or signs are related to instability of lhe upper cervical spine or other causes. '11,ere are four cardinal s}'mptoms and signs that may indicate the presence of upper cervical inslabiLity.lIO I. Overt Ios.~ of balance in relation

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10 head movements 2. Fadallip paraesthesia, rq>roducro by active or passive n«.k mO\'l':lTlt'11ts 3. Bilateral or quadrilateraJ limb paraesthesia either constant or reproduced by neck mO\'l':ments

Figure A.5.9 Cervical instability as a resutt of rheumatoid arthritis. Note forward displacement of C1 upon C2 and widening of the atlanto-dental interval (From Adams and Hamblen, 2(01).

Safety and high-velocity low-amplitude (HVLA) thrust techniques

A number of physical tests have been
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Illlldeman S, Kohlbeck r, McCregor M. lInpredictability of cereblO\lascular ischemia associated with cavial splOe manipulation therapy: a review of sixt), four cascs after cervical spine manipulation SplIle 2002, 27( I ):49-55. I Jaynes M. Stroke foUowlllg ttrVical manipulation in Penh Ollropr.lCOC J I\IJSt 1994; 24:42-46. Jaskoviak P. Complicalions aosing from manipulation of the ceMcal SPlIle. J Manipulam'C Physiol'I'her 1980; 3:213-219. Klougan N, 1.dxJeuf·Vrle C. Rasm~ lR. Safety in chiropractk prnake. Pan I: the ocrurfet'lQ of cerebrovucular accidents alto manipulation to the neck In Iknmark from 1978---1988. J Manipu]atn.-e Physiol1her 1996; 19:371-3n. Lee Kp, rc-manipulathoe test ing of the cervical spine. Aust I PhysiOlher 2001; 47:164. Powell Fe. I lanigan \IJC. Oli\'e/o \\"C,. A risk,lbenefit analysis of spinal manil)uladon therapy for relief of lumbar or cervical pain. Neurosurgery 1993; 33:73-79. Oi lJabio RI'. Manil>Ulation of the Cervical Spine; Hiskli and lk.'I1efi/5. Ph)'ll·I'her 1999; 79( t ):51-65. Iiaideman S. Kohlb«k 11 McCregor M. Risk fadors and precipitating nl'Ck 1ll00-etllellts causing \'enebrobasilar anery di5."o('C\ion after rervicaltTauma and spinal manipulation. Spine 1999; 24(8):785-794. K. Ichimaru K. ShimUTa II, Imakiire A. Cervical \oeniSO after hair shampoo Ircallllent al a hairdressing salon: a casc report. Spine 2000; 25:632. Smith W, Jotuwon S, Skalabrin F.. WC2\"" M.. Azari P, A1beB G.. Cress 0 Spinal manipulaln"f'

:.

.

.- -

,~

5:\

woo

3.


Lherapy is an independent risk factor for artel)' disseclion. Newology 2003; 60:1424-1428. \Villiams t. Biller J. Vertebrobasilar dissection and cervical spine manipuladon. Neurology 2003; 60:1408-1409. Kleynhans A, Complicalions of and cOll1raindications to spinal manipulative therapy. In: Haldeman S. ed. Modern DeveJopments in Lhe Principles and Practice of Chiropmctic. New York, NY: Appleton-CenturyCrofts; 1980:359-384. Senstad 0, l.cboeuf-Yde C. Borchgrevink C. rrequency and characteristics of side effects of spinal manipulative Lherapy. Spine 1997; 22(4):435-440. leboeuf-Yde C. Hennius B, Rudberg E, Leufvenmark r, Thunman M. Side effects of chiropractic treatment: A prospective study. J Manipulative Physiol"lller 1997; 20(8):511-515. Cagnie B. Vinck E, Beemaen A, Cambia- D. How common are side (>(fects of spinal manipulation and can thl'Se side effects be predicted? Man 111er 2004; 9(3):151-156. Cyriax R. Textbook of Orthopaedic Medicine, Vol 2,11 th edn. London: Bailliere TIndall; 1984. Maigne R. Diagnosis and treatment of rain of vertebral origin: a manual medicine approach. Baltimore,. MD: Williams & Wilkins; 1996. l-IerlOg W. Clinical Bioml'Chanics of Spinal Manipulation. New York. NY: ChurchiJl Livingstone; 2000, BenEliyahu D. Masnetic resonance imaging and clinical follow-up: Study of 27 patients receiving chiropractic care for cervical and lumbar disc herniations. J Manipulative Physiol Ther 1996; 19(9):597-606. Burton A, TIllotson K, Cleary ]. Single-blind randomised controlled trial of chemonucleolysis and manipulation in Lhe treatmenr of symptomatic lumbar disc ha-niation. EUT Spine I 2000; 9(3):202-207. Tseng S, Un S, Chen Y, Wang C. Ruptured cervical disc afta- spinal manipulation therapy. Spine 2002; 27(3): EBO-EB2. Haldeman S, Rubinstein S. Cauda equina syndrome in patients undergoing manipulation of the lumbar spine. Spine 1992; 17( 12):1469-1473. Markowitz H, Dolce D. cauda ('Quina s)'ndrome due to sequestrated recurrent disk herniation after chiropractic manipulation. Orthopedics 1997; 20(7):652-653. Olipham D. Safety of spinal manipulation in the treatnlem of lumbar disk hemiadons: A systematic review and risk assessment. I w~rtebral

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46 47

48

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Manipulative Physiol TIler 2004; 27(3):197-210. CSAG. Back pain. Oinical Standard" Advisol)' Group Ileport. London: HMSO; 1994. ZweibeJ WI. Introduction to Vascular Ultrasonography, 2nd edn. New York, NY: Harcourt Brace; 1986. Riven D. The prcmanipulative vertebral artel)' tl'Sting protocol. N Z J Physiother 1995(April):9-12. Silben r, Molabenf'gaU\-e alensiort/roration pre-manipulaU\-e !iOeening tesI on a patterll with an alretic and hypoplastic \'t"rtebral artery. Man 'I"her 2003; 8(2):120-127. 71 Grant R. Vertebral anery lesting - the AuslraIian Ph)'SiotheraPY Association Protocol aher 6 )'t"al$. Man 'I'her 1996; 1(3);149-153. n Magarey M. Rebbeck 1; Coughlan B. Grimmer K. Ri~t 0, Rdshauge K. Pte.manipulatr.'t" testing of the cervical liPine ra-iew, r!!Vision and new clinical guidelines. Man Ther 2004; 9(2}:95-108. 73 Symol\~ H, loonard 1; I Ier-lOIl W. Internal forces SU~lained by tht: \-enroral ar'ery during spinal manipulati\~ d\et'ilp)'. J Manipulalive Ph)'Siol'l"her 2002; 25(8):504-510. 74 McDermaid C. Vl'rtebrobasilar incidents and spinal manipulative thefap)' of lhe arvical spine. In: Vernon II. cd 'Ille Cr,mio-eervical Syndrome. Oxford: BUHerwonh-lleinanann; 2002:01.14. 75 'lerrell A. Did the SMT practitioner cause the aneriill injUly? Chiroprnoic I Awit 2002; 32(3):99-119. 76 O1iefC.oroner. Inquest Touching the Dealh of Lana Dale Lewis. IUlY Verdk! and Recommendations. f'roo,'ince of Onuuio. Canada; Office of the Olid Coroner: 2004 77 Schneider C. Vertebral anery complICations follov.ing gende c:ervkl\1 Ireatments. Au5I I l'Il)'SiOlher 2002; 48(2} 151 78 Penning L. Wilmlnk I PDtation of lhe cervical spine. a cr &lud,- in normal Spine 1987; 12(8P32-738.

41

HVLA thrust techniques - an osteopathic perspective 79 Louri H, Stewart W. Spontaneous atlantoaxial disloQllion. N fngl J Med 1961;

42

265( 14):677-681. 80 Swinkels R. Beeton K. A1ltree I. Pathogerleois of upper cuvkal instability. Man Ther 1996; 1(3):127-132. 81 Swinkels R. Oostendorp R Upper cervical instability: fact or fiction. ) Manipulative Physiollher 1996; 19(3):185-194. 82 Tredwell S, Newman D, Lockitch G. Instabilily of the upper cervical spine in Down syndrome. , I't'e of manual medicine approaches. '11e neurological models provide a framework for treatmem that is based. upon posLUlated mechanisms of imeraction between the somatic and neurological systems. 'These mechanisms are complex and beyond the scope of this manual. It is suggested that manual imefVflltion may influence: • the two divisions of the autonomic nervous system • the integration of function between the central and peripheral nervous systems for modulation of pain • the neuroendocrine-immune connection, resulting in both local and systemic effects.

Respiratory/circulatory This model is based upon the concept that normal fluid exchange is essential for the continued health of tissues at both the 'micro' and 'macro' level. Manual treatment is directed towards improving blood and lymph flow and aiding intracellular fluid exchange by ellhancing musruloskeletal funnion. Treatment is directed to\'imds restoring the capacity of the musculoskeletal system to assist venous and lymphatic return.

Bioenergy

46

This model is based upon the body's inherent energy fields that can be utilized for diagnosis and treatmenL Internal and external environmental factors may influence the vitality and quality of energy

flO'", within the human body. '111e aim of treatment is to restore balance and harmony to these fields of energy.

Psychobehavioural This model recognizes that many internal and external factors influence a patient's response to pain and dysfunction. Social. economic and cultural factors all impaa upon the way in which a patient deals with pain, dysfunaion and disability. An understanding of the factors that can influence a patient's coping mechanisms is pivotal to this model, as is a knowled~ of the psychosocial interventions that may assist the patient to deal with pain and disability. ,11ese five models provide a conceptual frame\vork upon which decisions relating to patient management can be made. It must be understood that these are simply conceptual models with varying amounts of evidence to support their use 'l1tese osteopathic models provide a framework for choosing a treatment approach and selecting osteopathic manipulative tedmiques. How£'Ver, the treatment models do not dearly establish a rationale for the use of HVlA thrust techniques as distinct from other osteopathic manipulative tedUliques.

CAVITATION ASSOCIATED WITH HVLA THRUST TECHNIQUES '111e aim of HVLA thrust techniques is to achieve joint cavitation Ihat is accompanied by a 'popping' or 'cracking' sound. This audible release distinguishes HVI.A procedures from other osteopathic manipulative tedUliques. Research involving the metacarpophalangeal joint indicates that the audible release is generated by a cavilation mechanism resulting from a drop in the internal joint pressure. 1s- n r"OIIO'ving cavitation, there is an increase in the size of the joint space and gas is found within that

Rationale for the use of high-velocity low·amplitude (HVLA) thrust techniques

space. l~-" ""e gas bubble has been described as 80% carbon dioxide'6 or having the density of nitrogen. 14 'Ine gas bubble remains within the joint for bt1,wero 15 and 30 min,l4.1S n.l'J whim is consistent with the time taken for the gas to be reabsorbed into the synovial f1uid. l6 An increased range of joim mOl ion immediately follO\~ng cavitation has been demonstrated. :19 Widening of lumbar zygapophysial joints post manipulation has been demonstrated by magnetic resonance imaging (MRI) foIlO\ving lumbar spine manipulation. lO It is possible that cavitation occurring al spinal synovial joints has similar characteristics to that exhibited al the metacarpophalangeal joint. A number of studies have reponed thai thrust lechniques are associaled with a temporary increase in the range of spinal motion."-loB Longer-leon effects of HVlA thruSl lechniques have also been reported"'~ aJld it is ~tulated that these may be due to reflex mechanisms that either direclly cause muscle relaxation or inhibit pain.s HO\vever, the sound of a 'crack' or 'pop' associated with a HVlA thrust technique does nOl necessarily indicate that reflex or tissue changes have ocrurred. Some authors have reported benefits from HVlA thrust techniques without the accompanying audible release.· ' There continues to be speculation as to the level and side of apophysial joint cavitalion when IIVLA thrust techniques are applied 10 lhe spine. Reggars and Pollard in a study of diver.:;ified rotation manipulation of the cervical spine found that cavitalion occurred more often on the ipsilaleral side to head rOLation.·' A study of lumbar and sacroiliac manipulative techniques found that there was no conclusive specificity of technique to level or side of cavitation.·) It is likely that the level and side of cavitation will be dependent upon a range of mctors that might include spinal positioning and locking. the specific technique applied, operator skill and patient compliance and whether the patiell1 is Symptomatic or asymplOmalic. 'Ine aim of IIVLA thrust

lechniques is to achieve ca,~tation 10wards 1I1e end of zygapophysial joim range but nol at the anatomical end range. Repeated 'cracking' or 'popping' of the joints of lIle hand associated ,~th cavitation, has not been shown to be linked ,~th an increased incidence of degeneralive mange. 4 4,O

EVIDENCE SUMMARY Best pl'3etice requires prnctitionel"S 10 embrace the prindpJes of Evidence Based Medicine (EB1I.i). Evidence based medicine incorporates the be51 results from clinical and epidemiological research with individual clinical experience and expenise whilst taking accoum of patient preferences.46,,·' Evidence for efficacy of interventions. such as spinal manipulation can be assessed aCfOrding to a hierarchy of evidence that exists in the literature for lhat intervention.

Hierarchy of evidence • • • • • • •

Randomi7.ed fOntrolled trials Non-randomized controlled trials Cohon or 10ngitudjJl31 studies Case-control studies Cross-sectional descriptions amI surveys Case series and case reports Expert opinion

I~ecommendationsarising from a review of the researdl reflect the strenglll of evidence and methodological quality, but not necessarily lIle clinical importUlce. Research evidence can be synthesized ill a number of different \\I3YS. A systematic review can be undertaken which is the systematic synthesis of evidence across all trials for a given intervention.

Syntheses • Systematic reviews including metaanalyses • Decision and economic analyses • Guidelines

47


48

Meta-analysis is when a systematic review uses special statistical meth<Xis for combining the results of several studies, Hecommendations based on research evidence can be used to develop clinical practice guideli.nes and standards for t.hirdparty payers and policy makers. Bronfort et al. report that since 1979, there have been in excess of 50 mostly qualitative, non-systematic reviews published relating to manipulation and mobiliZO-67 and chronic headache. 63 Bronfort et al. undertook an extensive search of computerized and bibliographic literature databases up to the end of 2002 relating to the efficacy of spinal manipulation and mobiliZinfOld M, NN.ore K O'lnry F. I loving J, Green

SO

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S. Buchbinder R. Validity and. intfmal consistency or a whipiash-spKific disability meawre. Spine 2004; 29(3):263-268. Kopec JA,. Functional disability salt'S for back pain. Spine 1995; 20(17).1943-1949. St.-tforo Gill C, W~away M, Binkley I. Msessing disability and change on individual patients: a "->pOrt of a patiem specific measure. Ph)'siOlher Can 1995; 47:258-263. WCSJa\Vll)' M, Slratford P, Binkley I. 11le patient. spedfic functional scale: validation of its use in penollli with nt' the applicalor on tht: contaa point until the technique is complett:. Keeping the hands in position, return the head to the neutral position. 7. Chin hold

Keep your right hand in position and slide the left hand, slowly and carefully, fOl'\vards until the fingers lightly clasp the chin. Ensure that your left forearm is over or slightly anterior to the ear. Placing the forearm on or behind the ear puts the neck into too much flexion. The head is now controlled by balancing forces between the right palm and left forearm. Maintain the applicator in position. B. Vertex contact

78

Move your body fonvard slightly so that your chest is in cOnlaa with the \'eI1ex of the patient's head. The head is nO\v securely

10. Adjustments to achieve appropriate pre-thrust tension Ensure the patient remains relaxed. Maintaining all holds, make any necessary minor changes in nexion. e>..1.t'Jlsion, sidebending or rotation until )00 can sense

Cervical and cervicothoracic spine

.

1.2

Figure 81.2.1

Figure 81.2.2

a state of appropriate tension and leverage at the contact point The patient should not be aware of any pain or discomfort. You should introduce these final adjustmentS by slight movements of the ankles. knees. h.ips and trunk. not by altering the position of your hands or arms. 11. Immediately pre-thrust

Relax and adjust your balance as necessary. Keep your head up; looking dow'll impedes the thruSt and can cause embarrassing proximity to the patient. An effectiw HVLA

thrust technique is best achieved if the operator and patient are relaxed and not holding themselves rigid. This is a common impediment to achieving effective cavitalion. Ensure the patient's head and neck remain on the pillow as Ihis fadJitates the arrest of the technique and limits excessive amplitude of thrust 12. Delivering the thrust

This is a difficult technique 10 masler, as the thrust must be applied along a curved plane.

79

HVLA thrust techniques - spine and thorax Apply a HVLA thrust to the posterior arch of the atlas in an anle.rior and superior direction along a curved plane. which follows the shape of the ocdpito-atJantal articulation. Apply no simultaneous rapid increase of celVic:a1 rotation. extension or sidebending with the left hand (Fig. 81.2.2).

'the thruSl, although very rapid, mUsl never be excessively forcible. The aim should be to use Ihe absolute minimum force necessary to achieve joinl ci1Vilation. A common faul! arises from the use of excessive amplilude with insuffidelll velocity of thrust.

SUMMARY Atlanta-occipital joint (0-(1 Contact point on atlas Chin hold

Patient supine • Contact point: Right posterior arch of atlas • Applicator: Lateral border, proximal or middle phalanx • Patient positioning: Supine with the neck in a neutral relaxed position • Operator stance: Head of couch, feet spread sltghtly • Palpation of contact point • Fixation of contact point • Chin hold: Ensure your left forearm is over or slightly anterior to the ear • Vertex contact: Essential in this technique • Positioning for thrust: Step to the right and stand across the right corner of the couch. Optimal alignment for the thrust is in a curved plane. Keep your right elbow close to the couch in order to keep the contact point on the atlas (Fig. 61.2.1)

• Adjustments to achieve appropriate pre-thrust tension • Immediately pre-thrust: Relax and adjust your balance • Defivering the thrust: The thrust must be applied along a curved plane. which follows the shape of the ocdpito-atlantal articulation (Fig. Bl.2.2) 80

Atlanta-axial joint (1-2 Chin hold Patient supine Rotation thrust

Assume somatic dysfunction (S-1:A-R-T) is identified and rou luisll I,D use a IhnlSl in the plane of the aI/mIlo-axial (CI-2) apophysial joint 10 produce cavililtiOlI Oil l1Ie rig111 (Figs 81.3.1. 81.3.2)

Figure B1.3.1

Figure 813.2

1. Contad point

KEY

Right posterior arch of alias.

.:;,

Stabilization

2. Applicator

•

Applicator

Lateral border, proximal or middle phalanx of operator's right index finger.

..

Plane of thrust (operator)

¢

Direction of body movement (patient)

Note: The dimensions for the arrows are not a pictorial representation of

3. Patient positioning

Supine with Ihe neck in a nama I relaxed position. If necessary. remove pillow or adjust pillow height. "Ine neck should not be in any significant amount of flexion or extension.

the amplitude Of force of the thrust.

8'

HVLA thrust techniques - spine and thorax

4. Operator stance I lead of couch, feet spread slightly. Adjust couch height so that the operator can stand as erect as possible and avoid crouching over the patient as this will limit the technique and restrict delivery of the thrust.

S. Palpation of contact point

9. Positioning for thrust

Place fingers of both hando; gently under the occiput. Uft the head slightly and gently rotate it to the left, taking the weight of the head in your left hand. Remove your right hand from the occiput and palpate the region of the right posterior arch of the atlas with the tip of your index or middle finger. Slowly but finnly slide your right index finger downwards (towards the couch) along the posterior arch of the atlas until it approximates the middle or proximal phalanx. Several sliding pressures may be necessary to establish dose approximation to the contact point.

Step to the right and stand across the right comer of the couch, keeping the hands firmly in position and taking care not to lose pressure on the contact point Cently introduce rOlation of !.he head to the left.. to the point at which the posterior arch becomes more obvious under your contad point. Straighten your right wrist SO that the radius and first me:taea.Jpal are in line. While maintaining finn applicator pressure. allow the right index finger to roll slightly on the contact point as you mO\'e your right ell>O\.... towards the patient's right shoulder to reach that point when your line of thrust is directed towards the comer of the patient's mouth. The thrust plane is into rotation. Ensure that yOU maintain a firm comact point on the posterior arch of the atlas and that your applicator is in line with )'our foreann. (a) Primary 'etremge of rotahOri. Maintaining all holds and contact points. complete full rotatjon of the head and neck to the left until slight tension is palpated in the tissues at your contact point (Fig. 81.3.3). Maintain firm pressure against the contact point. A common mistake is to use insufficient head and neck rotation. (b) Secorldnry k'lICmge. This technklue uses minimal secondary leverage. This technique does not use facet apposition locking. Extensive practice is necessary to dC\oclop an appreciation of the required tension.

6. Fixation of contact point Keep your right index finger finnly pressed upon the contact point while you flex the other fingers and thumb of the right hand. so as to clasp the back of the neck and occiput.. thereby locking the applicator in position. You must now keep the applicator on the contact point until the technique is complete. Keeping the hands in position, return the head to the neutral position. 7. Chin hold

Keep your right hand in position and slide the left hand, slowly and carefully, forwards until the fingers lightly clasp the chin. Ensure that your left forearm is over, or slightly anterior to, the ear. Placing the foreann on or behind the ear putS the neck into too much flexion. The head is 110\.... controlled by balancing forces bet\\ttr1 the right palm and left forearm. Maintain the applicator in position. 8. Vertex contact

82

the patient's head. The head is now securely cradled between the left forearm, the flexed len ell>O\..... the right palm and your chest. Vertex contact is onen useful in a heavy, sLiff or difficult case but can. on occasions. be omitted.

Move your body forward slightly so that your chest is in contact with the venex of

10. Adjustments to achieve appropriate pre-thrust tension

This is almost a pure rotation thrust but the appropriate tension can be achiC\'Cd by adjusting flexion, extension and sidebending. The patient should not be aware of any pain or discomfort. Introduce

I


7.3

Figure 81.33

Figure 81.3.4

any sidebending. flexion or extension by pivoting slightly via the legs and trunk. Do not attempt to introduce these leverages by moving the hands or arms as tJlis will lead to loss of contaa and inaccurate technique. 11. Immediately pre-thrust

Relax and adjust your balance as necessary. Keep your head up; looking down impedes the thrust and can cause embarrassing

proximily to the palient. An effective HVLA thrust technique is best achieved if the operntor and patient are relaxed and not holding themselves rigid. 'I'his is a common impediment to achieving effective cavitation. Ensure the patient's head and neck remain on the pillow as this facilitates the arrest of the technique and limits excess.iw amplitude of thrust.

83


12. Delivering the thrust Apply a I-IVI.A thrust to the posterior arch of Ihe alIas directed towards 111e comer of the patient's mouth. Simultaneously, apply a rapid 100'V·amplitude increase of head rotation to the left by supinating the left foreaml (Fig. 81.3.4). 1bis rotation movement of the head is very small but of high velocity. This ensures that the occiput and atlas mO\'e as one unit during the

thrust The alias rotates about the odontoid peg of the axis and cavitation occurs at the right CI-2 articulation. A very rapid cont.rn.clion of the flexors and adduaors of the right shoulder induces the thrust. 'Ibe thrust. although ''elY rapid. must never be excessively forcible. 'lbe aim should be to use the absolute minimum force necessary to achieYe jo;nt aMtat;on. A common fault arises from the use of excessive amplitude with insufficient velocity of thrust.

SUMMARY Atlanto-axial joint (1-2 Ch," hold Patient supine Rotation thrust • Contact point: Right posterior arch of atlas • Applicator: Lateral border, proximal or middle phalanx • Patient positioning: Supine with the neck in a neutral relaxed position • Operator stance: Head of couch, feet spread slightly • Palpation of contact point • Fixation of contact point • Chin hold: Ensure your left forearm is over or slightly anterior to the ear • Vertex contact: Optional • Positioning for thrust: Step to the right and stand across the right corner of the couch. Use primary leverage of rotation with minimal secondary leverage. Your direction of thrust is towards the patient's mouth and into rotation (Fig. B' .3.3) • Adjustments to achieve appropriate pre-thrust tension • Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: The thrust is directed towards the comer of the patient's mouth. Simultaneously, apply a rapid low·amplitude increase of head rotation to the left. The occiput and atlas move as one unit during the thrust (Fig. B1.3.4) 84

I

Atlanto-axial joint (1-2 Cradle hold Patient supine Rotation thrust

Assume somatic dysfunaio" (5-T-A-R-T) is identified a"d you wish to use a Ihrnsl ill Ihe pla"e of Ihe 0110"'0-11.\;01 (Cl-2) apophysial joi", In produce Clwitation on Ute right:

1. Contact point

KEY

*

Right posterior arch of alias. Stabilization

2. Applicator

•

Applicator


-

Plane of thrust (operatOf)


¢


Note: The dimensions for the arrows

are not a pictorial representation of the amplitude or force of the thrust.

Supine with the neck in a neutral relaxed position. If necessary, remove pillow or adjust pillO\v height. The neck should not be in any significant amount of flexion or extension. 4. Operator stance

I-lead of couch, feet spread slightly. Adjust couch height so thaI lhe operator can stand

85

HVLA thrust technIques - spine and thorax

as erect as possible and avoid crouching over the patient as this will limit the technique and restrid delivery of the thrust.

8. Vertex contact None in this technique. 9. Positioning for thrust

5. Palpation of contad point

Place fingers of both hands gently undcr the ocdpul. lift the head slightly and gently rotate it to lhe left. taking the weight of the head in your left hand. RemO\'t' your right hand from the occiput and palpate the region of the right posterior arch of the atlas with the tip of your index or middle finger. Slowly but finnly slide your right index finger downwards (towards the couch) along the posterior arch of the atlas until it approximates the middle or proximal phalanx. Several sliding pressures may be necessary to establish dose approximation to the contact poinL

6. Fixation of contact point Keep your right index finger firmly pressed

upon the contact point while you flex !.he other finger.; and thumb of the right hand so as to clasp the back of the neck and occiput, thereby locking the applicator in position. You must now keep the applicator on the contact point ulllil the technique is complete. Keeping the hands in position, return the head to the neutral position.

'llle elbows are held dose to or only sHghtJy away from your sides. This is an essential feature of the cradle hold method. Stand easily upright at the head of the couch and do not step to lhe right as in the chin hold method. (a) Primary' leveToge of rorarion. Maintaining all holds and conlaa points,. complete the rotation of the head and ned: to the left until tension is palpated at the contact point Supination of the left wrist and foreann and simultaneous pronation of the right wrist and forearm achieve the rotation mo,lement (Fig. 81.4.1). Do not lose finn pressure on the contact point Do not force rotation; take it up fully but carefully. A common mistake is to use insufficient primary Ie\~rage of head and neck rotalion. (b) Seamdttr}' laremge. This technique uses minimal secondary Ievt"rage. 'Ibis technique does not use facet apposition locking. Extensive praQice is necessary to de\'Clop an appreciation of the required tension.

7. Cradle hold

86

Keep your left h:'lnd under the he:'ld and sprc:'Id the fingers out for maximum contact. Keep the paticnt's ear resting in the palm of your left hand. Flex the left wrist, allowing you to cradle the patient's head in your palm, flexed wrist and anterior aspect of forearm. Keep your right index finger finnly on the contact point and press the right palm against the occiput 'Ibe weight of the patient's head and neck is nmV' balanced between your left and right hands with the celVical positioning controlled by the converging pressures of your nva hands and anns.

Figure 81.4.1

.. Cervical and cervicothoracic spine

t

1.4

Figure 81.4.2


This is aJmost a pure rotation thrust,. but the appropriate tension can be achie'\'ed by adjusting flexion, extension and sidebending. The patient should not be aware of any pain or discomfort. '£be operator makes final minor adjuslments by inuoducing any sidebending. flexion or extension with slight movements of the wrists. arms and shoulders. 11. Immediately pre-thrust

Relax and adjust your balance as necessary. Keep your head up; looking down impedes the thrust and can cause embarrassing proximity t.o lhe patient. An effective HVLA thrust technique is best achieved if the opera lor and patient are relaxed and not holding themselves rigid. 'Ihis is a common impediment to achieving effective cavitat.ion. Ensure the patient's head and neck remain on the pillO\v as this facililates the arrest of the technique and limits excessive amplilude of thrust.

12 Delivering the thrust

Apply a HVlA thrust to the posterior arch of the atlas directed towards the comer of the pat.ient's mouth. 11lis thrust is generated by rapid pronation of your right forearm. Simultaneously, apply a rapid low· amplitude increase of head rOlation to the left by supinating the left forearm (Fig. 81.4.2).11lis rOLation movement of the head is very small but of high velocity. This ensures that the occiput and atlas move as one unit during the thrusl. The atlas rotates about the odontoid peg of the axis and cavitation occurs at the right CI-2 aniculation. This is a HVLA 'flick' type thrust. Coordination between the left and right hands and forearms is criticaJ. The thrust, although very npid, must never be excessively forcible. The aim should be to use the absolute minimum force necessary to achieve joint caviUltion. A common fauh arises from the use of excessive amplitude with insuffident velocity of lhrust.

87


SUMMARY

Atlanto-axial joint (1-2 Cradle hold Patient supine Rotation thrust • Contact point Right posterior arch of atlas • Applicator: Lateral border, proximal or middle phalanx • Patient positioning: Supine with the neck in a neutral relaxed position • Operator stance: Head of couch, feet spread slightly • Palpation of contact point

I

• Fixation of contact point

I

• Vertex contact: None

• Cradle hold: The weight of the patient's head and neck is balanced between your left and right hands with cervical positioning controlled by the converging pressures

I I

• Positioning for thrust: Stand upright at the head of the couch. The elbows are held close to or only slightly away from your sides. Use primary leverage of rotation with minimal secondary leverage. Your direction of thrust is towards the patient's mouth and into rotation (Fig. 81.4.1) • Adjustments to achieve appropriate pre-thrust tension • Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: The thrust is directed towards the corner of the patient's mouth. Simultaneously, apply a rapid low-amplitude increase of head rotation to the left. The occiput and atlas move as one unit during the thrust (Fig. 81.4.2)

88

Cervical spine C2-7 Up-slope gliding Chin hold Patient supine

Assume somatic dysfunaion (5- T-A-R-T) is identified and }'Ou wish to use an upwards and forwards gliding thrust, parallel w the apophysial joint plane, w produce cavitation at C4-5 on tile right (Fig' 8J.5. J, 8J .5.2).

Figure 81.5.1

Figure 81.5.2

,. Contad point

KEY

Posterolateral aspect of right C4 artiQllar pillar.

.;t;

Stabilization

•

Applicator


-



l:)

Direction cl body movement

2. Applicator

Supine wilh the neck in a neutrnl relaxed position. If necessary, remOve pillow or adjust pillow height 'Inc neck should not be in any significant amount of flexion or extension.

(patient) Note: The dimensions fOf the arrows

are not a pkt01ial representation of

4. Operator stance

the amplitude Of force of the thrust. ./

Head of couch. feet spread slighliy. Adjust

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _.COU_.d.,.h.e.igh_l_SO_lh_3_1_Y"_U_Gl_"_'_la_"_d_as_e_'_ect

8'

l


as possible and avoid crouching over !.he patient as !.his will limit the technique and restrict delh'U)' of the thrust.

heavy, stiff or difficult case but can, on occasions, be omitted. 9. Positioning for thrust

5. Palpation of contact point Place fingers of bolh hands geTltty under the OCcipUL Rotate the head to the left. taking ils weight in your left hand. Remove your right hand from lhe occiput and palpate !.he right articular pillar of C4 wilh lhe tip of your index or middle finger. Slowly but finnly slide your right index finger downwards (to\...ards the couch) along the anicular pillar until it approximates !.he middle or proximal phalanx. Several sliding pressures may be necessary to establish dose approximation to the contact poinL 6. Fixation of contact point

Keep your right index finger finnly pressed upon lhe contact point while you flex the other fingers and lhumb of the right hand so as to dasp the back of the neck and thereby lock the applicator in position. You must nO\... keep the applicator on lhe contact point until the technique is complete. Keeping the hands in position, retum the head to Lhe neutral position. 7. Chin hold

Keeping your righl hand in position, slide Ihe left hand slowly and carefully forwards until the fingers lightly clasp the chin. Ensure that your left forearm is over or slightly anterior to the edy movement (patient)

Note: The dimensions for the arrOWs are not a pictorial representation of the amplitude or force of the thrust.

2. Applicator

Supine with lhe neck in a neutnll relaxed position. [f necessary. remove pillmv or adjust pillow heighl "'ne neck should not be in any significant amount of flexion or extension. 4. Operator stance

Head of couch. feet spread slightly. Adjust couch height so that you can stand as erect

93


as possible and .woid crouching over the patient as this will limit !.he technique and restrict delivery of the thrust. S. Palpation of contact point

Place fingers of both hands gently under the occiput. Rotate the head to lhe left.. laking its weight in }'Our left hand. RemO\'e your right hand from the occiput and palpate the right articular pillar of C4 with the tip of your index or middle finger. Slowly but firmly slide )'OUr right index finger dO\vnwards (IO\Y3rds the couch) along the articular pillar until it approximates the middle or proximal phalanx.. Several sliding pressures may be necessary to establish dose approximation to the contael poinL 6. Fixation of contact point

Keep your right index finger firmly pressed upon the contact point while you flex the olher fingers and thumb of the right hand so as to clasp the back of the neck and Ihereby lock Ihe applicator in position. You must now keep the applicalor on the con tad point until the technique is complete. Keeping the hands in position, return the head to the neutral position.

or slightl), anterior to the ear. Placing the foreann on or behind the ear puts the neck into too much flexion. The head is now controlled by balancing forces betwttn !.he right palm and left foreaml. Maintain the applicator in position. 8. Vertex contact MO\'e your bod)' fonovard slightly SO that your chest is in contact with the vertex of the patient's head. 'l1le head is now serurely cradled between )'Our left forearm. !.he flexed left elbow, the right palm and )'Our chesL Vertex contact is often useful in a heavy, stiff or difficult ca.se but can. on OCC3Stons, be omitted.

g. Positioning for thrust

Step to the right while allowing your applicator to roll on the contact poinL Keeping your right hand in position. slide the lefl hand slowly and carefully forwards

Keeping !.he hands firmly in position and taking care not to lose pressure on the comact poim, straighten the right wrist so that the radius and first metacarpal are in line. Maimaining applicator pressure. allow the right index finger to roll slightly on the contad point to align )'Our right wrist and forearm with the thrust plane. which is upwards and to\vards the midline in the direction of the patient's left eye. Keep the right elbO\.. . dose to the couch in order to maintain lhe (Ontad point on Lhe posterolateral aspect of the articular pillar. ((I) Prim(lry levemge of rolfltioll. Maintaining all holds and contact points,

Figure 81.6.1

Figure 81.6.2

7. Chin hold

94

until the fingers lightly clasp the cllin (Fig. HI .6.1). Ensure that your left foreann is over

Cervical and cervicothoracic spine complete the rotation of the head and neck to the left until tension is palpated at the coniao poim (Fig. BI.6.2). Do not lose finn pressure at the contao point. A common mistake is to use insufficient primary leverage of head and neck rolation. (b) Secondary lCl/Ierage. Add a \'CJ)' small degree of sidebending 10 the righL down to and including C4. 'Ioe operator pivoting slightly, via the legs and trunk. introduces the right sidebending. so then the trunk and upper body rotale to the left. enabling the hands and arms to remain in position (fig. B1.6.3). Do not anempt to introduce sidebending by moving the hands or anns as this will lead to loss of contact and inacoll7lte technique. , O. Adjustments to achieve appropriate pre-thrust tension

Ensure your patient remains relaxed. Maintaining all holds. make any necessary changes in flexion. extension. sidebending or rotation until )'Ou can sense a slate of appropriate tension and leverage The patient should not be aware of any pain or discomfort. You make these final adjuslments by slight movements of )'OUT ankles. knees, hips and trunk. not by altering the position of the hands or anus. 11. Immediately pre-thrust

Relax and adjust your balance as necessary. Keep your head up; looking down impedes

Figure 81.6.3

the thrust and can cause embarrnssing proximity to the patient. An effective 11VlJ\ thrust technique is best achi~'ed if both the operator and patient are relaxed and not holding themselves rigid. This is a common impediment 10 achieving effective cavitation. Ensure the patient's head and neck remain on the pillow as this facilitates the arrest of the technique and limits excessive amplitude of thrusL 12, Delivering the thrust

Apply a IIVLA thrust to the right ankular pillar of C4. ·rne thrust is upwards and towards the midline in the direction of the patient's lert eye, parallel to the apophysial joint plane. Simultaneously. apply a slight, rapid increase of rotation of the head and neck to the left but do not increase the sidebending le\'ernge (Fig. BLGA). The increase of rotation to the lefl is accomplished by slight supination of the left wrist and foreann. The thrust is induced by a \'er)' rapid contraetion of the flexors and adduClors of the right shoulder and, if necessary. trunk and lower limb movement. 1he thrust.. although very rnpid. must never be exCESSively forcible. The aim should be to use the absolute minimum force necessary to achieve joint cavitation. A common fault arises from the use of excessive amplitude with insufficient velocity of thrust.

95

Figure 81.6.4

J


SUMMARY Cervical spine C2-7 Up-slope gliding Chin hold Patient supine • Cooted point: Posterolateral aspect of right C4 articular pillar • Applicator: lateral border. proximal or middle phalanx • Patient positioning: Supine with the neck in a neutral relaxed position • Operator stance: Head of couch. feet spread slightly • Palpation of contad point Fixation of contad point • Chin hold: Step to the right before taking up chin hold (Fig. 81.6.1). Take up chin hold and ensure your left forearm is over or slightly anterior to the ear • Vertex contact: Optional • Positioning for thrust: Introduce primary leverage of rotation left (Fig. 81.6.2) and a small degree of secondary leverage of sidebending right. Keep the right elbow close to the couch in order to maintain the contact point on the posterolateral aspect of the (4 artkular pillar (Fig. 81.63) • Adjustments to achieve appropriate pre-thrust tension • Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: The thrust is directed towards the patient's left eye. Simultaneously. apply a slight. rapid increase of rotation of the head and neck to the left with no increase of sidebending to the right (Fig. 81.6.4)

96

Cervical spine C2-7 Up-slope gliding Cradle hold Patient supine

&slime somatic d)ls[unaion (5-'f.-A-R- T) is identified and you wis/l to use an upward and forward gliding linus', parallel to the apophysial joint plane, to produce caviUltion at C4-5 on the rlglll:

1. Contact point

KEY

Poslerol:1.1eral aspect of the right articular pillar of C4.

';T:'

Stabilization

•

Applicator

-


1:)

Direction of body movement (pattent)

Note: The dimensions for the arrows are not a pictorial representation of the amplitude or force of the thrust.

2. Applicator



Supine wilh the neck in a neutral relaxed position. If necessary. remove or adjust pillow height. The technique should not normally be executed in any significant degree of flexion or extension. 4. Operator stance Head of couch, feet spread slightly. Adjust couch height so rnat )'OU can stand as erect

97

_ _ _ _ _1


as possible and avoid crouching over the patient as this will limit the technique and restrid delivery of the thrust

8. Vertex contact None in this technique. 9. Positioning for thrust

5. Palpation of contact point Place fingers of lx>th hands gently under the occiput. lift the head to throw the anicular pillars into prominence. Rotate the head slightly to the left. taking its weight in your left hand. Remove your right hand from the occiput and palpate the right articular pillar of C4 with the tip of your right index finger. Slowly but firmly slide your right forefinger dO\\lnwards (towards the couch) along the articular pillar until it approximates the middle or proximal phalmlX. Several sliding pressures may be necessa.ry to establish close approximation to the contact point 6. Fixation of contact point Keep your right index finger fimlly pressed upon the Contad point while you flex the Other fingers and thumb of the right hand so as to clasp the back of the neck and thereby lock the applicator in position. You must now keep the applicator on the COntad point until the technique is complete. Keeping the hands in position. return the head to the neutral position. 7. Cradle hold

98

Keep your left hand under the head and spread the fingers out for maximum contact Keep the patient's ear resting in the palm of the your left hand. Flex the left wrist, allO\\ling you to cradle the patient's head in your palm, flexed wrist and anterior aspea of foreann. Keep your right index fmger finnlyon the contad point and press the right palm against the OCCipuL 'Ibe weight of the patient's head and neck is now balanced between your left and right hands with the cerviClI positioning controlled by the converging pressures of your two hands and arms. When treating the lower cervical segments, the middle or distal phalanx may be used as the applicator.

The elbows are held dose to or only sJightly away from your sides. lllis is an essential fealu~ of the cradJe hold method. Stand easily upright at the head of the couch and do not step to the right as in the chin hold method. (a) Primary letrerage of rotatioll. Maintaining all holds and COntad points, complete the rotation of the head and neck to the left until tension is palpated at the contact point. Supination of the left wrist and forearm and simultaneous pronation of the right wrist and forearm achieve the rotation movement {Fig. B1.7.1}. Do not lose firm pressure on the contad point. Do not force rotation; take it up fully but carefully. A common mistake is to use insufficient primary leverage of head and neck rotation. (b) S«orufary lea.reragtt Add a very small degree of sidebending to the right. dO\ffl to and including C4. This is achieved by moving the right arm a little forward and the left ann a little back or by rotating the trunk and upper body to the left (fig. 81.7.2). NDfe: strong sidebending will lock the neck. , O. Adjustments to achieve appropriate pre-thrust tension Ensure your patient remains relaxed. Maintaining all holds, make any necessary changes in flexion, extension, sidebending or rotation until you can sense a state of appropriate tension and leverage.. 'llIe patient should not be aware of any pain or discomfort. You make these final adjustments by slight movements of your ankles. knees. hips and trunk. not by altering the position of the hands or arms. 11. Immediately pre-thrust Relax and adjust your balance as necessary. Keep your head up; looking dO\ffl impedes


Figure B1.7.1

Figure B1.7.3

12. Delivering the thrust

Figure 81.7.2

the thrust and can cause embarrnssing proximity to the patient. An effective l-IVLA thrust technique is best achieved if both the operator and patient are relaxed and not holding themselves rigid. 'l11is is a common impediment to achieving effeaive cavitation. Ensure the pmient's head and neck remain on the pillQ\v as this facilitates the arrest of the technique and limits excessive amplitude of thrust.

Apply a HVLA thrust to the right anirular pillar of CA. The thrust is upwards and towards the midline in the directjon of the patient's left eye.. paralJelto the apophysial joint plane (Fig. 81.7.3). Trus thrust is generated by rapid pronation of your right forearm. Simultaneously, apply a slight rapid increase of rOlation of the head and neck to the left" but do not increase sidebending leverages. 'Ine increase of rotation to the left is accomplished by slight supination of the left wrist and forearm and is coordimnoo to match the thrust upon the contaa poinL This is a HVlJ\ 'flick' type thrust. Coordination between the left and right hands and forearms is critical. The thrust. although very rapid, must never be excessively forcible. 'nle aim should be to use the absolute minimum force necessary to adlieve joint cavitation. A common fault arises from the use of excessive amplitude with insufficient velocity of thnlSt.

• 99

_ _ _ _ _1


SUMMARY Cervical spine (2-7 Up-slope gilding Cradle hold

Patient supine • Contact point: Posterolateral aspect of the rtght (4 articular pillar • Applicator. Lateral border, proximal or middle phalanx • Patient positioning: Supine with the neck in a neutral relaxed position • Operator stance: Head of couch, feet spread slightly Palpation of contact point • Fixation of contact point • Cradle hold: The we;ght of the patient's head and neck is balanced between your left and right hands with cervical positioning controlled by the converging pressures • Vertex contact: None • Positioning for thrust: Stand upright at the head of the couch. The elbows are held close to or onfy slightly away from your sides. Introduce primary leverage of rotation to the left (Fig. B1.7.1) and a small degree of secondary leverage of sidebending right (Fig. B1.7.2). Maintain the contact point on the posterolateral aspect of the (4 articular pillar • Adjustments to achieve appropriate pre-thrust tension • Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: The thrust is directed towards the patient's left eye. Simultaneously, apply a slight, rapid increase of rotation of the head and neck to the left with no increase of sidebending to the right (Fig. B1.7.3)

,

"

"

,

I

I:

;

L.

100

Cervical spine C2-7 Up-slope gliding Cradle hold Patient supine Reversed primary and secondary leverage

Tn certain circumstances, the operator might wish to perform an upslope gliding t11nJSl but minimize the extelll of heml and neck rotation. Assume somatic dysfulletiUII (S-T-A-R-T) is identified mid YUII wish Iu use all upward mid furward glidillg thrust, parallel Iu the apaphysinl joitlt plane, (0 produce cavitation at C4-5 on the right:

1. Contact point

KEY

Posterolateral pillar of CA.

a.~pect

of the right articular

""

Stabilization

2. Applicator

•

Applicator


•



.~

Direction of body movement

(patient) Note: The dimensions for the arrows

are not it pktorial representation of the amplitude or force of the thrusL

Supine wilh the neck in a neut.rnl relaxed position. If necessaJy, remove or adjust pillow heigtn. The technique should not nonnally be executed in any significant degreE" of flexion or extension. 4. Operator stance Head of couch. feet spread slightly. Adjust couch height SO that you can stand as erect

101


as possible and avoid crouching over the patient as this will limit the technique and restrict delivery of the thrust. 5. Palpation of contact point

Place fingers of both hands gently under the occiput. Uft the head to throw the articular pillars into prominence. Rotate the head slightly to the left. taking its weight in your left hand_ Remove: your right hand from the occiput and palpate the right articular pillar of C4 with the tip of your right index finger. Slowly but finnly slide your right forefinger downwards (to\'Iards the couch) along the articular pillar until it approximates the middle or proximal phalanx. several sliding pressures may be necessaIy to establish dose approximation to the conl;lct point. 6. Fixation of contact point

Keep your right index finger firmly pressed upon the contact point while you flex the other fingers and thumb of the right hand SO as to dasp the back of the neck and thereby lock the applicator in position. You must now keep the applicator on the contact point until the technique is complete. Keeping the hands in position. return the head to the neutral position.


'l'he intent with this technique is to perform an up-slope gliding thrust but to limit the amount of head and neck rotation. This modification requires a greater emphasis upon the use of sidebending to achieve joint locking. It is critical that the direction of thrust be parallel to the apophysial joint plane in an up-slope direction. There should be no exaggeration of the sidebending l""""'8e. -Ine ellxn.YS are held dose to or only slightly away from your sides. This is an essential feature of the crndle hold method. Stand easily upright at the head of the couch and do not step to the right as in the chin hold method. (a) Primary leverage of sidebcndillg. Maintaining all holds and contact points. gently inlJOduce sidebending of the head and neck to the right until tension is palpated at the contact poim (Fig. BI.8.1). To introduce the right sidebending. the oper.ttor pivots slightly via the legs and

7. Cradle hold Keep your left hand under the head and spread the fingers out for maximum contact. Keep the patient's ear resting in the palm of the your left hand. Rex the left wrist, allowing you to crndle the patient's head in your palm, flexed wrist and anterior aspect of forearm. Keep your right index finger firmly on the contact point and press the right palm against the OCcipUl The weight of the patient's head and neck is now balanced between your left and right hands. with the cervical positioning controlled by the converging pressures of your two hands and erage. Add a little rotation to the left, down to and induding C4 (Fig. 81.8.2). This requires extensh-e practice before one develops a refined 'tension sense'. Movement of your hands and foreanns introduces the rotation. 10. Adjustments to achieve appropriate pre-thrust tension

Ensure your patient remains relaxed. Maintaining all holds, make any necessary changes in flexion, extension, sidebending or rotation until you can sense a state of appropriate tension and leverage. The patient should not be aware of any pain or discomfon. You make these final adjustments by slight movements of your

•

Figure 81.8.2

ankles, knees. hips and trunk. not by altering the position of the hands or arms. 11. Immediately pre-thrust

Relax and adjust ),our balance as necessary. Keep your head up; looking down impedes

the thrust and can cau.o;e embarrassing proximity to the patient. An effective HVl.A thrust technique is best achieved if both the opu3.tor and patient are relaxed and not holding themselves rigid. This is a common impediment to achieving effective cavitation. Ensure the patient's head and neck remain on the pillow as this facilitates the arrest of the technique and limits excessrve amplitude of thrusL 12. Delivering the thrust

Apply a I lVlA thrust to the right an.icular pillar of 01. The thrust is upwards and to\vards the midline in the direction of the patient's left eye. parallel to the apophysial joim plane (Fig. B1.8.3). This thrust is generated by rapid pronation of }'Our right forearm. Simultaneously, apply a slight rapid increase of rotation of the head and neck to the lefL A key element in this technique is to avoid exaggeration of the primary levernge of sidebending when the thrust is applied. The increase of rotation to the left is accomplished by slight supination of left wriSl and foreann and coordinated to match the thnlst upon the contaCt point. 'l1,is is a IIVLA 'nick' type thrust. ('-..cordi nation between the left O'Ind right hands and forearms is critical. It must be appreciated that the use of sidebending as a primal)' levcrnge is predicated upon the operntor"s desire to limit the amount of head and neck rotation. Generally, when sidebending is used as a primary leverage.. the aim will be to lhrust in a down-slope direction. Exaggeration of the sidebending leverage in this technique must be avoided. Sidebending enhances locking but does not assist with an up-slope gliding thrusL The thrust in lhis technique is accompanied by slight exaggeration of the

103


Figure 81.8.3

secondary leverage of IOlation and is directed towards the patiern's opposite eye. llle thnast. although very rapid. must never be excessively forcible. The aim should be to

'04

use the absolute minimum force necessary to achieve joint cavitation. A common (aull arises from lhe use of excessive amplitude with insufficient velocity of thrust.

----------


SUMMARY Cervical spine C2-7 Up-slope gliding Cradle hold

Patient supine Reversed primary and secondary leverage • Contact point: Posterolateral aspect of the right C4 articular pillar • Applicator. Lateral border, proximal or middle phalanx • Patient positioning: Supine with the neck in a neutral relaxed position • Operator stance: Head of couch, feet spread slightly • Palpation of contact point • Fixation of contact point • Cradle hold: The weight of the patient's head and neck is now balanced between your left and right hands with cervical positioning controlled by the converging pressures • Vertex contact: None • Positioning for thrust: Stand upright at the head of the couch. The elbows are held close to or only slightly away from your sides. Introduce primary leverage of siclebending to the right (Fig. Bl.8.1) and a small degree of secondary leverage of rotation left (Fig. 81.8.2). Maintain the contact point on the posterolateral aspect of the (4 articular pillar • Adjustments to achieve appropriate pre-thrust tension • Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: The thrust is directed towards the patient's left eye. Simultaneously, apply a slight rapid increase of rotation of the head and neck to the left with no increase of sidebending to the right (Fig. 81.8.3). A key element in this technique is to avoid exaggeration of the primary leverage of sidebending when the thrust is applied. The use of sidebending as a primary leverage is predicated upon the operator's desire to limit the amount of head and neck rotation

105

Cervical spine C2-7 Up-slope gliding Patient sitting Operator standing in front

Assume somatic d)'sfll'letion (S-'T-A-R-T) is identified and)'ou wish to use atl upward and forward thrust, parallel to the apophysial joint plane, to produce joint cavilllliml at C4-5 on the left

1. Contact point Poslerol~Iern.1 asped

KEY

of the left articular

pilhn of CA . .:t:

Stabilization

•

Applicator

Palmar aspect. proximal or middle phaltlllx of operator's right index or middle finger.

•



q


SitLing with the neck in a ncutrnl relaxed position. '!1le neck should not be in any significalll ameum of flexion or extension.

(patient)

Note: The dimensions for the arrows are not a pictorial representation of

the amplitude Of force of the thrust.

2. Applicator

4. Operator stance Stand in front and to the right of the patient. feel spread slightly. Adjust couch he:ighl SO that you can stand as eroo as possible: and avoid crouching over the

107


Figure 81.9.2

Figure 81.9.1

patient as Lhis will limit the technique and restrict delivery of the thrust (Fig. 131 .9.1). S. Palpation of contact point

Place the fingers and palm of your leC! hand ag:J.inst the patient's right occiput and neck. gently covering the patient's righl ear. Use the index or middle finger of your right hand 10 palpate the patient's left articular pillar of C4. Slowly but firmly slide your applicator along the articular pillar of CA until it approximates the proximal or middle phalanx (Fig. B1.9.2). Several sliding pressures may be necessary to establish dose approximation to the contact point. 6. Fixation of contact point Keep your right index or middle fingf'f

108

finnly pressed upon the contact point while you spread the other fingers and thumb of Lhe right hand to securely support the head, mandible and neck. thereby locking the applicator in posiLion. You must nO\\{ keep

the applicator on lhe contact poinl until the technique is complete. The weight of the head and ned: is nO\'I balanced between your left and right hands. with the cervical spine positioning cOnlrolled by the converging pressures of your two hands. 7. Positioning for thrust

The elbows are held close to or only slightly away from your sides. (a) PrillUlry If!l'emge. Ensure: that the p your head up; looking down impedes the thl'illit and can cause: embarrassing proximity t.o the patienL An effeah'e HVLA thrust technique is best achieved if both the ope.""3.tor and patient are relaxed and not holding themselves rigid. This is a common impediment to achieving effective cavitation.

FiguTl! 81.9.4

109


10. Delivering the thrust Apply a IIVIA thrust to the left articular

pillar of C4. 1be thrust is upwards and to\'lards the midline in the direction of the patient's right eye. parallel to the apophysial joint plane (l-ig. BI.9.4). Simultaneously, apply a 51ig11l. rapid increase of rOlation to the right, but do not increase sidebrnding Iewn.ges. This is a IIVl..A 'flick' type lhrust.

Coordination between the len and right hands and anus is critical. The thrust. although \'eI)' rapid. must lle\'e.r be excessively forcible.. The aim should be to use the absolute minimum force necessary to achieve joint cavitation. A common fault arises from the use of excessive amplitude with insufficient \'e1ocity of thrust.

SUMMARY

Cervical spine C2-7

Up-slope glidIng

Patient sitting Operator standing in front .. Contact point: Posterolateral aspect of the left C4 articular pillar .. Applicator: Palmar aspect, proximal or middle phalanx • Patient positioning: Sitting with the neck in a neutral relaxed position • Operator stance: In front and to the right of the patient.. feet spread slightly

(Fig. Bl.9.11 • Palpation of contact point • Fixation of contact point: Keep your right index or middle finger firmly pressed upon the contact point while you spread the other fingers and thumb of the right hand to securely support the head, mandible and neck (Fig. 81.9.2) • Positioning for thrust: Stand upright with the elbows held close to or only slightly away from your sides. Introduce primary leverage of rotation to the right (Fig. 81.9.3) and a small degree of secondary leverage of sidebending left. Maintain the contact point on the posterolateral aspect of the (4 articular pillar • Adjustments to achieve appropriate pre-thrust tension • Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: The thrust is directed towards the patient's right eye. Simultaneously, apply a slight, rapid increase of rotation of the head and neck to the right with no increase of sidebending to the left (Fig. 81.9.4). Coordination between both hands and arms is critical 110

~ ----

7_'-~'·--::

Cervical spine C2-7

. . _',

1.10

Up-slope gliding Patient sitting Operator standing to the side

Assume somatic dysfflrldion (5-T-A-R- T) is identified and )'ml luisll to use an upward and lanvard gliding thrust, parallel to the apopll)'Sial joint plane, to produce cavitation at C4-5 011 the left:

1. Contact point

KEY

Posterolateral aspect of the left anicuJar pillar of C4.

-:t:-

Stabilization

•

Applicator

-


¢



are not a pictorial representation of the amplitude Of force of the thrust

2. Applicator Palmar aspen. proximal or middle phalanx of operators right indeJ[ or middle fmger. 3. Patient positioning

Sitting with c.he neck in a nculml relaxed position. 1'he neck shouJd not be in any significant amOUni of flexion or extension. 4. Operator stance Stand to th~ right of th~ pati~nt. feet spread slightly. Adjust couch h~ight so that you can stand as erect as possibl~ and avoid

'"

.


Figure81.10.1

crouching over the patjem as this will limit the technique and restrict delivery of the thrust (Fig. B1. 10.1). 5. Palpation of contact point

Place the fingers and palm of your left hand over the right side of the patient's head and neck. gently covering the right ear. Reach in front of the patient with your right hand and palpate the left artiOJ.lar piJIar of C4 with the tip of your right index or middle finger. Slowly but finnly slide your applicator along the articular pillar of C4 until it approximates the proximal or middle phalanx. Several sliding pressures may be nec£SSary to establish dose approximation to the contact point. 6. Fixation of contact point

112

Keep your right index or middle finger finnly pressed upon the contaa point while you spread the other fingers and thumb of the right hand to securely support the head, mandible and neck. thereby locking the applicator in position. You must now keep

Figure 81.10.2

the applicator on the contact point until the technique is complete. 111e weight of the head and neck is now balanced Ixtween your left and right hands. with the cervical spine positioning controlled by the converging pressures of your two hands. 7. Positioning for thrust

The elbows are held close to or only slightly away from your sides. (a) Primary leverage. Ensure that the patient's head is securely supported between your two hands. Maintaining all holds and conlaO points. rotate the hrnd and neck to the right until tension is palpated at the conlaO point (Fig. Bl.tO.2). Do not lose contact between your applicator and the articular pillar of C4. Do not force rotation; take it up fully but carefully. A common mistake is to lise insufficient primary leverage of hrnd and neck rotation. (b) Secondary leverage. Add a very small degree of sidebending 10 the left. down to and including C4. NQte: Silong sidelxnding


1.10

Tne patient should not be aware of any pain or discomfort. You make lhese final adjustments by slight movements of your legs and I.n.1nk. not by altering the position of lhe hands or arms. 9. Immediately pre-thrust

RelaJe and adjust your balance as necessary. Keep your head up; looking down impedes the thrust and can cause embarrassing proximily to lhe palienL An effective HVLA thrust technique is best achieved if both the oper.alor and patienl are relaxed and not holding themselves rigid. This is a common impediment 10 achieving effective cavitation. 10. Delivering the thrust Ag.81.103

will lock the neck. Slighl movements of the operator's forearms, shouldeJS and I.n.1nk introduce lhe sidebending. 8. Adjustments to achieve appropriate

pre-thrust tension

Ensure your patient remains relaJeed. It is important (0 keep your elbows close 10 your sides. Maintaining aU holds, make any necessary changes in flexion, extension, sidebending or rotation unlil you can sense a state of appropriate lension and leverage.

Apply a HVLA thrust to the lefl arurolar pillar of C4. The thrust is upwards and towaros the midline in the direaion of the palient's riglll eye. parallel to the apophysial joint plane (Fig. 81.10.3). Simultaneously, apply a slight. r.apid increase of rotation to lhe righi, but do not increase sidebending leverages. This is a HVI.A 'flick' type thrust Coordination between the left and right hands and anns is critical. The thrust, although very rapid, must never be excessively forcible. 111e aim should be to use the absolute minimum force necessary 10 adlieve joint cavitation. A common faull arises from the use of excessive amplilude with insufficient velocity of thrust

113

r

------------

HVlA thrust techniques - spine and thorax

SUMMARY

Cervical spine C2-7

Up-slope gilding

Patient sitting Operator standing to the side • Contact point: Posterolateral aspect of the left (4 articular pillar • Applicator: Palmar aspect, proximal or middle phalanx • Patient positioning: Sitting with the neck in a neutral relaxed position • Operator stance: To the right of the patient. feet spread slightly (Fig. 61.10.1) • Palpation of contact point • Fixation of contact point • Positioning for thrust: Stand upright with the elbows held close to or only slightly away from your sides. Introduce primary leverage of rotation to the right (Fig. 81.10.2) and a small degree of secondary leverage of sidebending left. Maintain the contact point on the posterolateral aspect of the left (4 articular pillar • Adjustments to achieve appropriate pre-thrust tension • Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: The thrust is directed towards the patient's right eye. Simultaneously. apply a slight, rapid increase of rotation of the head and neck to the right with no increase of sidebending left (Fig. 81.10.3). Coordination between both hands and arms is critical

114

Cervical spine C2-7 Down-slope

~liding

71J.

I~~

vt/;il1

G-o

Chin hold Patient supine

Assume somatic dys/wiction (5- T-A-l?-T) is identified and you wish to use a dowT/ward a11d baclllvard gliding thrust, parallel 1.0 the apophysial joim plane, produce cal/itation at C4-5 on rhe right:

[0

1. Contact point

Lateral aspect of the right ~rticular pillar of C4.

KEY ->Ie

Stabilization

2. Applicator

•

Applicator

Lateral border, proximal or middle phalanx of operntor's right index finger.

..

Plane ofthrust (operator)


c:>



Supine with the neck in a ncuITal relaxed. position. If necessary, remove pillow or adjust pillow height The neck should not be in any significant amount of flexion or extension. 4. Operator stance

I-lead of COUdl, feel spread slightly. Adjust couch height so Lhat you can stand as erect

l1S


as possible and avoid crouelling over the patient as this will limit the technique and !"CStrict delivery of the thrust. 5. Palpation of contact point

Place fingers of both hands gently under the occiput. Rotate the head to thl' left. taking its weight in your left hand. Remove your right hand from the occiput and palpatl' the right articuJar pi1lar of C4 with the tip of your index or middll' finger. Slowly but firmly slide your right index finger dO\..nwards (to\vards the couch) along thl' articular pillar until it approximatl'S the middle or proximal phalanx. Several sliding pressures may be necessary to establish c!a;e approximation to Ihe contact point. 6. Fixation of contact point

until the fingers lightly clasp the chin. Ensure thai your left foreann is over or slightly anlerior to the ear. Placing the forearm on or behind the ear puts the neck into 100 much flexion. The head is now controlled by balancing forces between the right palm and left foreann. Maintain the applicator in position. 8. Vertex contact

MO\'e }'our body fon\'3rd slightly so that your chest is in contact with the venex of the patient's head. The head is nO\v securely cradled betwcen }OUr left forearm, the {Iexed left elbow, the right palm and your chest. Vertex contact is often usdUl in a heavy, stiff or diffICUlt case but can, on occasions, be omiued.

Keep your right index finger firmJy pressed

upon the contact point while you flex the other fingers and thumb of the right hand so as to clasp the back of the neck and thereby lock the applicator in position. You must now keep the applicator on the contact point until the technique is complete. Keeping the hands in position, return the head to the neutral position. 7. Chin hold

Keeping your right h:md in position, slide the left hand slO\..ly and carefully forwards


Step slightly to the right, keeping the hands finnly in position and taking care not lO la;e pressure on the COntact point. This inlroduc('$ an element of cervical sidebending to lhe right. Straighten your right wrist so that lhe radius and first met cavitation. 9. Delivering the thrust

Apply a IM.A thrust to the left transverse process of1"3 down to\Yards the couch and in the direction of the patient's left axilla. Simuhaneously, apply a slight. rapid increase of head and neck rotation to the left with your right hand (Fig. 6I.1G.3). The thmst induces local rotation of the T3 wnebra. focusing forces at the 1'2-3 segment. You must not overemphasize the thrust with your right hand against the patient's head and neck. Your right hand stabili7£s the leverages and maintains the position of the head and cervical spine against the thrust imposed upon the contact

Figure 81.163

point. 1be thrust is induced by a very rapid contraction of the triceps. shoulder adduoors and internal rotators. TIt€': thrust, although very rapid. must never be excessivt>ly forcible. The aim should be to use the absolute minimum force necessary to adlieve joint cavitation. A common fault arises from the use of excessive amplitude with insufficient velocity of thmSt.

141


SUMMARY

Cervicothoracic spine C7-T3 Rotation gliding Patient prone Operator at head of couch • Contact point: Left T3 transverse process • Applicator: Hypothenar eminence of the left hand • Patient positioning: Patient prone with the chin resting on the couch and the arms hanging over the edge of the couch or against the patient's sides. Introduce slight head and neck flexion. Introduce sidebending to the right (Fig. 81.16.1). Do not introduce too much sidebending • Operator stance: To the right of the head of the couch, feet spread slightly • Palpation of contact point: Place your hypothenar eminence against the transverse process of T3 on the left • Positioning for thrust Place your right hand against the left side of the patient's head and neck with your fingers pointing towards the couch, Rotate the cervical and upper thoracic spine to the left by applying pulling pressure to the left side of the patient's head and neck with your right hand until a sense of tension is palpated at the contact point (Fig. 81.16.2) • Adjustments to achieve appropriate pre-thrust tension • Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: The thrust is in the direction of the patient's left axilla and down towards the couch. Simultaneously, apply a slight rapid increase of head and neck rotation to the left with your right hand (Fig. 81.16.3), You must not overemphasize the thrust with your right hand against the patient's head

142

Cervicothoracic spine C7-T3 Sidebending gliding Patient sitting

Assume somatic dysfunction (S-T-A-R-T) is identified and you wish to use a sidebending gliding tlirust, fX1rallel to tlie apopliysial joint. plane. W produce cavil11lion at the 12-3 apophysial joint:

1. Contact point

Left side of the spinous process 0['1'2.

KEY .:f(o

Stabilization

2 Applicator

'Ibumb of left hand. •

Applicator

-


¢



Patient silting with bad: towards the operalor. 4. Operator stance Stand behind the palienL

Note: The dimensions for the arrows are not a pictorial representation of the amplitude or force of the thrust

5. Palpation of contact point Locate the spinous process of"2. Place the

thumb of your left hand gently but fumly against the left side of this spinous process.

143


FtgureBl.17.1

Ftgure 81.17.2

Spread the fingers of your left hand to rest over the patielll's left trapezius muscle whh your fingenips resting on the patient's left c1avide (Fig. B1.I7.1). I-:nsure that you have good contact and will not slip oIT the spinous process of'l"2 when you apply a force against h. Maintain this contact poinL 6. Positioning for thrust 144

Keeping your poshion behind the patient place your right hand and foreann

alongside the right side of the patient'S head and neck and gently rest the palm of your hand over the top of the patient's head (Fig. B1.17.2). Ensure that your forearm remains anterior to, and just over, the patient's ear. This hand will introduce and control the rotation and sidebending leverages. Use )'Our left hand to slightly rotate the patient's trunk to the left while using your right hand to introduce head and ned< rOl.ation to the right until a sense of tension is palpated at the conlact point (I:ig.. 81.17.3). Now gently inlrOdlXe cervical sidebending to the left by allowing the patient's body weight to fall slightly to the right. Keeping the patient's head centred over the sacrum, guide the neck into left sidebending with your right arm against the right side of the patient'S head. A vertex compression force call be added 10 assist in localizing forces to theTI-3 segment. Ensure that your applicator thumb forms a straight line with your left foreann. 7. Adjustments to achieve appropriate prethrust tension Ensure the patient remains relaxed. Maimaining all holds. make any necessary changes in flexion, extension, sidebending or rotation untjl )'Ou can sense a state of appropriate tension and leverage. "11le paliem should not be a\\'are of any pain or discomfort Make these final adjustments by bending to the right focus forces at the TI-3 segment and cause cavilalion at that level. Do not apply excessive sidebending at the time of the thrust as this can cause strain and discomfon. The thrust. although very rapid must never be excessively forcible. 'l'he aim should be to use the absolute minimwn force necessary to acruE:\'e joint cavitation. A common f.1UIt arises from the use of excessive amplilude with insufficient velOCity of thnlsl,

Apply a IIVLA thruSi to the spinous process of 1'2 down towards the couch in the

153

______________L


SUMMARY

Cervicothoracic spine C7-T3 Sidebending gliding Patient side·lying • Contact point: Right side of 12 spinous process • Applicator: Thumb of left hand • Patient positioning: Patient lying on the left side. Flex the patient's knees and hips for stability • Operator stance: Facing the patient. Place your right arm under the patient's head, supporting the patient's occiput • Palpation of contact point Place the thumb of your left hand against the right side of the spinous process of 12 • Positioning for thrust Using your right arm, sidebend the patient's head and neck to the right (Fig. 81.19.1).lntroouce cervical rotation to the left until a sense of tension is palpated at the contact point (Fig. 81.19.2) • Adjustments to achieve appropriate pre-thrust tension • Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: The thrust is in the directton of the patient's left shoulder and down towards the couch. The thrust is accompanied by a downward application of force with your chest to the patient's right shoulder girdle. Simultaneously, apply a slight rapid increase of head and neck sidebending to the right with your right arm (Fig. 81.19.3). Do not apply excessive sidebending

154

Cervicothoracic spine C7-T3 Sidebending gliding Patient side-lying Ligamentous myofascial tension locking

Assume sontatic dysfunaio71 (s·rf-A_R_T) is idelltified and }'Oll wish to use a sidebending gliding thrust, parallel to the apophysial join[ plane. CD produce caviUltion ill the 12-3 apophysial joint:

1. Contact point

Right side of the spinous process of1'2.

KEY ;i:.

Stabilization

2. Applkator Thumb of leCl hand.

•

Applicator


-


Palienllying on the left side. Plex !.he paLienl's knees and hips for stability.

Q

Direction or I:x>dy movement (pattent)


4. Operator stance

Stand facing the patient and gently plaet': your right arm under the head. lightly spreading rOUT fingers around the patient's occiput. The head should now be CT3dled in your riglll arm with your upper ann against the patient's forehead and ),our forearm and hand supporting the head and neck.

155


5. Palpation of contad point

Lcx::ale the spinous process of 1'2. Place the thumb of )'OUf lefl hand genLly but firmly against the right side of this spinous process.. Spread the fingers of your left hand to enable firm contact of your thumb and position }'Our left forearm 0\'eJ" the posterior aspect of the patient's thorax and Iwnbar spine. lhis will ensure that you ha\'e good contan and will not slip off the spinous process when you apply a force against it.

Maintain this contaa poinl but do not press too hard, as it can be uncomfortable. 6. Positioning for thrust

Using }'Our right arm, extend the patielll's head and neck (Fig. 81.20.1). Now introduce sidebending to the right until a sense of tension is palpable at the contaeL point "Ill is sidebending is achieved by gently lifting the patient's head, within the mdle of your right arm (Fig. 61.20.2). If necessary, you may add a compression force to the patient's shoulder girdle. from your chest. to stabilize the upper torso before applying the thrust. 7. Adjustments to achieve appropriate

pre-thrust tension

Ensure the patient remains relaxed. Maimaining all holds, make any necessary changes in flexion.. extension, sidebending or rotation Wltil you can sense a stale of appropriate tension and leverage at the rontaa point. The patient should not be aware of any pain or discomfort. Make these final adjustments by balancing the pressure and direction of forces between the left hand against the contact point and lhe right hand and forearm against the palient's head and neck.

Figure 81.20.1

156

Figure 81.20.2


1.20

Figure 81.203

8. Immediately pre-thrust

Relax and adjust your balance as necessary. Keep }'Our head up and ensure that your contacts are finn and that your body position is well controlled. An effective HVLA lhrust technique is best achieved if the operator and patient are relaxed and not holding themselves rigid. This is a common impe:d.imem to achieving effective cavitation. 9. Delivering the thrust

'J1lis ,eclmique uses ligamerllow rtI)'ofmrial tension locking and nOf facet apposiricm locking. 'J1lis apprOtlcll generaUy requires a greater erupluuis on IIle exLlggeramnJ of ptimary let/erage /Iran is ti,e case lIIi,h facet apposition locki"g tedmiques. Apply a HVLA thrust to the spinous process of1'2 down towards the couch in

the dircaion of the patient's left shoulder. The thrust is accompanied by a simultaneous downward application of force with your chest to the patient's right shoulder girdle. At the same time. introduce an increase in head and neck sidebe:nding to the right with your right arm (Fig. 81.20.3). llre thrust on the spinous process of1'2 and increase in neck side:bending to the right focus forces at the 1'2-3 segment and Cil.use cavitation at that level. Do not apply exce:ssh~ sidebe:nding at the: time of the thrust as this can Cil.use strain and discomfon. 11le thrust. although ''t'IY rapid. must never be excessively forcible. lhe aim should be to use the absolute minimum force necessary to adlie:ve joint cavit.ation. A comlllon fault arises from the use of excessive amplitude with insufficient velocity of thrust.

157


SUMMARY Cervicothoracic spine C7-13 Sidebendlng gilding Patient sid~lying ligamentous myofascial tension locking • Contact point: Right side of T2 spinous process • Applicator: Thumb of left hand • Patient positioning: Patient lying on the left side. Flex the patient's knees and hips for stability • Operator stance: Facing the patient. Place your right arm under the pattent's head. supporting the patient's occiput • Palpation of contact point: Place the thumb of your left hand against the right side of the spinous process of T2 • Positioning for thrust Using your right arm, extend the patient's head and neck (Fig. 81.20.1). Introduce sidebending to the right until a sense of tension is palpable at the contact point (Fig. 81.20.2) • Adjustments to achieve appropriate pre-thrust tension • Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: The thrust is in the direction of the patient's left shoulder and down towards the couch. The thrust is accompanied by a downward application of force with your chest to the patient's right shoulder girdle. Simultaneously, apply a rapid increase of head and neck sidebending to the right with your right arm (Fig. 81.203). 00 not apply excessive sidebending

158

Cervicothoracic spine C7-T3 Extension gliding Patient sitting Ligamentous myofascial tension locking

Assume somatic d)'s[zmclio7J (S-T-A-R-T) is identified and }'Oll lUisll to use ml extension gliding thrust, parallel to the apopllrsia1 joi1lt plane, to produce joint cavitation al12-3:

1. Contact points (a) Spinous process or1'3 (b) Patient's forearms.

KEY .~'"

Stabilization

•

Applicator

-


Q


2. Applicators (a) Operator's sternum, with a cushion or small rolled IOwel, tlpplied to the 1'3 spinous process (rig. 81.21.1)

(b) Operator's hands applied to the patient's forearms.

Note: The dimensions for the arrows are not a pidorial representation of the amplitude or force of the thrust

3. Patient positioning Sitting wilh arms comfortably b)' side. 4. Operator stance

Stand directly behind the patient wim your feet apart and one leg behind the other.

159

_ _ _ _ _ _ _ _ _ _1


Figure 81.21.1

Figure 81.21.2

Bend your knees slightly to 100\ler )'Our

the tension can be localized to the 1'2-3 segment. Maintaining all holds and pressures, bring the patient back"'lards until }'our body weight is evenly distributed between both feet.

body.

s. Positioning for thrust

'60

Place the thrusting pan of your sternum, with a cushion or small rolled towel. firmly against the spinaliS process of 1'3. Place your hands between the patient's chest and upper arms to take hold of the patients' forearms (Pig. B1.21.2). Maintaining your grip on the forearms ask the patient to put their hands behind their neck with fingers intertwined (Pig. BI.21.3). This results in your forearms contacting the patient's axillae. Lean forwards with the thrusting pan of your chest against the spinous process of 1'3 and introduce a baoovards and compressive force to the patient's arms and axillae. These combined movements introduce local extension to the thorndc spine. By balancing these different leverages.


Ensure your p:nient remains relaxed. Maintaining all holds, make any necessary changes in flexion, extension, sidebe.nding or rotation until you can sense a state of appropriate tension and leverage at the 1'2-3 segment. The patiem should not be aware of an)' pain or discomfort. Make these final adjustments by slight movements of the ankles, knees. hips and trunk A conunon mistake is to lose the chest and axillae compression during the final adjustments.


1.21

--

Figure 81.21.3

Figure 81.21.4

7. Immediately pra-thnut

thrust directJy forwards against the spinous process ofn via }'OUr sternum (Fig. BI.21.4). The thrust. although "ery rapid. must never be excessively fordble. The aim should be to use the absolute minimum force necessary to achieve joint cavtlalion. Common faults arise from the use of excessive amplitude. insufficient velocity of thrust and lifting the patient off the rouch. When delh-ering the thnlst. particular care must be taken to not allow' the patient's arms to mO\'e away from the chest wall. This technique has some modifications: • Respiration can be used to make the technique more effective. • A certain degree of momentum is often necessary for success in the technique.

Relax and adjust }'OUr balance as necessary. Keep your head up and ensure that your contaas are firm and the patient's body weight is well controlled. An effective HVLA thrust technique is best achieved if the operator and patient are relaxed and not holding themselves rigid. 'ibis is a common impediment to achiL>ving effective cavilation.

8. Delivering the thrust The shoulder girdles and thorax of the patient are now a solid mass against which a thrust may be applied. Apply a I IVLA thrust to'\vards you via your hands and forearms. Simuhaneously, apply a HVlA

161


SUMMARY

Cervicothoracic spine C7-T3 ExtensIon gilding Patient sitting ligamentous myofascial tension Jocking • Contact points: -Spinous process ofT3 -Patient's forearms • Applicators: -Operator's sternum applied to the T3 spinous process (Fig. 81.21.1) -Operator's hands applied to the patient's forearms • Patient positioning: Sitting with arms comfortably by side • Operator stance: Directly behind the patient with your feet apart. knees bent slightly and one leg behind the other • Positioning for thrust: Place your hands between the patient's chest and upper arm to take hold of the patients' forearms (Fig. 81.21.2). Maintaining your grip on the forearms ask the patient to put their hands behind their neck with fingers intertwined (Fig. 81.21.3). Lean forwards with the thrusting part of your chest against the spinous process ofT3 and introduce a backwards and compressrve force to the patient's arms and axillae. Maintaining all holds and pressures. bring the patient backwards until your body weight is evenly distributed between both feet • Adjustments to achieve appropriate pre-thrust tension • Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: The direction of thrust with your arms is towards you. Simultaneously, apply a thrust directly forwards against the spinous process of T3 with your sternum (Fig. 81.21.4) • Modifications to technique: -Respiration can be used to make the technique more effective -A certain degree of momentum is often necessary for success in the technique

162

Thoracic spine and rib cage

Q. ...hich enables the operator 10 efTectivel}'

PATIENT UPPER BODY

POSITIONING FOR SITIING AND SUPINE TECHNIQUES

/

There are a variety of upper body holds available (rigs U2.0.I-U2.0.S). The...!!old: se:lectoo for any panirolar techniquelSihat

Figure 82.0.1

SECTION

'f

Iocala. fO'CES '0 3 specific segment o(the_ spine or ~b_ cag! and d~iver ~ higtH1?:loo{)' 100...-ampIItlKle (11VlA) (ory

In

a controlled

manner. Patient comfort must be a major conside-:ation in selecting the m05t appropnate hold.

Figure 82.0.2

163


•

Figure 82.0.3

Figure 82.05

164

Figure 82.0.4


OPERATOR LOWER HAND POSITION FOR SUPINE TECHNIQUES There are a varirty of hand positions that can be adopted. The hand position selected for any particular technique is thai which enables Ihe operator 10 effeahoely localize forces to a specific segment of the spine or rib cage and deliver a HVU. force in a

controlled manner. Patienl comfort mUSI be a major consideration in selecting the most appropriate hand position. • Nrotnll hand position (Fig. B2.0.6) • Clenched hand position (Fig. B2.0.7) • Open fist (Fig.. B2.0.8) • Open fist with towel (Fig.. 82.0.9) • dosed ftst (Fig. B2.0.tO) • dosed fist with to\,'e! (Fig. 82.0. II)

Figure 82.0.6

Figure 82.0.9

Figure 82.0.7

Figure 82.0.10

Figure 82.0.8

FIQure 82.0.11

16S

Thoracic spine T4-9 Extension gliding-.. Patient sitting Ligamentous myofascial tension locking

Assume somatic dysfunction (5-T-A-R-T) is identified and )"u wish la use an exlension gliding tJlTUSI.. parallel to t.he apophysial jojtTL plane, to produce joint cavitation at 15-6 (Figs B2.1.1, B2.1.2):

Figure 82.1.1

Figure 82.1.2

1. Contact points

KEY .~,

(a) Spinous proct'Ss ofT6 (b) Patienl's elbows. Stabilization

2. Applicators •

Applicator

(a) Operator's sternum, with a cushion or slllall rolled towel. applied 10 the T6

-


spinous process (Fig. 82.1.3) (b) Opcratol/s flexed fingers. hands and wriSIS applied to the patient's elbows.

':> Direction of body movement (patient)

3. Patient positioning Note: The dimensions for the arrows are not a pictorial representation of the amplitude or force eX the thrust.

Sitting with arms crossed O\l(!r !.he chest and hands passed around the shoulders. 'Ine anns should be finnly clasped around the body as far as the patient can comfortabl}' "",ch.

167


Figure 82.1.3

4. Operator stance

Stand directly behind the patient wilh your feet apart and one leg behind the other. Bend your knees slightly to lower }'Qur body. S. Positioning for thrust

168

PIOlce Ihe Ihrusting pan of your sternum, with a rushion or small rolled towel. firmly againsl the spinolls proc€SS ofT6. Place your hands over the pmienl's elbows. Lean forwards wilh the thrusting part of your dll.~t ag.1insl the spinous proc€SS of '1'6 (Fig. 112.1.4). Introduce a backwards (compressive) and upwards force 10 the patient's folded arms. 11,ese combined movements introduce local extension to the thornoc spine. B}' balancing these different leverages.. the lension can be localized to the TS-6 segment. Maintaining all holds and pressures, bring the patirnt badwards until

Figure 82.1.4

}'Qw body weight is evenly distributed between both feet. 6. Adjustments to achieve appropriate

pre-thrust tension Cnsure }'our patient remains relaxed. Maintaining all holds. make any necessary dHmges in flexion, extension, sidebcnding or rotation until you can $Cnse a stale of appropriate tension ;md levernge OIl the T5-6 segment. The patient should not be aware of an}' pain or discomfon. Make these final adjustments by SliglH movements of the ankles.. knees. hips and trunk. A common mistake is to lose lI,e chesl compression during tlle final adjustments. 7. Immediately pre-thrust

Relax and adjust your balance as necessary. Keq> }'our head up and ensure that your

contacts are finn and the patient's body

------------


\\lCigJll is well controlled. An effective IIVU. thrust technique is Ix':st adlievoo if the operntor and patient are relaxoo and nOI holding themselvcs rigid. This is a rommon impediment to achieving effective cavitation.


Figure 82,1.5

This t«hllique uses ligamefllow m)'VflllCinl tension Inching and 1101 facel apposition lockillg. This approach gelleral1)' requires a gretller empluuis on the erilggertltion 0{ primary letfer-age tha" is dIe case with faat apposition locking techJ1Up.teS. The shouJder girdles and lhorax of lhe patient all" nO\\I a solid mass against which a thrust may be applied. Appl)' a J lVlA thrust to\vards you and slightly upwards in a cE'phalad direction via )'OUr hands. Simultaneously. appl)' a I tVlA thrust directly forwards againsl the spinous procl'SS of '1'6 via )'OUr sternum (rig. H2.1.5). 'me. thrust, although very rapid. must nC\-er bt> excessively forcible. The aim shouJd be to use the absolute minimum force necessary to achieve joint cavitation. A common faull arises from the use of excessive amplitude with insufficient velocity of thrust. 'Ihis technique has many modifications:

• Different shoulder girdle holds can be used • Respiration can be used to make the tedmique more effective • A cert..,in degree of momentum is often necessary for success in the technique.

169


SUMMARY Thoracic spine T4-9 Extension gilding Patient sitting ligamentous myofascial tension locking • Contact points: -Spinous process ofT6 -Patient's elbows • Applicators: -Operator's sternum applied to the T6 spinous process (Fig. B213) -Operator's flexed fingers, hands and wrists applied to the patient's elbows • Patient positioning: Sitting WITh arms crossed over chest • Operator stance: Directly behind the patient with your feet apart, knees bent slightly and one leg behind the other • Positioning for thrust: lean forwards with the thrusting part of your chest against the spinous process of T6 (Fig. B2.1.4).lntroduce a backwards (compressive) and upwards force to the patient's folded arms. Maintaining all holds and pressures, bring the patient backwards until your body weight is evenly distributed between both feet • Adjustments to achieve appropriate pre-thrust tension • Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: The direction of thrust with your arms is towards you and slightly upwards. Simultaneously, apply a thrust directly forwards against the spinous process of T6 with your sternum (Fig. 82.1.5) • Modifications to te'-~

Stilnd on the riglu side of the patient, facing

the head of the couch. 5. Posftlonlng for thrust

172

Reach over the patient with your left hand 10 lake hold of the left shoulder and gently pull it 100'J3rds you. With )'OUT right hand. locate the transverse processes ofT6. NO\v placc the clenched palm of)'ow right hand against the lram'\'erse procE'SSt'S ofT6 (Fig. 1l2.2.2). Keeping the right hand pressed againsr the lraos\'erse processes of 1'6. rolJ !.he

patient back 10 the supine position. As the patient approadles the supine position, tmnsfer yOllr lefl hand and forearm to support the patielll's head, neck and upper (horndc spine (Fig. 82.2.3). Allow' the pmiem to roll fully into the supine position. Flex the patient's head, neck and upper thoracic spint' until tension is localized to the 1'5-6 segment. Lean over the patient and resl )'QUr lower sternum or upper abdomen on the patient's elbows. Initially, a slO'o'll but finn pressure is applied with )'OUr 10'0\'£:1" sternum or upper abdomen dO'o,,"\vards to\vards the couch. Maintaining this dO'ovoward leverage. introduce a force in


. -

.

22

-,-'

Ftgure 82.23

line with the patient's upper arms. By baJancing these different leverages. tension can be locali7,.OO to the TS-6 segme.nL

6. Adjustments to achieve appropriate pre-thrust tension Ensure your patient remains relaxed. Maintaining all holds, make any necessary changes in nexion, extension, sidebendillg or rotation until you can sense a state of appropriate tension and leverage at the TS-G segment. 11le palielll should not be aware of any pain or discomfort. Make these final adjustments by slight movements of ankles, knees, hips and Hunk. A common mistake is to lose the chest compression during the final adjustments.

7. Immediately pre-thrust Ilelax and adjust your balance as necessary. Ensure that your contacts are firm and the patient's head, ned< and upper thoracic spine are well controlled. An effective HVLA thrust technique is best achieo.u1 if the operator and patient are relaxed and not holding themselves rigid. 'Ibis is a common impediment to achieving effective ca\~tation.

8. Delivering the thrust This tedmique uses ligamentous m}'Ofasdnl locking aud not facer apposition lockillg. This app;:ooe,rgelleraU,. retluires a greater emplwis on die exaggeration of primllry leverage dUIIl is tile CIISe widl facet ~itiOlI locking redmiques. The shoulder girdles and lhorax of the patient are now a solid mass against which a thrust may be applied. Apply a IIVLA thm"it dO\vnwards to\vards the couch and in a cephaJad direaion via your lower sternum or upper abdomen. Simuhaneously, apply a I-IVI.A thrust wilh your right hand against the tran"iVerse processes in an upward and caudad direction (Fig. 82.2.4), A common fault is to emphasize the thrust via the patient's shoulder girdles at the expen.se of the thrust against the transverse processes. The hand contacting the transverse proces."ies ofT6 must actively panidpate in the generation of thrust forces. The thrust. although \'el)' rapid, must never be excessivet), forcible. 11,e aim should be to use the absolute minimum force ne«ssary to achieve joint cavitation. A common fault arises from the use of excessive amplitude with insufficient \'elocity of thrusL tensiOlI

173


Ftgure 82.2.4

This technique has man}' modifications: • Different shoulder girdle holds can be

used • Different applicators can be used • Respiration can be used to make the technique more effecth-e

174


SUMMARY Thoracic spine 14-9 Flexion gliding Patient supine ligamentous myofascial tension locking • Contact points: -Transverse processes of T6 -Patient's elbows • Applicators: -Palm of the operator's right hand. held in a clenched position -Operator's lower sternum or upper abdomen • Patient positioning: Supine with arms crossed over chest (Fig. 82.2.1) • Operator stance: To the right side of the patient, facing the couch • Positioning for thrust: Take hold of the patient's left shoulder and pull it towards you. Place the clenched palm of your right hand against the transverse processes of T6 (Fig. 82.2.2). Roll the patient back to the supine position. As the patient approaches the supine position, transfer your left hand and forearm to support the patient's head, neck and upper thoracic spine (Fig. 82.23). Allowing the patient to roll fully into the supine position, flex the head. neck and upper thoracic spine until tension is localized to the T5-6 segment. Apply a firm pressure with your lower sternum or upper abdomen downward towards the couch. Maintaining this downward leverage, introduce a force towards the patient's head in line with the patient's upper arms • Adjustments to achieve appropriate pre·thrust tension • Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: The direction of thrust is downwards towards the couch and in a cephalad direction via your lower sternum or upper abdomen. Simultaneously. apply a thrust with your right hand against the transverse processes in an upward and caudad direction (Fig. 82.2.4). The hand contacting the transverse processes of T6 must actively participate in the generation of thrust forces • Modifications to technique: -Different shoulder girdle holds can be used -Different applicators can be used -Respiration can be used to make the technique more effective

175

Thoracic spine T4-9 Rotation gliding Patient supine Ligamentous myofascial tension locking

Assume somatic dysfunction (S-T-A-R-T) is identified and )'Otl wish to use a rotation gliding thrust, parallel to the apophysial joint plane. to produce joint cavitation at T5-6:

1. Contact points

KEY

*

(a) Left transverse process ofTG (b) Poltient's elbows and left forearm. Stabilization

2. Applicators •

Applicator

(a) Palm of the operator's right hand. held in a clenched position

-


(b) Operator's lower sternum or upper abdomen.

..)


(patient) Note: The dimensions for the arrows

are not a pidorial representation of the amplitude or force of the thrust.

3. Patient positioning Supine with the arms crossed over the chest and Lhe hands passed around the shoulden. The left arm is placed over the right arm (Fig. 82.3.1). The arms should be finnly clasped around the body as far as !.he patielll can comfortably reach.


Figure 823.1

Figure 82.3.2

4. Operator stance

Stand on the right side of the patient. facing the couch.


178

Reach over the patient with your left hand to take hold of the left shoulder and gently pllllthe patient's shoulder towards you (Fig. B2.3.2). With your right hand, locate the transverse processes of T6. Now place the thenar eminence of your righl hand againsl the left transverse process ofT6 (Fig. 82.3.3).

Keeping contan wiLh the left transverse process ofTG. roll the patient back towards the supine position. Rest }our lower sternum or upper abdomen on the

patient's elboo,vs and left forearm (Fig. 82.3.4). Initially, a slow bUI firm pressure is applied with your lower sternum or upper abdomen downward toward.. the rouch. Mailllaining this downward le...erage.

introduce left rotation of Ihe patient's upper thorax by directing forces 10\vards the palierll's left shoulder along the line of the patient's left upper arm. By balancing these


Ftgure 8233

Figure 82.3.4

different leverages, tension can be localized to the TS-G segment.

of the ankles. knees, hips and trunk. A common mistake is to lose the chest compression during the final adjuslments.


7. Immediately pre-thrust

Ensure your palient remains relaxed. Maintaining all holds. make any necessary changes in flexion, extension, sidebending or rotation until you can sense a stale of appropriate tension and levernge at the TS-6 segment. The patient should nol be aware of any pain or discomfort. Make lhese final adjustments by slight movements

Keep your head up and ensure that your

Relax and adjust your balance as necessary. contacts are firm and the patient's body weight is \vell controlled. An effective HVLA thrust technique is best achieved if the operator and palient are relaxed and not holding themselves rigid. This is a common impediment to achieving effective cavitation.

179


Figure 82.3.5

8, Delivering the thrust

'11lis loclmique II.ses IigmnetllOUs m)fJfascinJ fension locki"8 (l1ld Plot fllCel apposition locking. 'this approodl gerll!mlly requires a greater empllasis on dIe e:xJI8sermKm of primary letlerage dUI1l is tI,e case widl fllCer appositiorl lodrirlg rochl1iques. The shoulder girdles and thorax of the patient are nO\" a solid mass against which a thrust may be applied. Apply a IIVlA thrust dO\'lOwards towards the couch and in the line of the patient's left upper arm "ia your lower sternum or upper abdomen. Simuhaneously, apply a I fVlA thrust \...jth your right thenar eminence upwards against the lefl transverse process ofTG (Fig. 82.3.5). TIle force is produced by rapid pronation of your right forearm.

'80

A common fault is to emphasize the thrust via the patient's shoulder girdles at. the expense of the thrust against the left uallSverse process. The hand contacting IhI' transverse process 0('1'6 must activeh participate in the generation of thrust f(1 a The thrust. aJthough \'e.ry rapid. must fl("'\'ef be excessively forcible. The aim should hotuse the absolute minimum force necessat\ to achi~"e joint cavitation. A common fa arises from the use of excessi\"e ampllluck with insufficient velocity of thrusL This technique has many modifications • Different shoulder girdle holds can be used • Different applicators can be used • Respiration can be used to make the technique more effective..


2.3

SUMMARY ,

Thoracic spine T 4-9 Rotation gliding Patient supine ligamentous myofascial tension locking

• Contact points: -left transverse process of T6 -Patient's elbows and left foreann Applicators: -Palm of the operator's right hand, held in a clenched position -Operator's lower sternum or Upper abdomen • Patient positioning: Supine with anns crossed over the chest (Fig. 82.3.1) • Operator stance: To the right side of the patient, facing the couch • Positioning for thrust: Take hold of the patient's left shoulder and pull it towards you (Fig. 82.3.2). P1ace the thenar eminence of your right hand against the left transverse process ofT6 (Fig. 82.3.3). Roll the patient back towards the supine position. Rest your lower sternum or upper abdomen on the patient's elbows and left forearm (Fig. 82.3.4). Apply a slow firm pressure with your lower sternum or upper abdomen downwards towards the couch. Maintaining this downward leverage, introduce left rotation of the patient's upper thorax by directing forces towards the patient's left shoulder along the line of the patient's left upper arm • Adjustments to achieve appropriate pre-thrust tension Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: The direction of thrust is downwards towards the couch and in the line of the patient's left upper arm via your lower sternum or upper abdomen. Simultaneously, apply a thrust with your right thenar eminence upwards against the left transverse process ofT6 (Fig. 82.3.5). The force is produced by rapid pronation of your right forearm. The hand contacting the transverse process ofT6 must actively participate in the generation of thrust forces • Modifications to technique: -Different shoulder girdle holds can be used -Different applicators can be used -Respiration can be used to make the technique more effective 181

I

Thoracic spine T4-9 Rotation gliding Patient prone Short lever technique

Assume somali, dysjWlGliotl (S-T-A.R.Tj is identified and )'Ou wish to use a rotation gliding lhnlSt, parallel to the apopJT)'sial joim plane. to produce joint cavitation at. 1'5-6:

1. Contact points

KEY

Transverse processes ofTS (right applicator) and TG (left applicator).

~~

Stabilization

•

Applicator

-


¢

Direction ci body movement (patient)

2. Applicators Hypothenar eminence of left and right hands. 3. Patient positioning Patient lying prone with the head and neck in a comfortable position and arms hanging over the edge of the couch.

Note: The dimensions for the arrows are not a pictorial representation of the amplitude or force of the thrusL

183


Figure 82.4.1

Figure 82.4.2

4. Operator stance Stand at the left side of the patient. feet spread slightly and facing the patient. Stand as erect as possible and avoid crouching as this ,...ill limit the technique and restria delivery of the thnlst.

S. Palpation of contact points

184

111ere are man)' different ways to perform this technique. This is one approach. Locate the tral1S\'el1>e processes ofTS and T6. Place the hypothenar eminence of ),our right hand against the left transverse process ofTS and establish a 6ml ronlaa (Fig. 82.4.1). Place

the hypothenar eminence of your left hand against the right transverse process of '1'6 (Fig. B2.4.2). Ensure that you ha\>(': good contact and will not slip across the skin or superficial musrulature when )'Ou appl)' downward and caudad or cephalad forces againsl the trallS\'l?11>e processes. Maintain these contact points. 6. PositionIng for thrust

lhis is a shan lever technique and the \>(':Iooly of the thrust is critical MO\>(': your centre of g.r.tvity O\'er the patient by leaning your body weight forwards Onto )'Our anus


-

and hypothenar eminences (rig. B2.4.3). Shifting your centre of gravity forwards wjll direct a downward pressure on the transverse processes. You must apply an additional force dim::ted caudad with the left hand and cephalad wil.h the right hand. The finaJ dim::tion of thrust is influenct.>d by the degree of thoracic kyphosis and ally preexisting scoliosis. 'rhis technique does not use facet apposition locking. The pre-Ihrust tension is achieved by positioning the '1"5-6 segment towards the end range of available join! gliding. r.xtensive prnctice is necessary to de\-eJop an appreciation or the required tension. 7. Adjustments to achieve appropriate pre-thrust tension

Figure 82.43

[mure your patiem remains relaxed. Maintaining all holds and pressure upon thE" transverse prOCf'SSt'S,. make any necessary changes by introducing very slighl components or extension. sidroending and rotation until you sense a st::lIE" or appropriate tension and leverage at the 13-6 segmeOl. The patient should not be a\",""e or any pain or discomron. 8. Immediately pre-thrust

Relax and adjust your balance as necessary. Keep your head up and ensure that your comaas are firm. An effective HVLA thrust technique is best achieved if the operator and patient are relaxed and not holding themselves rigid. This is a common impediment to achieving effective cavitation. 9. Delivering the thrust

Apply a IIVLA thrust directed in a downward and cephalad direction against the transverse process arTS while simultaneously appl)'ing a thrust downwards and in a caudad direction against the transve~ process orT6 (F;g. B2.4.4). The thrust. although very rapid. must nt'\~ be excessively forcible_ The aim

185


Figure 82.4.4

should be to use the absolute minimum force necessary to achieve joint cavilation. A common fault arises from the use of excessive amplitude with insuffidem velocity of thrust.

186


SUMMARY Thoracic spine 14-9 Rotation gliding Patient prone Short lever technique • Contact points: Transverse processes ofT5 (right applicator) and T6 (left applicator) • Applicators: Hypothenar eminence of left and right hands • Patient positioning: Prone with arms hanging over the edge of the couch • Operator stance: To the left side of the patient, facing the couch • Palpation of contact points: Place the hypothenar eminence of your right hand against the left transverse process of T5 and establish a firm contact (Fig. 82.4.1). Place the hypothenar eminence of your left hand against the right transverse process ofT6 (Fig. 82.4.2) • Positioning for thrust: This is a short lever technique and the velocity of the thrust is critical. Move your centre of gravity over the patient by leaning your body weight forwards onto your arms and hypothenar eminences (Fig. 82.4.3). Apply an additional force directed caudad with the left hand and cephalad with the right hand • Adjustments to achieve appropriate pre-thrust tension • Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: The direction of thrust is in a downward and cephalad direction against the transverse process of T5 while simultaneously applying a thrust downwards and in a caudad direction against the transverse process of T6 (Fig. 82.4.4)

187

Ribs Rl-L

----

Patient prone Gliding thrust

Assume somalic drs/mIction (S·T-A-R-T) is identified and }'OU luisll lO produce cavitarion at the costolramverse joint of tile second rib on the rigllL (Figs 82.5.1, 82.5.2):

Figure 82.5.1

Figure 82.5.2

1. Contact point Angle of the second rib on the right.

KEY

.*.

Stabilization

•

Applicator

-


c:>

DIrection of body movement (patient)

2. Applicator Hypothenar eminence of the right hand.

Note: The dimensions for the arrows are not a pictOl"ial representation of the amplitude or force of the thrust.

3. Patient positioning Patient prone with the point of the dlin resting on the couch and the arms hanging over the edge of the couch. Introduce a small amount of sidebending to the left by gently lifting and moving the chin to the patient's left (Fig. 82.5.3). Do not introduce too much sidebending. 4. Operator stance

Head of the couch. feet spread slightly. Stand as erect as possible and a\'Oid

'89


crouching ()'I.'{'f the patient as this will limit the technique and restrict delivery of the thrust. 5. Palpation of contact point

Locate the angle of the second rib on the right. Place the hypothenar eminence of your right hand gently, bUI firmly, against the rib angle. Ensure that you have good contact and will not slip across the skin or superficial musculature when you apply a caudad and dO\Vll\vard force towards the couch against the angle of the second rib. Maintain this contact poinL 6. Positioning for thrust

Figure 82.53

190

Figure 82.5.4

Keq>ing your position at the head of the couch, gently place your left hand againsl the right side of the patient's head and neck. While maintaining the left sidl..>bending, introduce rotation to the right. in the cervical and upper thoracic spine. by applying gentle pressure to the right side of the patient's head and ned:: with yow left hand (Fig. 82.5.4). Maintaining all holds


Figure 82.5.5 and pressures, complete the rotation of the patient's he3d and neck until a sense of tension is palpatro at your right hypothenar eminence. Ket'p finn p~ure against the contact point 7. Adjustments to achieve appropriate pre-thrust tension

Ensure the patient remains relaxro. Maintaining all holds, make any necessary changes in extension, skkbending or rota Lion umil you can sense a Slate of appropriate tension and leverage. TIle patient should not be aware of any pain or discomfort. You make these final adjustments by altering the pressure and din.>(tion of forces between the left hand against the ptHiem's head and neck and your right hypothenar eminence against the comact point. 8. Immediately pre-thrust

Relax and adjust your balance as necessary. Keep your head up and ensurt' that yow contacts are firm and your body position is well controlled. An effective IIVL\. thrust techn.ique is best achieved if the operalOr and patient are relaxed and not holding

themselves rigid. This is a common impediment to achieving t'ffectivt' cavit.Ilion. 9. Delivering the thrust

Apply a IIVL\ thrust to the anglt' of tht' second rib on the right directed dowmvards towtlrds the coud, and also in a caudad direction 100vards the patit'nt's right iliac crest. Simultaneously, tlpply a slight, rapid increase of head and ner abdomen downwards towards the couch. Maintaining this downward leverage, imroduce left rotation of the patient's upper thorax by directing forces towards the patient's left shoulder along the line of the patient's left upper ann. By balandng these different leverages, tension can be

.


-..

2.6

Figure 82.6.4

loc.'lIi7.ed to lhe costotransverse joint of the sixth rib. 6. Adjustments to achieve appropriate pre-thrust tension

Ensure your paLient remains relaxed. Maintaining all holds. make any necessary changes in flexion, extension, sidebending and rotation until you can sense a SLale of appropriate tension and leverage at the COStotransvtne joint of the sixth rib. The patient should nOt be aware of any pain or discomfort. Make these final adjustments by slight movements of the ankles, knfi'S,. hips and trunk.. A common mistake is to lose the chest compression during the final adjustmentS. 7. Immediately pre-thrust I~elax and adjust your baltmce as necessary. Keep your head up and ensure that your contacts are firm and the patient's body weight is well controlled. An effective I [VL\ thrust technique is best adlieved if the operntor and patient are relaxed and not holding themselvt'S rigid. This is a common impediment to achieving effective cavitation.

'nlis lIpprcxu;h generally requires a greater empluzm Ofl Ole exaggeration of prirnmy leverage tJlim is tile cnse with faal appositiml locking Lechlliqu€S.. "Ille shoulder girdles and thora:< of the patient are now a solid mass against which a thrust may be applied. Apply a IIVLA thrust dO\vnward towards the couch and in the line of the patient's left upper arm via your lower sternum or upper abdomen. Simultaneously, apply a IIVlA lhrust with your right hypothenar eminence upo.V3.rd against the sixth rib (Fig. 82.6.4). The force is produced by rnpid supination of your right foreann. A common fault is to emphasize the thrust via the patient's shoulder girdles at the expense of the thrust against the sixth rib. The hand contacting the rib must :'!(lively participate in the generation of thruSl fOfCt$. The thrust, although very rnpid, must never be excessively forcible. "l'lle aim should be to use the absolute minimum force n«essary to :'!chieve joint cavitation. A common fault arises from the U~ of excessivt> amplitude ,,,ith insufficient velocity of thrust.


This technique I~ ligllment01lS mrofllSdal temiml locking and nor faat apposirion locking.

195

.,

J


SUMMARY Ribs R4-10 Patient supine Gliding thrust Ligamentous myofascial tension locking • Contact points: -Sixth rib on the left, lateral to the transverse process -Patient's elbows and left forearm • Applicators: -Hypothenar eminence of the operator's right hand -Operator's lower sternum or upper abdomen • Patient positioning: Supine with arms crossed over the chest • Operator stance: To the right side of the patient. facing the couch • Positioning for thrust Take hold of the patient's left shoulder and pull it towards you. Place the hypothenar eminence of your right hand against the rib just lateral to the left transverse process of T6 (Fig. 82.6.2). Roll the patient back to the supine position (Fig. 82.6.3). Continue until the patient's elbows are directly over your hypothenar eminence. This is a critical element in the technique. Rest your lower sternum or upper abdomen on the patient's elbows and left forearm. Apply a slow firm pressure with your lower sternum or upper abdomen downwards towards the couch. Maintaining this downward leverage. introduce left rotation of the patient's upper thorax by directing forces towards the patient's left shoulder along the line of the patient's left upper arm • Adjustments to achieve appropriate pre-thrust tension • Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: The direction of thrust is downwards towards the couch and in the line of the patient's left upper arm via your lower sternum or upper abdomen. Simultaneously. apply a thrust with your right hypothenar eminence upwards against the sixth rib (Fig. 82.6.4). The force is produced by rapid supination of your right forearm. The hand contacting the rib must actively participate in the generation of thrust forces

196

Ribs R4-10 Patient prone Gliding thrust

Assume somatic dysfunction (S-'J:A-R-T) is identified and )-'Oll wish to produce cavitation aL ti,e costotransverse joint of tlie sixth rib on tile left.:

1. Contact points

KEY "',.

Stabilization

•

Applicator

•


¢


Note: The dimensions for the arrows are not a pictorial representation of the ampmude or force of the thrust.

Angle of left sixth rib (right applicator). Right transverse process ofT6 (h:~ft applicator). 2. Applicators Hypothenar eminence of Idt and right hands.

3. Patient positioning Patient tying prom~ with the head and neck in a comfonable position and the arms hanging over the roW of the couch. 4. Operator stance Stand al the left side of the patient. feet spread slightly and fating the pallem. Stand

197


Figure B2.7,1

Figure B2.7.2

as erect as possible and avoid crouching as this will limit the technique and restrict delivery of the thrust. 5. Palpation of contact points

198

There are many different W3YS to perform this technique. This is one approach. !..ocate the transvm>e: proces.-.es ofT6. Place the hypothenar eminence of your right hand against the angle of the patient's left sixth rib and cstablish a firm contact (Fig. 82.7.1). Place the hypothenar eminence of your left hand against the right tranS\'Ene process ofT6 (Fig. 82.7_2). Ensure that you have good contaQ and will not slip across the skin or superficial musculature.


This is a short lever technique and as a consequence the velocity of the thrust is critic.l!. Move your (entre of gTtlvity over the patient by I~ning )'Our body weight fonvards onto your arms and hypothenar eminences (Fig. 82.7.3). Shifting )'Our centre of gravity forwards will direct a dcnvnward pressure on both the tmnsverse pnxess of '1'6 and the sixth rib. You must apply an addition31 force directed cephalad with the right hand against the angle of the sixth rib_ The finaJ direction of thrust is influenced by the degree of thorncic "''YPhosis and 3ny preexisting scoliosis. This technique does not use facet apposition locking. 1he pre-thrust


tension is achieved by positioning the of the sixth rib to\vards the end f3.n~ of av


(patient) Note: The dimensions for the arrows are not a pidorial representation of the amplitude or force of the thrust

Sitting astride the treatment couch with the anns crossed over the chest and the hands passed around Lhe shoulders. 1he arms should be finnly daslX>d around the body as far as the patient (an comfonably ream. 4. Operator stance Stand behind and slighlly to the left of the patient with your feet spread. Pass )'OUf left arm across the front of the patient's chest to

20'


Figure 82.8.2

Figure 82.8.3

lightly grip over the patient's right shoulder rt.'gion (Fig. 82.8.2). 5. Positioning for thrust

202

Trnnsltlte the patient's trunk to the right and tlwtly from you. This opens up the intercosttll sptlce between the sixth and seventh ribs U-ig. B2.8.3) and allo\'.s beUer tlccess to the inferior aspect of the sixth rib. pltlce your right hypothenar eminence on the inferior surftlce of the angle of the sixth rib. The thorax is now rotated to the left (Fig. 82.8.4). Sidebending to the right is introduced to lock the spine down to T6. The operntor maintains tlS ered a posture as possible. Keep your right hypothenar eminence firmly applied to the sixth rib with your right elbow held close to your body (F;g, 82.8.5).

Figure 82.8.4


Figure 82.85


Ensure your patient remains relaxed. Maintaining all holds, make any necessary change; in flexion, extension, sidebending or rotation until you can sense a state of appropriate tension and leverage at the costotransverse joint of the sixth rib on the right. 'l1u: patient should not be aware of any pain or discomfOrL Make these final adjustments by slight movements of the shoulders, trunk. ankles, knees and hips 7. Immediately pre-thrust

Relax and adjust your balance as necessary. An effooiw HVlA thrust technique is best

achieved if both the operator and patient are relaxed and not holding themselves rigid. This is a common impediment to achk"Ving effective c3Vi~tion.

Figure 82.8.6


A degree of momentum is necess.ary to achieve a successful cavitatjon. Rock the patient into and out of rotation while maintaining the other leverages. When you sense a state of appropriate tension and leverage at the sixth rib, apply a HVlJ\ thrust ag::.inst the inferior aspect of the angle of the rib in a cephalad and anterior direction. Simultaneously, apply slight exaggeration of left trunk rotation (Fig. B2.B.6). 'l11e thrust, although \'tlY rapid,. must nevt'f be excessively forcible. 111e aim should be to use the absolute minimum force necessary to achieve joint cavitation. A common fault arises from the use of excessive amplitude with insufficient velodty of thrust. 203


SUMMARY Ribs R4-1 0 Patient sitting Gliding thrust • Contact point: Angle of right sixth rib • Applicator. Hypothenar eminence of right hand • Patient positioning: Sitting astride the couch with the arms crossed over the chest and the hands passed around the shoulders • Operator stance: 8ehind and slightly to the left of the patient with the feet spread. Pass your left arm across the front of the pattent's chest to lightly grip over the patient's right shoulder region (Fig. 82.8.2) • Positioning for thrust: Translate the patient's trunk to the right and away from you (Fig. 82.8.3). Place your right hypothenar eminence on the inferior surface of the angle of the sixth rib. The thorax is now rotated to the left (Fig. 82.8.4). Sidebending to the right is introduced to lock the spine down to T6. The operator maintains as erect a posture as possible. Keep your right hypothenar eminence firmly applied to the sixth rib with your right elbow held close to your body (Fig. B2.8.5) • Adjustments to achieve appropriate pre-thrust tension

!

• Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: A degree of momentum is necessary to achieve a successful cavitation. The direction of thrust is in a cephalad and anterior direction against the inferior aspect of the angle of the rib. Simultaneously, apply slight exaggeration of left trunk rotation (Fig. 82.8.6)

"

204

-

•

Lumbar and thoracolumbar spine

SECTION

UPPER BODY HOLDS FOR SIDE-LYING TECHNIQUES

LOWER BODY HOLDS FOR SIDE-LYING TECHNIQUES

All techniques in this manUtll tire described with the operator taking up the axillary hold (Fig. B3.0.1). The hold selected for any particular technique is that which enables the operator to effeoively localize forces to a specific segment of the spine and deliver a high-velocity low-amplitude (IIVIA) force in a controlled manner. Patient comfort must be a major consideration in selecting the most appropriate hold. "I'm~e alternative upper body holds 3rc available: • Pectoral hold (Fig. 83.0.2) • Elbow hold (Fig. B3.0.3) • Upper arm hold (Fig. 83.0.4)'

There are a variety of lower body holds ~i1able (Figs 83.0.5-83.0.9). The hold seledoo for any particular technique is that which enables the operator to effectively 1000lize forces to a specific segment of the spine and deliver a I fVLA force in a controlled manner. Patient comfort must be a major consideration in selecting the most appropriate hold.

Figure 83.0.1

205


Figure B3.0.2

Figure B3.03

Figure 83.0.4

206


Figure B3.0.5

Figure B3.0.6

Figure B3.0.7

Figure B3.0.8

Figure B3.0.9

207

Thoracolumbar spine T1 O-L2 Neutral positioning Patient side-lying Rotation gliding thrust

Assume sOl1JlJLic d)'sfunclion (S-'f-A-R-T) is identified and you wish to use a rotllli011 gliding (hmst to produce cavililtion at T12-Ll on the

left (Figs 83.1.1,83.1.2):

Figure 83.1.1 Figure 83.1.2

KEY ,. Patient positioning ~"

Stabilization

•

Applicator

•


¢



Lying on the right side wilh a pillow to support the head and neck. The Upp€T portion of the couch is raised 10-15" to introduce left sidebending in the lower thoracic and upper lumbar spine. Experienced practitioners may choose to achieve the left sidebending wilhout raising me upper portion of the couch. Lmuer hotly. Straightm the paLiem's JO\\'ef (right) leg and ensure that the leg and spine an~ in a straight line. in a neutral position. l;Jex the patient's upper hip and knee slightly and place the upper leg just anterior to me lower leg.. The lower leg and spine should form as near a straight line as

- - -

209

1


possible, with no flexion at the lower hip or

knee. Upper body. Cently extmd the patient's upper shoulder and place the patient's left foreaon on the lower ribs. Using your right hand to palpatE' theTI2-L1 interspinous space, introduce left rotation of the patient's upper body down to lhe T12-Ll segmenL This is achieved by genll)' holding the patient's right elbow wim your left hand and pulling it towards )'OU, but also in 3 cephalad direction towards the head end of thE' couch. Be careful nOl 10 introduce any flexion to lhe spine during this movement. Left rotation is continued unlil your palpating hand al the TI 2-Ll segment begins to sense motion. Take up the axillary hold: This arm controls the upper body

rotation. 2. Operator stance Stand dose to the couch with your feet spread and onE' leg behind the other (Fig. B~.1.3). Maintain an upright posture, facing slightly in lhe direction of the patient's upper body. Keep your righl ann as dose to your body as possible.

3. Positioning for thrust Apply your right foreaml to the region between gluteus medius and maJcimus. Your right foreann now controls lower body rotation. Your left foreann should be resting against the patient's upper pectoral and rib cage region and will control upper bod)' rotatioll. First. rotate the patient's pelvis and lumbar spine to\\'3rds you until motjon is palpated at the T12-Ll segmenL Rotate the patient's upper body a\\'3}' from you using )'Our left ann until a sense of tension is palpated at lhe T12-Ll segment. Be careful to a\'oid undue pressure in the axilla. Finally, roilihe patient about 10-1S" to\vards you while mailuaining the build-up of 1E:\'erages at lhe T12-Ll segment. 4. Adjustments to achieve appropriate pre-thrust tension EmUTe your patiel1l remains relaxed. Mail1laining all holds, make an)' necessary changes in flex.ion, extension, sidebending or rotation until you can sense a state of appropriate tension and leverage at the T12-Ll segment. The palient should nOt be aware of any pain or discomfort. Make these final adjustments by slight movemeOlS of the shoulders, trunk, ankles. kne€S and hips.

5. Immediately pre-thrust Relax and adjust your balance as necessary. Keep your head up; looking down impedes the thrust. An effective IIVI.A thrust technique is best adlieved if both the operator and patient are relaxed and not holding themselves rigid. This is a common impediment to adlieving effective cavitation. 6. Delivering the thrust

210

Figure 83.13

Your left arm against the patient's pectoral region does not apply a thrust but acts as a stabilizer only. Keep the thrusting (right) arm as dose to your body as possible. Appl)' a IlVlA thrust ""ilh your right fo~nn against the palient's buttock. The direction of force is down towards the

lumbar and thoracolumbar spine

TtIIIUST IS OOWH 1'DWoUIDS T*. CClUCtt

.....

wmt SlJQHt I'tLVlC

""'

Figure 83.'.4

couch accompanied by a slight exaggeration of pelvic rotation towards the operator (Fi& B3.1.4).

The thrust, although very rapid, must never be cxc€SSively forcible. The aim

should be to use the absolute minimum force necessary to achieve joint cavitation. A common fault arises from the use of excessive amplitude wilh insufficient velocity of lhrust.

211


SUMMARY Thoracolumbar spine T1 O-L2 Neutral positIoning Patient side-lying Rotation gliding thrust • Patient positioning: Right side-lying with the upper portion of the couch raised 10-150 to introduce left sidebending in the lower thoracic and upper lumbar spine: Lower body. Right leg and spine in a straight line. left hip and knee flexed slightly and placed just anterior to the lower leg Upper body. Introduce left rotation of the patient's upper body until your palpating hand at T12-l1 begins to sense motion. Do not introduce any flexion to the spine during this movement. Take up the axillary hold • Operator stance: Stand close to the couch, feet spread and one leg behind the other. Maintain an upright posture, facing slightly in the direction of the palienr, upper body (Fig. 83.1.3) • Positioning for thrust: Place your right forearm in the region between gluteus medius and maximus. Rotate the patient's petvis and lumbar spine towards you until motion is palpated at the T12-l1 segment. Rotate the patient's upper body away from you until a sense of tension is palpated at the T12-L1 segment. Roll the patient about 10-15 towards you 0

• Adjustments to achieve appropriate pre-thrust tension • Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: The direction of thrust is down towards the couch accompanied by exaggeration of pelvic rotation towards the operator (Fig. 83.1.4). Your left arm against the patient's axillary region does not apply a thrust but acts as a stabilizer only

212

Thoracolumbar spine T1 O-L2 ~ositioning Patient side-lying Rotation gliding thrust

Assume somatic d).function (S-T-A-R-T) is identified and )'011 lUish to use a rotat.ion gliding thrust Lo produce cavitation at T12-L I 011 tlle lefr:

KEY


.:t: Stabilization •

Applicator

•


...,

Direaion of body movement (patient)


are not a pictorial representation of the amplitude or force of the thrust

Lying on the left side with a pillO\\I to support the head and neck. A small pillO\v, or rolled lo\'"el. should be placed under tbe patient's \vaisl to introduce left sidebending in the thorncolumbar spine. Experienced prnaitionel'5 may choose to ad\ievE' the left sidebending without the use or a small pillow or rolled towel. Lotver bod}" Straighten the paLient's lower (left) leg at Lhe knee joint while keeping the lefl hip flexed. Flex the patient's upper hip and knee. Rest the upper flexed knee upon lhe edge of the couch. anterior 10 the left lhigh, and place lhe patient's righl fOO( behind Ihe left calf. This posilion provides slability 10 the lower body.

213


Upper

bod}~

Gently extend Ihe patient's upper shoulder and place the patient's right foreallTl on the lower ribs. Using your left hand to palpate the T12-Ll interspinous space, introduce right rotation of the patient's upper body down to the Tl2-Ll ~~nL Rotation with flexion positioning IS achIeved by gently holding the patient's ~efI elbow with )'Our right hand and pulling It towards you, but also in a caudad direction towards the foot end of the couch. Left rotation is continued until )'Our palpating hand at the T12-Ll segment begins to sense motion. Take up the axillary hold. This ann controls the upper body rotation. 2. Operator stance

Stand dose to the couch with your feet spread and olle leg behind the other. Maintain an upright posture, facing slightl)' in the direction of the patient's upper body. Keep )'Our left arm as dose to )'Our body as possible. 3. Positioning for thrust Apply the palmar asped of your left forearm to the sacrum and posterior superior iliac spine. Your left forearm 00\\1 controls lower body rotation. Your right forearm should be resting against the patient's upper pectoral and rib cage region and will control upper body rotaUon. First, rotate the patient's pelvis and lumbar spine towards you until motion is palpated at theTl2-Ll segment. Rotate the patient's upper body away from you using your right arm until a sense of tension is palpated at the T12-LI segment. Be careful to avoid undue pressure in the axilla. Finally, roll the patient about 10_15° to\\lards you while maintaining the build-up of leverages at the T12-Ll segment.

214

4. Adjustments to achieve appropriate pre-thrust tension Ensure your patient remains relaxed. Maintaining all holds, make any necessary changes in flexion, extension, sidebending or rotation until you can sense a state of appropriate tension and leverage at the Tl2-U segment. The patient should not be aware of any pain or discomfOrL Make these final adjustments by slight movements of the shoulders, trunk. ankles. knees and hips. 5. Immediately pre-thrust

Relax and adjust your balance as necessary. KeqJ your head up; looking down impedes the thrust. An effective I-IVLA thrust

technique is best achieved if both the operator and paU€Jlt are relaxed and not holding themselves rigid. This is a common impediment to achieving effective cavitation. 6. Delivering the thrust

Your right ann against the patient's pectoral region does not apply a thrust but acts as a stabilizer only. Keep the thrusting (left) arm as dose to your body as possible. Apply a HVLA thrusl with your left forearm against ~he patient's sacrum and posterior superior Iliac spine. The direction of force is dO\\ln tmvards the couch accompanied by slight exaggeration of pelvic rotation towards the operator (Fig. 83.2.1). TIlt' thrust, although very rapid, must never be excessively forcible. The aim should be to use the absolute minimum forcE' llt'Cessary to achieve joint cavitation. A common fault arises from the use of excessive amplitude wilh insufficient velocity of thrust.


----. - T .......

.....

Figure 83.2.1

215


•

SUMMARY Thoracolumbar spine Tl0-L2

Flexion positioning

Patient side-lying Rotation gliding thrust • Patient positioning: Left side-lying with a small pillow or rolled towel placed under the patient's waist to introduce left sidebending in the thoracolumbar spine:

Lower body. left hip flexed with knee extended. Right hip and knee flexed with patient's right foot behind the left calf Upper body. Introduce right rotation of the patient's upper body until your

palpating hand at T12-L1 begins to sense motion. Introduce flexion to the spine during this movement. Take up the axillary hold

• Operator stance: Stand dose to the couch, feet spread and one leg behind the other. Maintain an upright posture. facing slightly in the direction of the patient's upper body • Positioning for thrust: Place the palmar aspect of your left forearm against the patient's sacrum and posterior superior iliac spine. Rotate the patient's pelvis and lumbar spine towards you until motion is palpated at the T12-L1 segment. Rotate the patient's upper body away from you until a sense of tension is palpated at the T12-L1 segment. Roll the patient about 10-15° towards you • Adjustments to achieve appropriate pre-thrust tension • Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: The direction of thrust is down towards the couch accompanied by exaggeration of pelvic rotation towards the operator (Fig. 83.2.1). Your right arm against the patient's axillary region does not apply a thrust but acts as a stabilizer only

I

I 216

Lumbar spine L1-5 Neutral positioning Patient side-lying Rotation gliding thrust

Assume somatic dysfullction (5-TAR-T) is idelltified alld 1"'" wis" to use II rottltion gliding thrust CO produce cavililliol1 at 13-4 011 tile righl (Figs 83.3.1, 83.3.2):

Figure 83.3.1

Figure 83.3.2

KEY .:+: Stabilization

,. Patient positioning

•

support the head and neck

Lying on the left side with a pillow 10 Applicator

Lower bodJ~ Straighten the paliclll's lower

..


¢


Note: The dimensions for the arrows are not a pictorial representation of the am~itude or force of the thrust. -~------~

leg and ensure that the leg and spine are in a straight line. in a neutral position. Flex the patient's upper hip and knee slightly and place the upper leg just anterior to the lower leg. The Imver leg and spine should form as near a straight line as possible. with no flexion at the lower hip or knee. Upper bod)'. Cently extend the pauent's upper shoulder and place the patient's right foreann on the lower ribs. Using your left hand to palpate the L3-4 inleJSpinous

217

I


Figure 83.3.3

space. introduce right rotation of the patient's upper body down to the L3-4 segment. This is achie\u1 by gently holding the patient'S left elbow with your right hand and pulJing it towards you, but also in a cephalad direction towards the head end of the couch (Fig. U3.3.3). Be: careful not to introduce any nexion to the spine during this movement. Right rotation is continued until your palpating hand at the 1..3-4 segment begins to sense motion. Take up the axillary hold. This arm controls the upper body rotation. 2. Operator stance

Stand dose 10 the coud, with your feet spread "nd one leg behind the ot.her (J:ig. 1\3.3.4). Maintain an upright posture. facing slightly in the direction of t.he patient's upper body. Keep your left aml as dose to your body as possible. 3. Positioning for thrust

218

Apply your left forearm to the region between gluteus medius and maximus. Your left forearm now controls lower body rotation. Your right forearm should be resting against the patient's upper pCCloral and rib cage region and will control upper

Figure 83.3.4

lumbar and thoracolumbar spine body rotation. First, rotate the patient's pelvis and lumbar spine towards you umil motion is palpated at thE' 1.3-4 segmenL Rotate the paLient's upper body 41.\'13)' from you using your right arm until a sense of tension is palpated at the 1.3-4 segment. Be careful to avoid undue pressure in the axilla. Finally, roll the patient about 10_15 0 towards you while maintaining the build-up of leverages at the 13-4 segment. 4. Adjustments to achieve appropriate

pre-thrust tension Ensure your patient remains relaxed. Maintaining all holds. make any necessary changes in flexion, extension, sidebending or rotation until you can sense a state of appropriate tension and 1C\'E':rage at the 1.3-4 segment. The patient should not be aware of any pain or discomfon. Make these final adjustments by slight movements of the shoulders. trunk, ankles, knees and hips_ 5. Immediately pre-thrust

the thrust. An effective HVlA thrust technique is best achieved if both the operator and paLient are relaxed and not holding themselves rigid. This is a common impediment to achieving effectiw cavitaLion. 6. Delivering the thrust Your right ann against the patient's pectoral region does not apply a thrust but aas as a stabilizer only. Keep the thrusting (left) ann as dose to your body as possible. Apply a HVLA. thrust with your left foreann against the patient's bUllOCk. The direction of force is down to\vards the couch accompanied by slight exaggeration of pelvic rotaLion towards the operator (Fig. B3.3.5). The thrust. although vel)' rapid, must never be excessively forcible. The aim should be to use the absolute minimum force necessary to achieve joint cavitation. A common fault arises from the use of excessive amplitude with insufficient velocity or thrust.

Relax and adjust your balance: as necessary. Keep your head up; looking down impedes

Figure 833.5

219


SUMMARY Lumbar spine L1-5 Neutral positIoning Patient side-lying Rotation gliding thrust • Patient positioning: left side-lying: Lower body. left leg and spine in a straight line. Right hip and knee flexed slightly and placed just anterior to the lower leg Upper body. Introcluce right rotation of the patient's upper body until your palpating hand at l3-4 begins to sense motion. Do not introduce any flexion to the spine during this movement (Fig. 833.3). Take up the axillary hold • Operator stance: Stand dose to the couch, feet spread and one leg behind the other. Maintain an upright posture, facing slightly in the direction of the palienf, upper body (Fig_ 83.3.4)

• Positioning for thrust Place your left foreann in the region between gluteus medius and maxim us. Rotate the patient's pelvis and lumbar spine towards you until motion is palpated at the l3-4 segment Rotate the patient's upper body away from you until a sense of tension is palpated at the l3-4 segment. Roll the patient about 1~15° towards you • Adjustments to achieve appropriate pre-thrust tension • Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: The direction of thrust is down towards the couch accompanied by exaggeration of pelvic rotation towards the operator (Fig. 83.3.5). Your right arm against the patient's axillary region does not apply a thrust but acts as a stabilizer only

220

Lumbar spine L1-5 Flexion positioning Patient side-lying Rotation gliding thrust

Assume somatic dysfunction (S-T-A-R-T) is identified and )00 wisll W use a rotation gliding thrust to produce cavitation at 13-4 on the right:

KEY


*:-

Stabilization

•

Applicator

•




Lying on the left side wilh a pillow to suppon the head and neck. A small pillow. or rolled lowel, should be placed under the patient's waist to introduce left sidebending in the lumbar spine. Experienced practitioners may d100se 10 adlievc the left sidebending without the use of a small pillow or rolJed lowel. Lower bod)'. Straighten the patient's lower (left) leg at the knee joim while keeping the left hip flexed. Hex the patient's upper hip and knee. Resl the upper flexed kntt upon the edge of the couch, anterior to the left thigh, and place the patient's right foot behind the left cal( This position provides stability 10 the lower body.

221

_ _ _ _ _ _ _ _1


Figure 83.4.1

upper bod}~ Gently extend the patient's upper shoulder and place the patient's right forearm 011 the 100ver ribs. Using your left hand to paJpate the 1.3-4 interspinous space, introduce right rotation of the palient's upper body down lO the 13-4 segment. Rotation with flexion positioning is achieved by gently holding the patient's left elbow with your righl hand and pulling it towards you, but also in a caudad direction to\-r.lrds the fOOL end of the couch (Fig. 83.4.1). Right rolation is continued until your palpating hand al the 1.3-4 segment begins to sense mOlion. Take up lhe axillary hold. This arm conlrols the upper body rolalion. 2. Operator stance Stand dose to lhe couch with your feet spread and one leg behind !.he olher (1181\3.4.2). Maintain an upright posture. facing slighlly in the direction of the patient's upper body. Keep your left arm as dose lO your body as possible. 3. Positioning for thrust

222

Apply your left forearm to the region between gluteus medius and maximus. Your left forearm now controls 10wCT body rolation. Your right foreann should be

Figure 83.4.2

lumbar and thoracolumbar spine resting against the patient's upper pectoral and rib cage region and will control upper body rotation. First, rotate the patient's pelvis and lumbar spine to\Yards you unlil motion is palpated at the 13-4 segment. Rotate the patient's upper body away from you using your right arm until a sense of tension is paJpated at the L3-4 segment. Be careful to avoid undue pressure in the axilla. Finally, roll the patient about 10_15 to\vards you while maintaining the build-up of leverages at the L3-4 seg.menL 0


Ensure your patient remains relaxed. Maimaining all holds, make any necessary changes in flexion, extension, sidebending or rotation until you can sense a state of appropriate tension and leverage at the 13-4 segment. The patient should not be a\Yare of any pain or discomfort. Make these final adjustments by slight movements of the shoulders, I.IUnk. ankles. knees and hips.

the thrust. An effective HVLA thrust technique is oot achieved ifboth the operator and patient are relaxed and not holding themselves rigid. This is a common impediment to achieving effective cavitation. 6. Delivering the thrust

Your right arm against the patient's pectoral region does not apply a thrust but aas as a stabilizer only. Keep the thrusting (left) arm as dose to your body as possible. Apply a J-1VLA thrust with your left forearm against the patient's buttock. The direction of force is dovm towards the couch accompanied by a slight exaggeration of pelvic rotation towards the operator (Fig. B3.4.3). The thrust. although very rapid must never be excessively forcible. The aim should be to use the absolute minimum force necessary to achieve joint cavitation. A common fault arises from the use. of excessive amplitude with insufficient velocity of thrusL

S.lmmediatefy pre-thrust

Relax and adjust your balance as necessary. Keep your head up; looking down impedes

Figure 83.43

223


SUMMARY Lumbar spine L1-5 Flexion positioning Patient side-lying Rotation gliding thrust • Patient positioning: Left side-lying with a small pillow or rolled towel placed under the patient's waist to introduce left sidebending in the lumbar spine: Lower txxty. left hip flexed with knee extended. Right hip and knee flexed with the patient's right foot behind the left calf Upper body. Introduce right rotation of the patient's upper body until your palpating hand at L3-4 begins to sense motion. Introduce flexion to the spine during this movement (Ftg. 83.4.1). Take up the aXillary hold • Operator stance: Stand close to the couch, feet spread and one leg behind the other. Maintain an upright posture. facing slightly in the direction of the patienr, upper body (Fig. 83.4.2) Positioning for thrust: Place your left forearm in the region between gluteus medius and maximus. Rotate the patient's pelvis and lumbar spine towards you until motion is palpated at the L3-4 segment Rotate the patient's upper body away from you until a sense of tension is palpated at the L3-4 segment Roll the patient about 10-15" towards you • Adjustments to achieve appropriate pre-thnast tension • Immediately pre-thnast Relax and adjust your balance • Delivering the thrust: The direction of thrust is down towards the couch accompanied by exaggeration of pelvic rotation towards the operator (Fig. 83.4.3). Your right arm against the patient's axillary region does not apply a thrust but acts as a stabilizer only

22.

Lumbar spine L1-5 Neutral positioning Patient sitting Rotation gliding th,ust

Assullle ,olllolic dyn despite normalization of different types of clinical tests."r However, an alteration in petvic tilt was identified post-manipulation in one study of patients with low back pain 48 and a further study demonstrated an immediate improvement in iliac crest symmetry immediately after manipulation.4\!

Various models of sacroiliac motion have been proposed and there have been a number of studies relating to mobility in the sacroiliacjoint,lO-J7 but the precise nature of nonnal motion remains unclear.l..us There is significant variation in sacroiliac joint movement between individuals and within individuals when mobility of one sacroiliac joint is compared with the other side.14

HVlA thrust techniques - pelvis

Sacroiliac region manipulation has been demonstrated to provide significant short·

term symptomatic and functional improvement in a subgroup of patients presenting wnh low back pain.§O A clinical prediction rule with five variables - symptom location. symptom duration. lumbar spine hypomobility, fear avoidance beliefs and range of hip internal rotation - was developedso and subsequently validatedS1 to identify those patients most likety to respond favourably to sacroiliac region manipulation. Many practitioners believe that t-M..A thrust techniques applied to the sacroiliac joint can be associated with good dinical outcomes. As a result many clinicians continue to use HVI..A

thrust techniques to treat somatic dysfunction of the joints of the pelvis. Somatic dysfunction is identifted by the S-T-A~R·T of diagnosis:

• 5

relates to symptom reproduction

• T relates to tissue tenderness • A relates to asymmetry • R relates to range of motion • T relates to tissue texture changes

238

Part C describes in detail five HVlA thrust techniques for the pelvis. All techniques are described using a variable-height manipulation couch. After making a diagnosis of somatic dysfunction and prior to proceeding with a thrust. it is recommended the following checklist be used for each of the techniques described in this section: • Have I excluded all contraindic.ations? • Have I ex~ained to the patient what I am going to do? • Do I have informed consent? • Is the patient well positioned and comfortabte? • Am I in a comfortable and balanced position? • Do I need to modify any pre-thrust physical or btomechanical factors? • Have I achieved appropriate pre-thrust tissue tension? • Am I relaxed and confident to proceed? • Is the patienl relaxed and willing for me to proceed?

Sacroiliac joint Left innominate posterior Patient prone Ligamentous myofascial tension locking

Assume somatic dj~function (S-T-A-R-T) is identified and )'ou wish to thrust the left imlOmiunt£ anteriorly:

1. Contact points


(a) Left posterior superior iliac spine (PSIS) (b) Anterior aspeCl of left lower thigh.

Patient lying prone in a comfonable position.

2. Applicators

4. Operator stance

(a) Ilypothenar eminence of right hand (b) Palmar aspect of left hand.

Stand at lhe right side of the patient.. feet spre3d slightly and facing the palienL Stand as erect as possible and avoid crouching as this will limit the technique and restrict delivery of the thrusL 5. Palpation of contad points

KEY

oJ!:

Stabilization

•

Applicator

-



Note: The dimensions (Of the arrows are not a pictOfial rept"esentation of

the amplitude or force of the thrust.

Place the hypothenar eminence of ),our right hand against the inferior aspect of the left PSIS. Ensure that you have good contact and will not slip across the skin or superficiaJ musculature. Place the palmar aspect of your left hand gently under the anterior aspect of the left thigh just proximal to the knee.


Uft the patient's left leg into extension and slight adduction (fig. Cl.I). Avoid introducing extension into the lumbar spine. Apply a force directed downwards towards the (ouch and slightly cephalad to fix )'our right hand against the inferior aspect of the PSIS.

239

HVLA thrust techniques - pelvis

direaion of pressure applied to the PSIS until applicator forces are balanced and you sense a state of appropriate tension and leverage at the left sacroiliac joint. 'llle patient should not be aware of any pain or discomfon. Make these final adjUSlments by slight movements of the shoulders. trunk.. ankles. knres and hips. 8. Immediately

p~thrust

Helax and adjust )'Our balance as necessary. Keep your head up and ensure that )'Our contacts are finn. An effeaive HVLA thrust technique is best achieved if the operator and patient are relaxed and not holding themselves rigid. 'Ibis is a common impediment 10 achieving effective cavilation. 9. Delivering the thrust

Figure C.l.l

Move )'Our centre of gravity O\'tt the patient by leaning your body weight rorwards ontO }'Our right ann and hypothenar eminence. Shifting your centre or gravity rorwards assists firm (Ontao point pressure on the PSIS. 7. Adjustments to achieve appropriate pre-thrust tension

Ensure your patient remains relaxed. Mai ntaining all holds. make any necessary changes in hip extension, adduction and rOtation. Simultaneously, adjust the

240

T'hu teclmilfue uses ligamentous m)'oflUCitll tetlSion locking and not fnat nppositibn locking. 'f1Jis approach generally reqllim a grmler emphasis 01'1 the emggenuiotl of primary levrrage dlQn i.s die case Willi facer. apposilion locking lechniques.. Apply a I rvl.A thrust with }'Our right hand direoed against the PSIS in a curved plane towards the couch. Simultaneously, apply slight exagger.uion of hip extension with your left hand (Fig. C.I.2). It is imponanl that you do not overemphasize hip extension at the time of thrust. 'Ibe aim of this technique is to achieve anterior rotation of the left innominate and movement al Ihe left sacroiliac joint. 'Ihe direction of thrust will alter between patients as a result of the wide variation in sacroiliac anatomy and biomechanics. 'llle thrust, although veJ}' rapid, must never be excessi\rety forcible. 'llle aim should be to use the absolute minimum force necessary,

Sacroiliac joint

left innominate posterior

Figure C.1.2

241


SUMMARY Sacroiliac joint Left innomInate posterior Patient prone Thrust anteriorly Ligamentous myofascial tension locking • Contact points: -Left posterior superior iliac spine (PSIS) -Anterior aspect of left lower thigh • Applicators: -Hypothenar eminence of right hand -Palmar aspect of left hand • Patient positioning: Prone in a comfortable position • Operator stance: To right side of patient, facing the couch • Palpation of contact points: Place the hypothenar eminence of your right hand against the inferior aspect of the left PSIS. Place the palmar aspect of your left hand under the anterior aspect of the left thigh proximal to the knee • Positioning for thrust: Lift left leg into extension and slight adduction (Fig. Cl.1). Avoid introducing extension into the lumbar spine. Apply a force directed downwards towards the couch and slightly cephalad to fix your right hand against the inferior aspect of the PSIS • Adjustments to achieve appropriate pr~thrust tension: Make any necessary changes in hip extension, adduction and rotation. Simultaneously, adjust the direction of pressure applied to the PSIS • Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: The thrust against the PSIS is in a curved plane towards the couch and accompanied by slight exaggeration of hip extension (Fig. C.1.2)

242

Sacroiliac joint Right innominate posterior Patient side-lying

Assume somatic dysfunction (5- T-A-R-T) is identified and yvu wish 10 thrust the light innominate anteriorly:


Lying on the Jeft side with a pillow to support the head and neck. '[he upper portion of the couch is raised 30_35 to inuoduce right sidebending in the lower thoracic and upper lumbar spine. Lotver bod)~ Straighten the patient's !O\\'er leg and ensure that the leg and spine are in a straight line. in a neutral position. "'ex the patient's upper hip to approximately 0

KEY ->f'"

Stabilization

•

Applicator

•


90". Flex the palielll's upper knee and place the heel of the fOOL just anterior to the knee of the lower leg. In.e lower leg and spine should form as near a straight line as possible with no flexion at the lower hip or knee. Upper body. Gently extend the patient's upper shoulder and place the patient's right foreann on the lower ribs. Using your left hand to paJpate the 1.5-S1 interspinous space, introduce riglll rotation of the patient's trunk. dm...n to and including the lS-S I segment. This is achieved by gently holding the patient's left elbow with your right hand and pulling it 10\.,,-ards you, but also in a cephalad direction towards the head end of the couch. Be careful not 10 inlroduce any nexioo to the spine during this movement Now modify the peCloral hold by positioning the patient's upper afm behind the thorax. 2. Operator stance

¢


Note: The dimensions for the arrows are not a pictorial representation of the amplitude or force of the thrust

Stand dose to the couch with your feet spread and one leg behind the other. Ensure that the patielll's upper knee is placed between your legs. This will enable you to make the necessary adjustments to achieve the appropriate pre-thrust tension (Fig. C.2.l). Mailllain an upright posture. facing in the direaion of the patient's upper body.

243

HVlA thrust techniques - pelvis

Figure C~l 3. Positioning for thrust

S. Immediately pre-thrust

Apply the h«1 of )'Our left hand to the inferior asped of the posterior superior iliac spine (PSI ). Your right hand should be resting agaima the patient's upper pectoral and rib cage region_ Cently rotate the patient's trunk away from you using your right hand until you achieve spinal locking. Avoid applying direct pres,'mre to the glenohumeral joint. Finally, roll the patielll aboul 10_15° towards you \"hile maintaining the build-up of leverages.

Relax and adjust your balance as necessary. Keep your head up and ensure your contacts are firm. An effective IIVLA thrust technique is best achieved if the operator and patient are relaxed and not holding lhemsel\'U rigid. This is a common impediment to achieving effective cavitation.

4, Adjustments to achieve appropriate pre-thrust tension

244

Ensure )'Our palient remains relaxed. Maimaining all holds, make any necessary changes in hip flexion and adduction. Simuhaneously, adjust the direction of pressure applied to the PSIS Wltil the forces are balanced and you sense a state of appropriate tension and leverage at the right sacroiliac joint. The patient should not be aware of any pain or discomforL Make these final adjuStmenlS by slight movements of the shoulders,. trunk,. ankles. knees and hips.

6. Delivering the thrust Apply a IIVLA. thrust with the heel of )'Our left hand directed against the PSIS in a curved plane towards you (rig. C.2.2). Your righl aml against the patient's pectoral region does not apply it thrust but acts as a stabilizer only. '111e aim of this technique is to achieve alllelior rotation of the right innominate and movement at the right sacroiliac joint. '111e direction of thrust will alter between patients as a result of the \\'ide variation in sacroiliac anatomy and biomechanics. 'l11e thrust, although very rapid. must never be excessively forcible. -111e aim should be to use the absolute minimum force necessary.

- .- . Sacroiliac joint

Right innominate posterior

-

2

Figure (.2.2

245


SUMMARY Sacroiliac joint

Right innominate posten or

Patient side-lying Thrust anteriorly • Patient positioning: left side-lying with the upper portion of the couch raised 30-350 to introduce right sidebending in the lower thoracic and upper lumbar spine: Lower body. left leg and spine in a straight line. Right hip flexed to approximately 90". Right knee flexed and heel of right foot placed just anterior to knee of lower leg Upper body. Introduce right rotation of the patient's upper body down to and including lS-Sl. Do not introduce any flexion to the spine during this movement. Modify the pectoral hold by positioning the patient's upper arm behind the thorax • Operator stance: Stand close to the couch, feet spread and one leg behind the other. Ensure that the patient's upper knee is placed between your legs (Fig. C2.1). Maintain an upright posture facing in the direction of the patient's upper

body • Positioning for thrust: Apply the heel of your left hand to the inferior aspect of the PSIS. Rotate the patient's upper body away from you until spinallocldng is achieved. Roll the patient about 10-1So towards you • Adjustments to achieve appropriate pre-thrust tension: Make any necessary changes in hip flexion and adduction. Simultaneously, adjust direction of pressure applied to the PSIS • Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: The thrust against the PSIS is in a curved plane towards you (Fig. C2.2). Your right arm against the patient's pectoral region does not apply a thrust but aet5 as a stabilizer only

246

Sacroiliac joint Left innominate anterior Patient supine

Assume somntic d).ftmction (S-T-A-R-TJ is identified mul )"u wish to thrust the left innominate posteriorly: 1. Contact points

(a) Left anterior superior iliac spine (ASIS) (b) Posterior aspect of left shoulder girdle.

2 Applicators (a) Palm of right hand (b) Palmar aspect of left hand and wria 3. Patient positioning Patient lying supine in a comfortable position. Move the patient's pelvis towards

their righL M.ove the feet. and shoulders in the opposite direction to introduce left sidebending of the trunk. Place the patient's left fOOL and ankle on top of the riglu ankle. Ask the patient to clasp their fingers behind the neck (Fig. C.3.1)_

4. Operator stance St.and at the right side orthe patient. feet spread slightly and facing the couch. Stand as erect as possible and a\lOid crouching as this will limit the technique and restria delivery of the thrusL

5. Palpation of contact points

KEY ->f,

Stabilization

•

Applicator

•


Place the palm of your right hand over the ASIS. Ensure that you have good contact and will not slip across the skin or superficial musculature. Place the palmar aspect of your left hand and wrist gently over the posterior aspect of the left shoulder girdle.



(patient)

Rotate the patient's trunk to the right and towards you. Il is criticaJ to maintain the left trunk sidebending introduced during initial positioning. Apply a force directed dmvnwards towards the couch and sHgtu!)' cephalad to fix your right hand against the inferior aspect of the ASIS (Fig. C.3.2).


are not a pictorial representation of the amplitude or force of the thruSL

247


Hgurec.J.l

Figure (.3.2

Move your centre of gravity over the patient by leaning your body weight forwards onto your light ann and hand. Shifting your centre of gravity forwards assists finn contao point pressure on the ASIS. 7. Adjustments to achieve appropriate pre-thrust tension

248

F.nsure your patient remains relaxed. Maintaining all holds,. make any necessary changes in trunk rotation. flexion and sidebending. Simultanootl5ly. adjust the direction of pressure applied to the ASIS until applicator forces are baJanced and ),ou sense a state of appropriate tension and leverage. The patient should not be aware of any pain or discomfort. lI.take these final

adjusunenlS by slight movements of the shoulders. trunk. ankles. knees and hips. 8. Immediately pre-thrust

llelax and adjust your balance as necessary. Keep your head up and ensure lhat your contacts arc firm. An effective I-IV[1\ thrust technique is best achieved if the operator and patient are relaxed and not holding themselves rigid. This is a common impedimenl to achieving effective cavitation. 9. Delivering the thrust Apply a HVLA thrust \vith your right hand directed against the ASIS in a curved plane towards the couch (Fig. C.3.3). Your left

Sacroiliac joint

Left innominate anterior

forearm, wrist and hanOSith~ sacroiliac: Kreenlng tests in asymptomatic adults. Spine 1994; 19:1138-1143. 20 Dreyfuss I~ Michaelsen M. PalIZa K. MeLan)' I, Bogduk N. The value of medical history and physical examination in diagnosing sacroiliac joint pain. Spine 1996; 21:2594-2602-

21

Herzog W. Read ... Conway P. Shaw L. McEwen M. ReliabiLity of motion palpation procedures to detect sacro-iliac: joint fwlttons. I Manipulam'\' Physioll'her 1986; 11:151-157.

22

laslett"'l Williams M. The reliability of selected pain ptO\'OCation tests for sacroiliac joint padlology. Spine 1994; 19:1243-1249. Deunm ILJM Van. Patijn I, OckhU)'Sefl AI... \'Orunan BI. The value of some dinicall£SlS of the sacro-iliac joint. Man t.Ied 1990; 5:96-99. Riddk D, Frebu~ I. E\'a!uation oi till" presern of sacroiliac joint region d)'Sfunction mins a combination of tests; A multiCf'nter intertesler reliabilily Sluef)'. 1"h)'S Ther 2002; 62(8):7n-781. Young S. Aprill C Laslen "'l Correlation of c1inkal examination chaf3C\er1.sco with three sources of chronic low back pain. SpilW 2003; 3(6):460-465. ~1eijne W, Neerlxts K \'an. Aufdemkampe C. Wurff P \'an der. Intrnexaminer and inteJCX'3lniner rdiabilily of the Gillet tt'Sl.. I Manipulath~ Physiollher 1999; 22(1}:4-9. Sturcsson B. Uden A. Vlecming A. A I'3diosterrometric anal)'Sis of the mO\'Cments of the sacroiliac. joints during the standing hip nexlon lest. Spine 2000; 25(3):364-368. Vincent-$mith 8, Gibbons P. 1I1t(''r-examincr and intra-cx:aminer rclial)i1it)' ofpalpatol)' findings for the standing nl.'xion tt'Sl. Man Ther 1999; 4(2):87-93. O'Haire C. Gibbons I'. Inlel-examiner and inlra-examinCf agreernelll for asSC5sing sacro·i1iac analomical landmarks ming palpation and observation: A pilot study. Man Ther 2000; 5( I}: 13-20. Colachis ' ordcn RF.. Brechtol CO, Snohm BR MO\~ent of the sacroiliac. joint in the adult male: a preliminary repon. Arch ptl)'S Mcd Rehabil 1963; 44:490-498. Egund N. Olsson 'Ili. Schmid H, Selvik C. MO\-ements in the sacroiliac joints demonslrated with Roentgen stereophotogr.unmeuy. Acta R."ldiol Diagn 1978; 19:833-846. Sture:sson B, Sdvik G, Uden A. MCJ\IeIT}ents of the sacroiliac joints. A Roent~n

23

24

2S

2.

27

28

"

IS Her:7..Clg W. Oinical Biomechanics of Spinal M:Ulipulation. New Uvingstone; 2000.

'rk Churchill

30

I. Maigne IV, AivalikJis A. pf(.fer F. Results of

17

sacroiliac joim double block and value of sacroiliac pain provocation tests in 54 patients with low back pain. Spine 199G; 21:1889-1892. Speed C. ABC of rhcumalology. Low back pain. BMI 2004; 328: 1119-1121.

18 Carmichael JP. Intt.'r and intra-examiner rcliabiliry of palpation for sacroiliac joint

1'h)'Siol Tiler 1967;

I' Dreyfuss 1',

S Cibulka M. Understanding sacroiliac joint [I)()\'Cment as a guide to the managemenl of a patient v.;th unilateral low back pain. Man Ther 2002; 7(4 ):21 S-221. Brolinson P, Ko7.aJ A. Obor G. sacroiliac joint dysfunction in athletes. Olrr Spons MOO Rep 2003; 2(1):47-56.

Manipulati\~

31

32

sc. ....

259

Technique failure and analysis

Techniques in this manual have been described In a structured format. This format allows flexibility so that each technique can

be modified to suit both the patient and practitioner. Competence and expertise in the use of

HVLA thrust techniques Increase with practice and experience. Development of ahigh level of skiU in the use of HVLA thrust techniques is predicated upon critical reflection of performance. When a tM.A thrust technique does not produce cavitation with minimal

force. the practitioner should reflect upon how the technique might have been modified and improved. Even the experienced practitioner should review each HVlA thrust technique to identify factors that might improve technique delivery.

Inability La achieve cavitation with minimal force may arise for a number of reasons and can be reviewed under three broad headings:

PART

• General technique analysis

-Incorrect selection of technique -Inadequate localization of forces -Ineffective thrust • Practitioner and patient variables

-Patient comfort and cooperation -Patient positioning -Practitioner comfort and confidence -Practitioner pOSture • Physical and biomechanical modifying fact"" -Primary leverage -Secondary leverages -Contact poVlt pressure -Identif.cation of appropriate pre-thrust tension -Direction of thrust -Vek>city of thrust -Amplitude of thrust -Force of thrust -Arrest of technique.

Technique failure and analysis

Box 0..2 Practitfon« and patient van.bles

Common hutts • Patient not comfortabty positioned • Patient not relaxed • Rough patient handling • Rushing techntque • Poor practitioner posture • lack of practitioner confidence Checklist

Patient comfort and CoopBation Dependent upon: • Confidence and trust In practitioner • Patte-nt experience of prevJous successful HVLA thrust technique • Slow, firm and gentle patient handling • Confident and reassuring approach by practitioner • E>cplanatlon of technique and Informed

coo""',

• Optimal patient positioning PDtknt positioning

Dependent upon: • Appropriate positioning to match patient's physkal and medical condition • COl'J'eCI identification of primary leverage and secondary Ieo.Ierages • Pai......free positioning • Appropriate use of pillows and treatment couch adjustment ProctitioMr comfort ond confidence Dependent upon: • Establishing a working diagnosis • Selecting a technique to match patient's physical and medical condition • Confidence that the technique will improve and not worsen the patient's symptoms • Previous e)(perlence and success with the seleded HVLA thrust technique • Optimal practitioner posture

_-

Box 0.3 Physk.aI and biomet symmetry, 237 Imaging ta:hnkjUl'S cwilalion du(' 10 tlVLA, 47 cervical inllabillty, 34 Inflammalory cervlcal instability, 33 Infonnation e::xchinse 38 Informed consctll. 37-38, 38f Instability $N I4)peJ (UViQ1 illSlability Inter- and intra.etaminer reliability, 5-6

Index =

J Joint cavitation. 46-47, 66 failure to achieve. 261 pelvis, 237 Joint 'cJa(king.' 47

MallUillthcr.apy approaches. 48 MetxarpopNl.lllfPl joint avtution. 46--47 Miaotra~, cumulative. 45 Muscle cnogy technique (MET), 9 MUK\.l!ar activity, 14

N

K Kinematics, ofspine, 9-16 lee ~bD biom«haria; coupled motMln

"'"

man! pulation complicilliom. 25-26

efI1acy, 48

L Ul;iU'lcnlOUS myoWciaI tension. 17 low bad( pain acute 14,48 apoph)'$I~1 joint lrophism, 14 chronic, 14,48 clinical trials, 48 coupled motion. 14 racet trophism. 13-14 manipulalion. ~ ,lnal'.$lht$ia. 28 rating. 58-61 sacroiliac joiN. 237-238 __ ~lso lumbar spine IU-I.5) l.ower body holds, 205-207 I.umbar 'Pine (1.1-LS) axillary hold. 205 elbow hold. 205 racet appO!;ilion locking. 19-21 Rexion pcw;itioning, rotation g1ldil"G 221-224 HVlA thrust tochniq.M:s. 217-228 \ower bod)' holds. 205- 2C11 manipulation, 47 neutr.1I plXitioning. roullkJn gIldillfl, p.1Itimt ~ 217-220 patient siuillfl,. 225-228 pectoral hoKI, 205

siddlendi"&

12~13

spinallockillfl,. 19-21 upper ann hold. 205 uppet'" body holds, 205-207 Lumbar zygapoph)'Seal joint cavitation. 47 Lumbosacral joint (15-51) nexion positioning. 233-236 HVIA thrust I«hni~ 22?-236 neuual ~tloning. 229-232

p.1Iin. 48 __ b «'IVkaJ spirx (0-7) Nt.'Opl.lst:ic ~I ill$labiliry. 33 NeurologicallIUlmftU rnode:l. 46 NcurOYa!lCUlar compromisr, 25 Neuualfextenskm ~tioning, 20-22, 21/. 22f Ncutnl\ sideblendlng, 11 Non-neulr.l.l sidebendh1!,. II NWllcricai rating scale, 60, flJf N)'Sl:agJJ1us, 34

o Odontoid process incompetentt. 33 ()ppo5ituidcbendillfl,. 19, l'lf cervical rolation. 17-18 Ollteopathk tlI'atmenl, 5-8 manipulati,t' tochniques, 7-8, 7. philOllOphy, 5-8, 5f trealment models, 45-4(, Oswcslfy toW' Back Disability Questionnaire, 59-60 Outcome mCZl.uemefll, 58-61

p

..

Pain low back 5« kJw back pain

"""-

plO\'OCal.ion. somalic dysfurxtion, 6 ratitlg r.ca1f'S, 58-61. 60f spinal, 49, 56, 58-61 Palpation. diagnostic classification puIJ)CI5CS. 56 intra·inter C%iUJliner rdiabiUty, 5-6 spine. '.I

.....

Pa~34

M Magnetic resonance imaging (MID), 34. 47 Manipul~tioll

efficacy, 48 evidence hierarchy, 47-48 genenl anaesthesia, 28 validation apptoachf'S, 45-46 jl'JI! o15D spt!Cifi£. tec:hniqurs

Patient

clasliification. 56-58 po5itioning. HLVA thrust techniques. 163-164 Idualion, 67 \'3riables, 2631 PccIOfaI hold, 205 Pt!1~ 237-238

pre·thrust checklist. 238 also saaocoo:ygcal join~ .sacroiliac joim

~

267

I

Manipulation of the spine, thorax and pelvis

t'hysical modifying faclOf$, 2631 PhysiQI therapy dlagnl;Jlliis classification. S8I !"islolgril>. 70, 70f I'oMUIn" 28 Spinal pain contraindicalions,. 4') dia8'JO'is issua,. 56 rating. 58-61 Spine blomuhania, 9 coupling behaviour, 19 HVlA thrust teChniques. 66-67 mobilily. 12-13 m0\1?ITICI1t jtIE ",enebral molion palpatory ~ment. 9 pOlIitionlng. 10-11. 17-24 _ Ollso specifIC rqJtm$/ioinLS Standardised testing. 6 SI:-'RTacronym, diagnosi5, (>-7. 49. 491 SteroophOlogrnmml'lry. 12, 237 Stroke. 25. 30 StfUCIl.lralJp06lul'1l1 trelllmt:nt model, 45-46 Symptom reproduction. 6 somatic dysfunction, 6 SynO'llial joint cavitation, 47

T l:-'RT acronym, diagnosis. 6. 49 Techniques analysis, 2621 failure. 261-263 HVlA _ high-\Uocity lOw-amplitude (HVL\) Ihrust tochniqllC$ ~263t

manipulation

jtIE

manipulation

Index

thlU!ll, 2631 5te

/lJso 5~jflC joinu/spirlQ/ regiom

'Iboracic spine (T4-T9) coupled motion. II, 19-20 elCtension g:iding. 167-17'0 facet apposition locking.. 19-21, 21! flexion gliding. 171-175 UVlA thrust l«;hni~ 167-188 opeIaIor hand position. ) 65 rotation ~kling palient prone, 183-188 patient supine. 177_183 spinalloddng. 19-21 upper body posilioning. 163-164 Thoracolumbar spille' (TIo-l.2) fIerion positioning. 213-216 Ilftltral positioni~ 200-212 Thrusllcchniqua. 26Jf 'rlS5UC tendn"1lCSll,. 6, 60. 611 Tissue II'XtUrt: chang,es. 7 Tr;u1S\'et'5I.' allanl~llig.1mml

atlanto-Mial subiliry, 33 incompc'lcncr.. 33 SU'e5lI te5l,

3S/

TreauT'lcm nlOde\l, 45-46 Tronk rotation Ouion position. 20. 2Jf m.'uuaJ/cxICJ'llIion pOSition,. 20, 21( Type I movernmU. 10. III. 17, 18f

Upper ann hold, 205 Upper body holds, 163-164. 205-207 Upper body positioning. lhor.Jcic spine and ribagc l-fVlA thJUlillcchniqoes. 163-164

Uppe- «JVia1 inwbility. 33-38 symptoms, 33-JS 1C50. 35-37

v \bbal r;Jling lIOle. 60. 611 \\>nd)ral arwy «fVica1 roution, 29/ ~ ~inr rmtionship. 2S{ \'Cnd>n!moc.ion" 9-15

-'.

coupled mocion _ coupled motion £acd uophism. 13-14 roUtion, 9 sidebmdi~

10-15 Vcrtebrobasilar anery diss«tioo. 25-26, 261 \'t:ncbrobasilar insufficinJcy (VBI), 28-33 ~~29 ~ClI

examination, 29-31

prf'-manipula(i\-~~ 31-33. 31/. 32{

KreUling lt51$, 30 S)'TnplOffiS, 29

\rlSU

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