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
Fnt edition 2000 Second edition 2006 ISBN 0 44] 10039 X
British Ubnlry c.blIoguIng in Pubtic;ation Oat. A ~ re<:on:l for this book is cwaiIabIe from the British library
Ubrary 01 Congr." c.hl50glng In PubliQrtlon ~ A catalog record for this book is CMlNble from the Ubriwy of CongA!S5
Nolk. Nl!itht!f the Publisher nor the Authors ~ any responsibility for any loss or injury and/or damage to ~ or PfOPertY aris«1g out of or related to any use of the rt'Iiltl!fial contained in this book. It is thP rtipOf"ISlbility of the treating practitioner, relying oro independent expMist' and I<nowIedge of the piitti«lt, to deterr'rline the bt!S1 trealment imd method 0( application for the patient.
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Contents The CD-ROM accompanying this text indudes video sequences of all the techniques described in Part Band the first four techniques described in Part C. These are indicated in the text by the . To look at the video for a given technique. clid. on the relevant icon in the
following symbol
contents list on the CD-AOM. The CD-ROM is designed to be used in conjunction with the text and not as a stand-alone product.
Foreword ix Preface xi Acknowledgements
xiii
PA1?f A HVLA thrust techniques - an osteopathic perspective 1 1
Introduction
3
2
Osteopathic philosophy and technique
3
Kinematics and coupled motion of the spine
4
Spinal positioning and locking
5
Safety and I-M.A thrust techniques='--'2::S'--'
6
Rationale for the use of HVLA thrust technques
7
Validation of clinical practice by research
5
9
17
_ 45'-___ _ __
55
PART B HVLA thrust techniques - spine and thorax 65 SeCflON 1 Cervical and cervkothoracic spine 69 1.1
Atlanto-ocdpital joint (O-Cl: contad point on ocdput; chin hold; patient supine; anterior and superior thrust in a curved plane
71 ---1.2 Atlanto-occipital joint Co-O: contact point on atlas; chin hokI; patient supine;
anterior and superior thrust In a curved plane 1.3
Atlanto-axlal joint Cl-2: chin hold; patient supine; rotation thrust
~ttan~~xial ~~rvical
1.6
77
joint Cl-2: cradle hold;
patie~
81
supine; rotation thrust
85
spine 0-7: up-slope gliding; chin hold; patient supine 89
Cervical spine 0-7: up-slope gliding; chin hold; patient supinevariation 93
--=='--..:..: ----J.7 Cervical spine 0-7: up-slope gliding; cradle hold patient supine
97
1.8
Cervical spine 0-7: up-slope gliding; cradle hold; patient supine; reversed primary and secondary leverage 101
1.9
Cervical spine C2-7: up-slope gliding; patient sitting; operator standing in front 107
-----
v
Manipulation of the spine, thorax and pelvis
1.10 CeNfcat spine 0-7:
to the side
u~slope gliding;
patient sitting; operator standing
111
J. U Cervical spine 0-7: down-slope gliding; chin ~d; patient supine
115
J.12 Cervical spine C2-7: down-sk>pe gliding; cradle hokI;patient supine
121
J .13 Cervical spine C2-7: down-slope gliding; patient sitting; operator standing
to the side
127
'-:----:::::-=-
, .14 Cervkothoracic spine 0-1'3: rotation gliding; patient prone; operator at side of couch 131 1. 15 Cervicothoracic spine 0-D: rotation gliding; patient prone; operator at head of couch 135
':-_------,-----,-----
1.16 Cervicothoracic spine 0-1'3: rotation gliding; patient prone; operator at head of couch - variation 139 /.17 Cervicothoradc spine 0-D: sidebending gliding; patient sitting
---,'_4~3
_
1.18 Cervicothoradc spine 0-D: sidebending gliding; patient sitting; ligamentous myofasdal tension locklng,---~'4~7,---
_
1.19 Cervicothoradc spine 0-D: sidebending gliding; patient side-lying,,-_',,5::',-_~ 1.20 Cervicothorack spine 0-D: sidebending gliding; patient side-lying; ligamentous myofasdal tension locking 155
-- -
----
1.21 Cervkothoradc spine O-D: extension gliding; patient sitting; ligamentous myofasdal tension locking 159
S£Cl10N 2 Thoracic spine and rib cage
163
2.1
Thoracic spine T4-9: extension gliding; patient sitting; ligamentous myofascial tension locking 167
2.2
Thoracic spine T4-9: flexion gliding; patient supine; ligamentous rnyofascial tension locking:c-"'-7''-----,-_ Thoracic spine T4-9: rotation gliding; patient supine; ligamentous myofasdal tension locking 177
2.3 2.4
Thoracic spine T4-9: rotation gliding; patient prone; short lever technique 183
2.5
Ribs R1-3: patient prone; gliding thrust 189 Ribs R4-1O: patient supine; gliding thrust; ligamentous myofasdal tension locking 193
2.6
2.7 3ibs A4-10: patient prone; gliding thrust
197
2.8
201
Ribs R4-10: patient sitting; gliding thrust
SEcnON 3 lumbar and thoracolumbar spine
205
3.1
Thoracolumbar spine n o-t.1: neutral positioning; patient side-.Mng; rotation gliding thrust 209
3.2
Thoraco'umbar spine T1 o-t2: flexion positioning; patient side-lying; rotation gliding thrust 213
---
Contents 3.3
Lumbar spine L1-5: neutral positioning; patient side-lying; rotation gliding thrust 217
3.4
Lumbar spine L1-5: flexion positioning; patient side-lying; rotation gliding thrust 221
3.5
Lumbar spine ll-5: neutral positioning; patient sitting; rotation gliding thrust 225
3.6
Lumbosacral joint l5-51: neutral positioning; patient side-tying; thrust direction is dependent upon apophysial joint plane 229
3.7 Lumbosacral joint l5-S 1: flexion positioning; patient side-lying; thrust direction _ _i::'.:d",ependent upon apophysial joint plane 233
PART C HVLA thrust techniques - pelvis 237 1
Sacroiliac joint left innominate posterior; patient prone; ligamentous myofascial tension locking 239
2
Sacroiliac joint right innominate posterior. patient sK:le-.Jying
3
Sacroiliac joint left innominate anterior; patient supine'---:-24_7
4
Sacroiliac joint sacral base anterior; patient side-tying
5
Sacrococcygeal joint coccyx anterior; patient side-iying --=:25::5'--References
243 _
251 _
259
PAKT 0 Technique failure and analysis 261 Index
265
vii
Foreword
This second edition builds upon the strengths of the firsL The aumors focus upon high-velocity low-amplitude (HVLA) thrust technique. It continues to be one of the mOSt widely used forms of manipulation by many health care professions. The book is again divided into four parts: (A) HVlA thrust techniques. an osteopathic perspective; (8) HVl.A thruM techniques. spine and thorax; (C) HVLA thrust techniques. pelvis; and (D) technique failwe and analysis. It is in the first section that the aumors have added much to this volume. and the profession's understanding. of two very important areas. namely in spinal biomechanics and coupled motion of the spine. and in the area of safety and the prevention of complications. In Chapter 2, the authors have added to their diagnostic criteria for somatic dysfunction, with S signifying symptom reproduction. 111e new mnemonic is S-T-A· R-T with S for symptom reproduction; T for tissue tenderness; A for asymmetry; R for range of motion; and T for tissue texture changes. "llle accurate diagnosis of somatic dysfunction is critical for me proper application of HVLA thrust techniques. Chapler 3 on Kinematics and coupled motion of the spine has been updated with the most currelll research and with an
expanded reference lisL Coupling of spinal motion continues to be difficult to understand and current research has cast some doubts about some of me original meoret.ical const.ruets. The authors h3Vl" cogently bridged the original concepts with me results of current research. aiding me reader's understanding of complex concepts and preparing their undemanding for me technique chapters that follow. Chaptet" 5 on Safety and high-velocity low-amplitude techniques brings an update to an area of controversy. The authors have expanded the references by 63 new citations.. bringing new darity to the concerns previously expressed about the safety of HVLA. They conclude that the risk is extremely low but that the key to prevemion of complications is adequate training and experience. The technique chapters in sections 8 and C are again comprehensive in their description of the techniques and follow a standard step-by-step format for student learning. Several n~.... techniques are added. 'nlis second edition continues to add to the reader's knowledge of high-velocity low-amplitude (HVLA) thrust techniques in a dear, concise and easily readable fashion. Philip E. Greenman
ix
Preface
'Ibis second edition of MaFlipulntilm of the Spine. T11Ora:c arul PellJis: An Osteopathic Perspec:titJe has been produced at a time of increasing knowledge related to the use of manipulative techniques in clinical practice. Patient safety remains a major consideration when selecting a tteatmeOl approach. Thrust techniques have been considered potentially more dangerous when compared with other osteopathic techniques, particularly relating to the cervicaJ spine. Recent research has questioned the appropriateness of a number of commonly used venebrobasilar insufficiency protocols and the text has been updated to embrace current research finding<; and recommendations. The evidence base for the use of spinal manipulation in patients with disc lesions has been included, as the application of thrust techniques in these patients remains controversial. ·11,c move towards an evidence·based and patient-centred approach to healthcare requires the modern practitioner to utilize the best available evidence 10 inform clinical practice, to be cognizant of the legal and ethical requirements for informed consenl and 10 use the appropriate instnllllems to monitor patient progress. ·111e second edition has been updated to re(Jea these changing requirements of practice. Our goal remains to present a text that will provide the necessary infonnation relating 10 all 3SpccL.. of the delivery of High-Velocity Low-Amplitude (HVU\) thrust lechniques in one comprehensiw volume.
so that practitioners can use thew techniques safely and in the appropriate ci.rcumslances. Since the first edition. there has been extensive research published within peer-revie\\u1 journals that suppons the use of a multi-modal approach, induding the use of HVLA thrust techniques. for the treatment of spinal pain and cervirogenic headache. fur a commonly used treatment approach. it is surprising that there are such limited resources to support learning and skill refinement in HVLA thrust techniques. Most of the learning of HVl.A thrust techniques has been dependent upon personal instruction and demonstration. 'I'here are still only a handful of osteopathic technique books and manuals and few of these relate solely to thrust techniques. 'Ibe material presented in this te:
Manipulation of the spine, thorax and pelvis
TE'finement of the psychomotor skills necessary for the effeaive delivery of HVlA thrust techniques, Experience has shown that the video images included on the CDROM ha\'f' proved useful for both students and praaitioners. 'l1le second edition CD· ROM has been updated with the additional thrust techniques and has been expanded 10
xii
include fluoroscopic images of spinal coupling in the lumbar spine. 'l1le principles of spinal positioning and locking elaborated in the text are clarified by the addition of video images on the CD-ROM, Melbourne 2006
Peter Gibbons
Philip Tehan
HVLA thrust techniques - an osteopathic perspective
PART
I
Introduction
3
2
Osteopathk philosophy and technique
3
Kinematics and coupled mOlm of the spine
4
Spinal positioning and locking
5
Safety and high-velocity low-amplitude (t-MA) thrust techn~ues 25
6
Rationale for the use of high-velocity Iow-amplitvde (H\IlA) thrust techniques 45
7
Validation of clinical practice by research
5
9
17
55
Introduction
Manipulative techniques for the spine. thorn" and pelvis are commonly utilized for the treatment of pain and dysfunction. Proficiency in their use requires training, practice and development of palpatol)' and psychomotor skills. lhe purpose of this book is to provide a resource that will aid development of the knowledge and skills necessary to perform high-velocity lowamplitude (HVl.A) thrust techniques in practice. It is written not just for the novice manipulator but also for any practitioner who uses thrust techniques. While the book presents an osteopathic perspeaive, it does not promote or endorse any panirular treatment model or approach. 'Ille term 'manipulation' is often used to describe a range of manual thern!')' techniques. 'Ihis text focuses specifically upon IIVI.J\ procedures where the practitioner applies a rapid thrust or impulse. l"e aim of ItVLA thrust techniques is to achieve joint cavitation that is accompanied by a 'popping' or 'cracking sound. '111is audible release distinguishes IIVLA thrust techniques from mher osteopathic manipulative techniques. IIVLA thrust techniques are also known by a number of different names. e.g. adjusunent, high-velocity thrust, mobilization with impulse and grade V mobilization. 11le book is divided into four pans. Pan A comprises seven chapters that provide an osteopathic perspective on the use of HVLA thrust techniques and reviews indications, kinematics. safety and research.
An overview of the ostropathjc philosophy that underpins osteopathic manipulative technique and treatment is presented in Chapter 2, Chapter 3 reviews spinal kinematics and coupled motion of the spine. Practitioners require knowledge of biomechanics and coupled motion characteristics in order to apply the principles of spinallocl-ing used in l-fVUI. thrust techniques. 11le osteopathic profession has developed a classification of spinal motion. Chapter 4 describes type I and type II movements and the relevance of coupled mOlion to spinal positioning and joint locking. Complications of, and contraindications to, IIVLA thrust techniques are outlined in Chapter 5. Pre-manipulative assessment of venebrobasilar insufficiency and upper cervical instability is described and the use of testing protocols for vertebrobasilar insufficiency is revie\...m in light of the published literature. Chapter 6 examines osteopathic treatment models, reviews the literature relating to cavitation and the efficacy of spinal manipulation and outlines a d€Cision making process that will assist practitioners to determine when a I IVIA thrust technique might be used in clinical practice. Research is necessary to validate the use of osteopathic techniques in clinical practice. including HVlA thrust techniques.. Chapter 7 identifies stratq;ies that can be used by practitioners to classify patients and document patient outcomes in clinical practice.
3
HVLA thrust techniques - an osteopathic perspeaive
Parts Band C oUlline in detail spedfic I [VIA thmst techniques for the spine. rib cage and pelvis. These two parts combine photographs and descriptive text that is supported by the video images of HVLA thmst techniques on the accompanying CD·ROM. IIVLA thrust techniques can be described in terms of bone movement or joint gliding. In this text, all 41 techniques are outlined utilizing the principle of joint gliding. This approach has been shown to be effect.iw in the teaching of IIVLA thrust techniques to both undergraduate and postgraduate students. n'le text has been designed to provide a logical step-by-step format that has consistency throughout the book. Each technique is described from the moment the patient is positioned on the couch. through a series of steps up to and including segmentallocali7..ation and delh'ery of the thrust. Each individual technique is logically organized under a number of specific headings: • • • • • •
Contact point(s) Applicator(s) Patient positioning Operator stance Positioning for thmst Adjustments to achieve appropriate pre-thrust tension • Immediately pre-thmst • Delivering the thmsl Individuals use a variety of methods to acquire complex psychomotor skills, with structured and repeated practice a key element in the development and maintenance of proficiency. Experiencing these both as an operator and as a model can enhance the learning of 11VLA thrust techniques.
4
.
"
The art of manipulation is very individual, requiring IIVIA thrust techniques to be adapted to the needs of both practitioner and patient. While some modification to the described techniques will occur with developing proficiency, the underty;ng principles remain the same. lhese principles can be summari7.ed as follows: I. Exclude rontr:aindicaliollS. 1. Obtain informed consent. 3. Ensure patient comfort. 4. Ensure operator comfort and optimum posture. 5. Use spinal locking. 6. Identify appropriate pre-thrust tissue lension. 7. Apply IIVLA thrust.
If these principles are applied, HVlA thrust techniques provide a safe and effective treatment option. A common experience in the evolution of proficiency in thrust techniques is a sense offrustralion and impatience when skill development is slow or variable. Experienced practitioners can similany experience difficulties achieving cavitation in certain circumstances. Part D provides a troubleshooting and self-evaluation guide to identify those problems that may limit the effective application of llVLA thmst techniques. Integral to the practice of osteopathic medicine is an understanding of the interrelationship of mind. body and environment. Osteopathic treatment encompasses mOfe than joint manipulation alone and this manual represents only part of the art and science of osteopathic medicine.
Osteopathic philosophy and technique
Osteopathy, or osteopathic medicine. is II philosophy, II science ami an arL lis pllilosoplry embraces the concept oJ the unity of body stmcture and {mulian in heaIIIl and disease. Its science includes the chemical, pllysimI ami mologiall sciences rclntell fa tlie maintenmu:e of healIIi Glut llie l,revenlion, cure and alleviation of disease. //$ an is the applicafitm of I/le plliIosop/IY and /lie science it' flle practice of osteopathic medicine mId surgery in all its lJranches and specialties. Ilealf1l is billed 011 ti,e natural capacity of fIJe IlUman organism /0 resisl and combat noxinus i'lf/uences in llle elllJiromllenl Glllt /0 compml$o/e for II/ciT clfec/!;; to meet, willi {UIeqUlltc reserllC, IIJe flsuol stresses of daily life
and tile occasilmal severe stresses imf'osetl by ex/remes of emJirommml mul actilli'y. Disease begim w/lim I/li$ naltlral cnpllcity is reduced, Dr when il is exceediuf ar overcome by noxious hl/luences. OSleot1al1lic metlicifJe recognizes /lUll many faC/OTs impair IIlis C/lpacil1' mui 'lie 'laturtll Imulem:1' /owaTfls recol.rery anli IIlat among tlie most importam of llzese faC/ors are llie local liisturlJafJces or lesions of llle musclilosuelelal s1's/em. Osteopalhic I1lellidne is IIlerefore concerned witli liberafing anli developing all tlie T/?S()llrc£s tliat ctmstitute lile capacity far resistam::e and recovery. tlius recogrlizing tlie validit1' of llie ancient obsenlafiO,J Illllt lize pllysicum deals willi a patient as well as a llisease. I lhe philosophy underpinning the osteopathic approach to patient care can be enunciated as shown in Box A.2.1.
Box A.2.1 Philosophy underpinning osteopathic approach
• The body is an integfilted unit • The body is self-regulating with inherent capacity for healing • Structure and function are inter-dependent • Somatic component to disease • Neuromusculoskeletal dysfunction impacts on ovefiltl health status • Neuromusculoskeletal dysfunction impacts on recovery from injury and disease • Unhindered fluid interchange necessary for maintenance of health
DIAGNOSIS OF SOMATIC DYSFUNCTION ,1,e accepted definilion for somatic dysfunction in the 'Glossary of osteopathic terminology' is as follows: Somatic dysfunction is an impaired or altered function of related components of the somatic (bod}' framework) system: skeletal, anhrodial and myofasdaJ structures. and related vaSOJlar, lymphalic. and neural
rlemems. 2 Osteopaths diagnose somatic dysfunaion by searching for abnonnal funnion within the somatic system. Palpation is fundamental to structural and functional diagnosis.} Research has explored both inter~ and inlm-examiner reliability of various
5
• HVLA thrust techniques - an osteopathic perspective
--.;.......;....;..-------
6
diagnostic palpatory procedures. Inter· examiner reliability consists of one assessment of all subjects by each of two or more raters, blinded to each other's observations, and allows assessment of rater agreement. Intra~examiner reliability is detennined by repeated measurements of single individuals 10 evaluate rater seJfconsistency. Osteopaths have shO\vn reasonable levels of inter-examiner agreement for passi\'E" gross motion testing on selected 5ubjfftS ,,,ilh consistent findings of regional motion asymmetry.4.S One osteopathic study demonstrated low agreement of findings for patients with acme spinal complaints when practitioners usro their own diagnostic procedures.' level of agreemmt can be improved by nt'gOLiating and selecting specific tests for detecting patient improVE"mt"nL7 Standardization of testing procedures can improve boc.h inter- and intra-examiner reliability.! In asymptomatic somatic dysfunction. high levels of inter- and intra-observer agreement for palpatory findings have yet to be demonstrated. Many studies show that intc:r- and intra-ex.aminer reliability for palpatory motion testing without pain provocation is poor.~·18 Poor reliability of clinical tests involving palpation may be paniaJly explained by error in location of bony landmarks. 19 HO\vever, palpation as a diagnostic 1001 can demonstrate high levels of sensitivity and specifidty in del.octing symptomatic intervenebral segments. 21),21 Traditionally, diagnosis of somatic dysfunction ,.;as made on the basis of a number of positive findings. Specific criteria in identifying areas of dysfunction were dC\'elopro and related to the observational and palpatory findings of a!loymmetry, altered range of motion, tissue texture changes and tenderness. 111is was represented as the acronym TART (tissue tenderness, al>)'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
• 5
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
,
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.
,.
. 2
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
7
HVLA thrust techniques - an osteopathic perspective
techniques are articulatory, high-velocity
11
!O\...·amplitude (1IVlA) lhnlSl, rounterslrain, muscle energy, Ill}'ofascial/neuromuscular release and soft tissue techniques. u
12
References
13
2
3
• 5
• 7
8
• 10
8
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.
14
15
I. 17
18
I' 20
21
22
23
24-
25
Connella C l'
ml motton of the cervical spine. Man Ther 2000; 5(2):97-101. l-leslOOek I.. 1.ebcxuf·Yde C. Are chiroprnctic tests for the lumbo·peh
Kinematics and coupled motion of the spine
Clinicians use palpatory assessment of individual intervertebral segmenls prior to the application of a thrust technique. The osteopathic profession has used I~elte's model of the physiological mO\'ements of the spine to assist in the diagnosis of somatic dysfunaion and the application of treatment techniques. FrYE.'tte l outlined his research into the physiological movemrnts of the vertebral column in 1918. I-Ie presented a model that indicated coupled motion ocamed in the spine and displayed different coupling characteristics dependent upon spinal segmental level and posture. The muscle e"eJ'XY approach is one system of segrnenlal spinal lesion diagnosis and treaunent predicated upon Fryette's LaWs.' Practitioners utilizing muscle energy techniquE.' (MET) use these Laws of coupled mOlion, as a predictive model. to both (annulate a mechanical diagnosis and to selecl the precisely conuolled position required in the application of both muscle energy and thnlst techniques. Current literature challenges the validity of Pryette's UlWS.
BIOMECHANICS Convention dictates that intervertebral motion is described in relation to motion of the superior vertebra upon the inferior venebra. Motion is further defined in relation to the anterior surface of the vertebral body; an example of which would be the direclion of vertebral rOlation which is described in rdation to the direction in
which the anterior surface of the vertebra mO\'eS rather than the posterior elements. In the dinical setting. Vertebral motion is described using standard anatomical cardinal planes and axes of the body. Spinal motion can be described ~ rotation around, and translation along. an axis as the vertebral body mO'\'es along one of the cardinal planE'S. By convention the \'ertical axis is labelled the y-axis; the horb.ontal axis is labe.Ued the x-axis; and the antere> 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
9
HVLA thrust techniques - an osteopathic perspective
,.....
Figure A3.1 Axes of motion. (Reproduced with permission from Bogduk..l )
10
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)
Kinematics and coupled motion of the spine
Sdebending left
Sld9bending left
Rolarion righl
Figure A.3.2 Type 1 movement.Sidebending and rotation occur to opposite sides. (Reproduced with permission from Gibbons and Tehan.l~ neutral (facets not engaged) and nonneutral (facets engaged and controlling vertebral motion) positioning. Fryelle defined neulral '10 mean the position of any area of the spine in which the mcets are idling, in the position between the beginning of flexion and the beginning of extension'. In the cervical spine below C2, the facets are considered to always be in a non-neutral position and are therefore assumed to control vertebral motion. lhe thoracic and lumbar regions have the possibility of neutral and non-neutral positioning. MitcheUZ summarius F'ryelte's Laws as follows:
Fryette's Laws • Law I. Neutral sidebending produces rO(;ltion to the other side or in other
Rotarion Ief1
Figure A33 Type 2 movement. Sidebending and rotation occur to the same side. (Reproduced with permission from Gibbons andTehan.~
words, the sidebending group rotates itself toward the convexity of the sidebend, with maximum rotation at the
apex. Law 2. Non-neutral (vertebra hypernexed or hyperextended) rotation and sidebending go to the same side individual joints aoing alone time. • Law 3. Introducing motion 10 a vertebral joint in one plane aUlomaLicalJy reduces its mobility in the other two planes. •
Research into coupled movement has been undertaken on cadavers and live subjects. Cadaver research has allowed precise measurements 10 be "'ken of coupling behaviour, but has the disadvantage of being unable to reOect the activity of muscles or the accurate effects of load on different postures. Plain
11
HVLA thrust techniques - an osteopathic perspective
12
radiography has been superseded by the more accurate biplanar radiographic studies that allow' research to bE': undertaken under more nonnal physiological conditions. Most research has been pe:rfonned on the lumbar spine:. Brown U•.l 2 indicates. after an extensive literature review, the conflicting results of ~1.udies into coupled motion. Many authors have demonstrated a coupling relationship between sideflexion and rotationlll,lJ.n but there is inconsistent reporting of the direction of coupling. 2J Other authors maintain that sidebending and rotation are pure:ly uniplanar mOl ion occurring independently of each other.2c.u Stoddard I) demonstrated radiologically that sidebending in the celvical spine is always accompanied b)' rotation to the same side regardless of cervical posture. Stoddard's observations in relation to the cervical spine are consistent with Lovett's findings and Fryette's Laws. These. findings are further supported b)' research undertaken using biplanar X-ray analysis. la In 20 nonnal male \'Olunteers, when the head was rotated, lateral bending occurred by coupling in the same directjon at each segment below the C3 vertebra. Interestingly coupling was not restricted to lateral bending. At the same time. flexion took place by coupling at each segment below the C5-6 vertebra and extension abO\'e: the C4-5 leve:l. In a study of active range of motion in the cervical spine during daily fWlCtional tasks, Bennett et aI. noted thaI tht' normal coupling pattern for the cervical spine is rotation and sidebending to the samt' side:. 21 While there is agreement as to the direction of axial rotation and lateral flexion coupling in the cervical spine below Cl, i.e. sidebending and rotation occurring to the same side the patterns for coupling in the lumbar spine are less dear. Stoddard's findings in the lumbar spine were that 'sidebending is accompanied by rotation to the opposite side if the commencing position is an erea one of extension. U; hO\Y'{'ver, the starting position is full flexion,
side-bending is then accompanied by rotation to the same side'. U Russell et al. U in a study of the range and coupled movements of the lumbar spine. using a 3Space lsotrak system on 181 asymptomatic volunteers aged between 20 to 69 )'ears,. found mat in the erect position there was strong coupling of opposite axial rotation on lateral bending. Despite subjects being told to make lateral flexion as pure a lateral movement as possible, Russell et aI. also noted a slJong coupling of flexion as well as opposite axial rotation on lateral bending. Other authors do not support these findings and report inconsistent cOllpling.lI,n.17.19 Plamondon et al. llsing a stereoradiographic method to study lumbar intervertebral motion itl llioo demonstrated that axial rotation and lateral bending were coupled motions but reponed there \vas 'no strict pattern that the \'enebra follow in executing a TnO\'emenl~17 Pearcy and Tibrewa.l 's in a threedimensional radiographic study of nonnal voluntan. with no hislory of back pain requiring time off work or medical treatment. found that the relationship between axial rotation and laleral bending is not consistent at different levels of the lumbar spine. Some individuals occasionally demonstrate 'mO\"€:ments in the opposite direction to the \'Oluntary movement at individual intervertebralleve.ls. most commonly at L4-5 and 1.5-SI. In lateral bending. there was a general tendency for 1.5-SI to bend in the opposite direction to the voluntary movement'. TIlis unexpected finding is consistent with a study by WeiLZ. 16 Panjabi et al.," using fresh human cadaveric lumbar spines from L1-Sacnlm, assessed coupled motion under load in different spinal postures using stereophotogrammeuy. 1'hey concluded that coupling is an inherent property of the lumbar spine as advocated by Lovett but that in vitro coupling patterns are more complex than generally believed. 'l1ley demonstrated the presence of muscles is not a requirement for coupled motion, but acknowtedged that they may significantly
Kinematics and coupled motion of the spine
alter coupling behaviour. The specific effect of physiological loading and muscle activit)' upon coupled motion is presently unknO\\ln. In a neutral posture. left axial torque produced right lateral bending al Ihe upper lumbar levels and left lateral bending at the lower 1\"0 I€:\>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
13
-.
14
HVLA thrust techniques - an osteopathic perspective
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.
, I.
II
12
13
14
I)."
15
16
17
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
IS
" 2. 21
22
23
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.
" ~
~~'. ~
3'-.
15
...
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<. Miller A, Schultz A. Andersson C. Load displacemelll behaviour of the human lumbo-sacral joinL J Orthop Res 1987; 5:488-496. 26 Weitz E. 101.' lateral bending sign. Spine 1981; 6(4):388-397. 27 FrymO)'tt JW, Frymo)'er \VW, Wilder DC, Pope MH. lbe mechanical and kinematic analysis of t1w lumbar spine ill Ilonnalliving human
24
'6
subiects in vivo. J Biomechanics 1979; 12:165-172. 28 Cyron 8M. Hutton we Articular lropism and stability ofthe Iwnbar spine. Spine 1980; 5(2):168-1n. 29 l.und T, N}'degger T, Ing D. Schlenzk D, OxIand T. Three-dimensional motion pauems during acti,,. bending in )Xl.lienu with chronic 10l.... back pain. Spine 2002; 27(17):1865-1874. 30 Cool.: C ShOl....altft C. A survey on the importance of luntbaf coupling biomechanics in physiotherapy practice. Man lher 2004; 9(3):164-172.
Spinal positioning and locking
SpinaJ locking is necessary for long-lever, higlH'Clocily Jow-amplitude (HVI.A)
CERVICAL SPINE
ttthniques
Creenman7 describes lhe normal coupled motion of sidebending and rolation at the occipitcratlalllal (CO-C1) segment as being type I. The principle of facet apposition locking does not apply to HVI..A thrust to:::hniques directed 10 Ihe co-C 1 segment llC\'>'eVef, facet apposition locking of the CO-CI segment can be utilized for IlVI.A thrust techniques directed to other cervical levels (see Table A.4.1). '(he Iype of coupled rnO\·ement av.ailable at the Cl -2 segment is complex, This segment has a predominalll role in total cervical rotation.,...l' lip to 77% of total cervical rotation occurs at the atlanto-axial joint., with a mean rotation range of 40.5° to either side.'.11 The great range of rotation at the atlanto-axial joint can be attributed to facet plane, the loose nature of the ligamentous fibrowi capsule and the absence of ligamentum fiavum above: C2. 12 Only a small amount of rOlation occurs at the joinu above and below the atlanto-axial joint. 1l- 1S Below e2, normal coupling behaviour in the cervical spine is type 2, i.e. sidebending and rotation occur to the same side.;·16-11 'rlle average range of cervical spine rotation from neutral position is 80° (Fig. A.43V' For patient comfort and safety lhe practitioner should limit the total range of cervical spine rotation when applying thrust techniques. Below C2 lhis is achieved by combining cervical spine rotation with
10
locali7...e forces and achieve 1 7 -
cavitation at a specific venebral segment. Short-lever HVlA techniques do not require locking of adjacem spinal segments. tocking can be achieved by e:iLher facet apposition or the utilization of Jigamelllous myofascial tension. or a combination of both. ' -17 The principle used in th€Se approaches is 10 position the: spine in such a ,vay that levernge is localized to one joint
without undue stmin being placed upon adjacent segments. The osteopathic profession developed a nomenclature to classify spinal motion ba.~ed
upon the coupling of sidebending
and rotation movemems. This coupling behaviour will vary depending upon spinal positioning:
• 'IYpe
J 1U00ICmerJI - sidebending and rolation occur in opposite diredions (see
Fig. A.4. I")
• 'lyPe 2 movemen!. - sidebending and rounion occur in the same diro:::tion (see Fig. A.4.2"). TIle prindple of facet apposition locking is to apply leverages to the spine that cause the facet joinu of uninvolved segments to be apposed and consequently locked. To achieve locking by facet apposition. the spine is placed in a position opposite to thai of normal coupling behaviour. The vertebral segment at which you wish to produce cavitation should neveT be locked.
17
HVLA thrust techniques - an osteopathic perspective
SidoOOnding IeII
Sidebeoding lett
Rotation left
Figure A.4.1 Type 1 movement. Sidebending and rotation occur to opposite sides. (Reproduced with permission from Gibbons and Tehan.1)
Figure A.4.2 Type 2 movement. Sidebending and rotation occur to the same side. (Reproduced with permission from Gibbons and Tehan.1)
TableA.4.1
18
Spinal level
Coupled motion
Facet apposition lodting
(O-Cl (occiplto-atlantal) (1-2 (atlanta-axial) C2-T4
Type 1 Complex - primary rotation Type 2
Type> Not applicable Type 1
opposite sidebending (Fig. A.4.4). 'Ib generate facet apposition locking for HVI.A thrust techniques. the opET.l.tor must inuoduce a type I movement, which is sidebending of the cervical spine in one direaion and rotation in the opposite direction. e.g. sidebending right with rotation lefL lnis positioning locks the segments abmre the joint to be cavitated and
enables a thrust 10 be applied 10 one venebrnl segment. The amount or degree of sidebending and rotation can be varied to obtain facet locking. The intent should be 10 have a primary and secondary 1C\'efage. The prindpal or primary leverage can be either sidebending or rotation (Fig. A.4.5). The principles of facet apposition locking that apply to the cervical spine are also
Spinal positioning and locking
Figure A.4.3 Full left cervical spine rotation.
Figure A.4.4 Introduction of right sidebending limits the range of available left cervical spine rotation. utilized for HVLA technique> to the cervicothoracic junaion (C7-T4). If cervkothoradc region techniqUe> require locking via the cervical spine.. this is achieved by introducing type I movements to the cervical spine.
THORACIC AND LUMBAR SPINE Current research relating to coupled movements of sidebending and rotation in the thoracic and lumbar spine is
Figure A.45 Cervical HVlA positioning for up-slope gliding thrust. Primary leverage of rotation to the left and secondary leverage of sidebending to the right achieve facet apposition locking down to the desired segment on the right.
inconsistent. Although researrh does not validate any single model for spinal positioning and locking in the Ihorade and lumbar spine the model in Table A.4.2 is useful for leaching IIVLA techniques. Evidence suppons tbe view that spinal pn 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.
19
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.
20
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.
4
Figure A.4.7 Note increased rotation necessary to achieve facet apposition locking with introduction of trunk flexion from below.
21
HVLA thrust techniques - an osteopathic perspective
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).
22
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).
....
-~---
F.igure A.~.12 Flexion positioning. Type 1 locking_ Rotation and sldebendtng to opposite sides. i.e. sidebending left and rotation right.
23
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 ubtication5; 1972. 4 Ilanman L IlandOOok of Osteopathic Technique, 3rd edn. l.ondon: Chapman & 1Ia11; 1997. 5 8«:31 Me. Thaching of basjc principles of 05tcopathk manipulati\-e teehniqtxS. In: BeaI Me. eds.. 1be l'rincipies of I'alpatory Oi3gnosis and Manipulatiw Technique. Newarlc American Academy of O&tropa!hy; 1989:162-164. Kappler R£. Direct action techniques. In: Beal Me. eds. '!be Principles of Palpatory Diagnosis and Manipulati\~l«hnique. Newark American AGKIemy Ostropathy; 1989: 16S--168. 7 Greenmail I'Eo. l'rinciples of M.anual Medicine 3rd edn. Philadelphia. PI\: uppincott Williams & Wilkins; 2003.
12
Cuth M. A comparison of cervical rotation in 38C-matdlt.'d adoll'SCt'1lI competitive swimmers and hl'31thy mail'S. 1Orloop Sports Phys Ther 1995; 21(1):21-27.
13
Penning I~ Normal mO\'C!nents of the cnvical ~inc. 1 Roeut8ICnoi 1978; 130(2):317-326. White A. Panjabi M. Clinical Uiomechanics of the SpillC'. 2nd edn. Philadclphia. 1'1\: Uppiocott 1990.
14
15
l'oner6eld JA. DeRo5a e. Mechanical Neck Pain: 1'l'Bpt"Cti\"t'lIi in functional AnalOmy. Sydnty. WB saunders; 1995.
I'
Mimura M. Moriy.l II. Watanabe T, Takahashi K. Yarnagalill M. Tamaki T. Three dimensional motion anatysis of the ceJVkal spine with special reference 10 thE' axial rotation. Spine 1989; 14(11):1135-1139.
17
Stoddard A. Manual of Osteopathic Ptaaice. London: Ilutehinson Medical Publications; 1969. Bmnett Sf~ Schenk It Simmons Eo Active ..-anse motion utilized in the cervical spine to perform daily functionallasb. J Spinal Disord Tech 2002; 15(4):307-311. American Medical Associalion. Guides to the Evaluation of l'Umafll'nt Impainnent. 4th edn. Chicago, II.: American M«Iical AssodaLion; 1999. VKeflZino G, TwOmey 1~ Sillel1exion induced lumbar spine conjunct rotation and its influencing factors. Aust PhysiothE:f 1993; 39(4):299-306. I ~te II. ['rinaples of Ostcopalhic Technic. Newark. 01 [: American Academy of Osteopathy; 1954:15-21 (reprinted 1990). Panjabi M, ,'anwnoto I, Oxland"r, Oisco J. 110\'" d0C5 posture affect coupling in the lumbarspinef Spine 1989; 14(9);1002-1011. Russell P, Pearey M, Unsworth A M'-'3.Surt-ment of the range and coupled mowmt>nlS oooerved in the lumbar spine. Br' RheumalOl 1993; 32(6):490-497.
•
18
or
8
• 10
II
24
Gibbons Po Tehan Po MU5de ene..gy concepts and coupled motion of the spine. Man 11ln 1998; 3(2):95-101. Pe.nning I.. Wilmink fl'. Rotation of the cen'ical spine: a cr study in normal subjeas. Spine 1987; 12(8):732-138. Mimura M. Moriya II. Watanabe 1: Takahashi K. Yamagata M. Tlunaki T. 'l1uec dimellSional motion analYSIS of the cervical spine with special rcll..-ence to aJual rotation Spine 1989; 14( II): 1135-1139 lai II. Mor;ya II, Takahashi K. Yamagata M, Tamald T 'nm~ dimensional motion analysis of upper cervical Spilll' during axial rolation. Spine 1993; 18(16):2388-2392.
I.
20
2\
22
23
or
HVlA thrust techniques - an osteopathic perspective
Table A.S.1 Description of trivial trauma associated with vertebrobasilar artery dissection/occlusion cases Type of trivial trauma
Examples
No. of cases
Sporting activities
Basketball. tennis. softball. swimming. calisthenics Walking. kneeling at prayer, househc:Hd chores, sexual
18
leisure activities Sustained rotation Clndlor extension Short-lived rotation
and/or extension Sudden head movements
intercourse Wallpapering. washing walls and cetlings, archery, yoga Turning head white driving. backing out of driveway, looking up Sneezing. fair ride. violent coughing. sudden head
-
Misceflaneous. minor Imuma
Minor fall, 'b<w1ging' head
Mtsc:eUaneous Total
Adantc;axial instability, postpartUll\ post-gastrectomy
8 10 7
7 2
6 58
Haldeman et aI."
Difficulties arise in the estimation of risk for vertebrobasilar dissection afteT ned< manipulation, as patients may in faa seek treatmem for symptoms of a progressing dissection. Smith e1 al. attempted to address this issue in a case controlled study of the association bet""ttn neck manipulation and cervical arterial dissection and reported that neck manipulation is an independent risk faaor for vertebral artery dissection even after controlling for neck pain. JO , lowever, Williams et al. indicate that estimates for stroke following neck manipulation will always be difficult to quantify. Selection and realll bias in case control studies and agerelaled variables have the rx>tentiaJ to confound the estimation of the risk of vertebrobasilar disseaion after neck manipulation. Z1
Classification of complications Serious non-reversible impairment
26
• • • •
Dealh Cerebrovascular accident Spinal cord compression Cauda equina syndrome
Substantive reversible impairment • • • •
Disc herniation Disc prolapse Nerve root compression !'racture
Transient • • • • • • • • • •
Local pain or discomfort lleadache Tiredness/fatigue Radiating pain or discomfort I}araesthesia Dizziness Nausea Stiffness Ilot skin Fainting
Less common transient reactions include early or heavy menstruation, epigastric pain, tremor, palpitation and perspiration. n Transient side.-effects resulting from manipulative treatmenl may be more common than one might expect and may remain unreported by patients unless infonnation is explicitly requested. Prospective studies repon common side-
Safety and high-velocity low-amplitude (HVLA) thrust techniques
effects n~ulting from spinal manipulation occur betv,.'een 30% and 61% of patients. noon lnese: side..fff"eclS usually begin within 4 h and are resolved within the next.
•
24 h. 1.5
Causes of complications Incorrect patient selection • Lack of diagnosis • Lack of awareness of possible complications • Inadequate palpalOry assessment • Lack of patient consent
Poor technique • • • • • • •
f.:xcessive force Excessive amplitude Excessive leverage Inappropriate combination of leverage Incorrect plane of thrust Poor patient )Xlsitioning Poor operator positioning • lack of patient feedback
CONTRAINDICATIONS Whenevt?r a pranitioner applies a therapeutic intervention. due consideration muSI be given 10 the risk-benefit ratio. The benefit to the patient must outweigh any potential risk associated wilh the intervention. Traditionally, contraindications have been classified as absolute and relative. 'Ille distinction between absolute and relative contraindications is influenced by faclors such as the skill, experience and training of the practitioner, the type of technique sellXted, the amOunt of leverage and force used, the age. b'eneral health and physique of the patient.
Absolute • Bone: any pathology thai has led to significant bone weakening: - Tumour, eg. metastatic deposits -Infection. e.g. tuberculosis - Metabolic. e.g. osteomalacia - Congenital, ego dysplasias -Iatrogenic, e.g. long-term corticOSteroid medication
•
• • •
-Inflammatory. e.g. severe rheumatoid arthritis - Traumatic. eg. fracture Neurological - Cervical myelopathy - Cord compression - Cauda equina compression - Nerve root compression with increasing neurological deficit Vascular - Diagnosed vertebrobasilar insuffidency - Aonic aneurysm - Bleeding diatheses. e.g. severe haemophilia Lack of a diagnosis Lack of patient consent Patient positioning cannOI be achieved because of pain or resistance
Relative Certain categories of patients have an increased potential for adven;e reanions following the application of an HVI.A thrust technique. Special consideration should be given prior to the use of HVLt\ thrust technique in the following circumstances: • Adverse reaaions to previous manual therapy • Disc herniation or prolapse • Inflammatory arthritides • Pregnancy • Spondyiolysis • Spondylolisthesis • Osteoporosis • Anticoagulant or long-term corticosteroid use • Advanced degenerative joint disease and spondylosis • Venigo • Psychological dependence upon 1fVl.A thrust technique • Ugamentous laxity • Arterial calcification 'me abo\'e list is not intended to cO'\.'tt all possible clinical situations. Patients who have pathology may also haw coincidental spinal pain and discomfort arising from mechanical dysfunction that may benefit from manipulative treatment.
27
HVLA thrust techniques - an osteopathic perspective
HVLA THRUST TECHNIQUES AND DISC HERNIATION
28
'n,e use of HVLA thrust techniqul'S for patients with disc bulging or herniation is controversial but cited as a treatment option in a number of te>i:ts.7fo.-ze One study of 27 patients with MRI documented and symptomatic disc herniation of the cervical and lumbar spine reported that 80% of subjects achieved a good clinical outcome suggesting that chiropraaic care including spinal manipulation may be a safe and effective lreatmem approach for patients presenting with symptomatic cervical or lumbar disc hemialion.;z, In a single-blind randomized clinical triaJ comparing osteopathic manipulative lreauuent with chemonucleolysis for 40 patients with symptomatic lumbar disc herniation confirmed by imaging, a statistically significant greater improvement for back pain and disability was recorded in the first few \veeks in the group of patients receiving manipulation. AI. 12 months, the outcOITlE'S from both interventions were comparable with manipulation being less expensive 'n,e authors conclude thal osteopathic manipulation can be considered as an option for the treatment of symptomatic lumbar disc herniation. JO Ilowever, there have been case reports of a ruptured cervical di~ and lumbar disc herniation progressing to cauda equina syndrome following manipulative procedures.'UJ What is nOt known is whether the disc herniation would have progressed without manipulation or whether the force and torque of the manipulation wa.s a faClor. A systematic reviC\y of the safety of spinal manipulation in the treatment of lumbar disc herniations reponed the risk of a patient suffering a dinicaUy worsened disc herniation or cauda €quina syndrome following spinal manipulation to be less than 1 in 3.7 million.14 'Ille use of manipulaLion techniques under general anaesthesia for low back pain is associated with an increased risk of serious neurological damage.·n 'l'here is no
evidence that this approach for the treatment of 10..... back pain is effective.)j
VERTEBROBASILAR INSUFFICIENCY 'Ille vertebrobasilar system comprises the twO \mebral arteries and their union to form the basilar artery (Fig. A.S.l). Th..is S)'Slem supplies approximately 20% of intracranial blood supply.36 Blood flow in the vertebral artery may be affeaed by intrinsic and extrinsic faaoTS. Intrinsic faao~ such as atherosclerosis, narrow the vessel lumen. increase tmbulence and reduce blood flow. Extrinsic faaoTS compress or impinge upon the external wall of the vertebral anery.
Figure A.5.l Relationship of the cervical spine to the vertebral artery. 'Illere are three areas where the vertebral artery is vulnerable to external compression: I. At the level of the venebral foramm of
C6 by the contraaion of the longus colli
and/or (he anterior scalme muscles. 2. Within the foramm transversarium
between C6 and C2. 3. At the level of Cl and C2 (Fig. A.S.2).
Safety and high-velocity low-amplitude (HVLA) thrust techniques
,,,..,,,0,81 art"" Altas (Cl)
Axis (C2)
Figure A.S.2 Upper cervical rotation stretches the vertebral artery between the atlas and the axis.
Diagnosis of VBI For patients presenting ,-.rith head and neck pain, especially sudden and severe symptoms, it is impol1ant to determine if there is associated dizziness and/or signs of brain stem ischaemia such as nausea and/or vomiti ng. Dizziness is also a common presenting complaint ,-.rith multiple aaiologies that must be distinguished from dizziness arising from VBI (Box AS.I). It has been suggested that questioning about nausea during VB! testing is as important as inquiring about diz7Jness. J1 Diagnosed VBI is an absolute contraindication to IIVL\ techniques to the cervical spine.
Symptoms and signs of vertebrobasilar insufficiency
Box A.5.1 causes of dizziness
'l1le ability to recogni7.e symptoms that may indicate vertebrobasilar insufficiency (VBI)
Systemic: causes of dlzziness • Medication • Hypotension
is essential for safe practice. Symptoms of VBI OCQJr because of ischaemia in the structures supplied by the venebrobasilar system. ,11ere are a number of signs and symptoms that may be suggestive of VB!. Signs of VBI
• Nystagmus • Cait disturbaoces • I lomas syndrome Symptoms of VBI
• Ileadad1e/nec.k pain (especially if sudden and severe) • Dizziness/vertigo • Nausea • Vomiting • Diplopia • TInnitus • Drop attacks • Dysarthria • Dysphagia • Facial paraesthesia • Tingling in the upper limbs • Pallor and sweating • Blurred vision • Light·hcadedness • Fainting/blackouts
• Diabetes • Thyroid disease
• cardiac or pulmonary insufficiency
Central causes of dizziness • Demyelinating diseases • Tumours of brain or spinal cord • Seizures
• Vel1ebrobasilar insufficiency • Post-traumatic (concussion) vertigo
Peripheral causes of dizziness • Benign positional vertigo • Meniere's disease
• Cervical spine dysfunct\on • labyrInthitis • Vestibulotoxk medication One diffi01lty in recognizing the symptoms of VBI is thai many of the common symptoms, e.g. headache pain and stiffness in the cE"IVical spine. are similar to those for mechanical non-specific neck
pain.·"
Physical examination Pre-manipulative testing movements for VBI have been advocated as a means of risk management with a view to minimizing patient hann. 40 'l1lere are many physical
29
HVLA thrust techniques - an osteopathic perspective
lests described for determining the presence or absence of VlII.(I.../> Tests for VBI have been based upon the premise that cervical spine positioning may reduce the lumen and blood flow in the venebral aneries. t1 .51 Studies on cadaverk specimens have demonstrated reduced flow through contralateral venebral arteries in combinoo extension and TOtation.S)'s( In vim studies also support the view that cervical spine JX)Sitioning may roouce venebral artery blood. f1.ow.".so..sus--~ A study of nonnal volunteers conduded that blood velocity altered signifiGlntly at 45 cervical spine rotation and again at fuJI range cervical spine rotation and in the p["{'manipulative JX)Sition"~uz Other studies of vertebral anery blood flow have not identified significant change in flow related to cervical spine positioning. »~) Evidence linking vertebral aneJY narrO\ving or occlusion with cervical spine extension and rotation positioning has comributed to the devE'lopment and use of many pre-manipulativE' tests for VBI. It is postulated that a reduaion in blood flow as a resull of cervical spine positioning \vill produce detect.lble symptoms or signs in a palient with VIR Positive tests are assumoo 10 be a prediaor of patients at risk from cerebrOV3SCUlar complications of manipulation. Ilowever. tests for VBI may have low sensitivity and specificity for predicling cerebral ischaemia prior to neck manipulation!>" and the value of these tests in determining VBI has been questiolled. l 6.tMl-70 Research over recent years has questioned the continuing role of diagnostic VIU tests. Screening tesls should be both valid and reliable predictors of risk. VIII testing movements have neither of these qualities. \'I1th available scientific evidence failing to shO\... predictive value. I1•6u7 Westa\vay et al. report a false-negative VB! test in an as)'mptomatic subject with a radiographically unstable CI-2 segment and a hypoplastic and atretic righl vertebral anery funher questioning the predictive value of such screening procedures. 1O Screening procedures should not be 0
30
harmful. It has been suggested that the tests themselves may hold certain risks and could have a morbid effect on the vertebral artery.ll Minor adverse effects associated with examination procedures involving rotation. induding those related to the use of an established vm testing protocol. have been documented. n Symons et al. auempted to quantify the internal forces on the vertebral anery during neck manipulation and VBI testing on five un-embalmed post.rigour cadavers. Strains sustained internally by the vertebral artery during neck range of motion testing. VBI screening and I M.A thrust techniques were similar and all were significantly less than the forces required to disrupt the vertebral arteJY mechanically. They condude that a single typical' M..A thrust technique to the neck is unlikely to cause mechanical disruption of the vertebral artery." An analysis of the published literature does not support the continuing use ofVBI screening tests or protocols in isolation as none of the rotation. extension or combination test movements havE' been shown to be valid or reliable prediaors of risk. Is it possible through physical examination or screening procedures to identify patients at risk of vertebrobasilar injury from cervical spine manipulation? Q.lTTent evidence would suggest that the answer is no.6,7(·15 A jury in an inquest inlo the death of a female chiropraaic patient follO\....ing a neck adjustment recommended thaI: 'based on evidence heard that practitioners ... be informed by their respective regul:noly bodies that provocative testing (prior to performing high neck manipulation) has not been demonstrated 10 be of benefil and should not be performed. Universities and Colleges teaching high neck manipulation should also be teaching their students that these: tests have nOI been demonstrated to be of benefit and should not be pecfonned~7'6 In the light of alTTent research findin~ what would ronstitute a suitable approach to the pre·manipulatiw assessment of the cervical spine?
Safety and
high~velocity low·amplitude
Pre-manipulative assessment If a significant number of symptoms, e.g. head pain, neck pain, di7.ziness,. nausea and \Cmiting. are suggestive ofvm, it \youid be advisable to proceed with caution when testing full range IllO\"(':ment of the cervical spine in patients who present with cervical and cervicothorack spinal syndromes. Such patients should be referred for the appropriate medical investigation to confinn or rule out the presence of VBI. 'Ille use of I rVIA thrust techniques in such patients would be contraindicated until such time as the cause of the symptoms has been dearly established. If a patient presents with a few .!>-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
31
Figure AS.3 Active rotation right.
Figure AS.4 Active rotation left.
HVLA thrust technIques - an osteopathic perspective
32
Figure A55 Active sidebending right
Figure A5.6 Active sidebending left
Figure A.S.7 Active flexion.
Figure A5.8 Active extension.
safety and high-velocity low-amplitude (HVLA) thrust techniques
<'\nd the <'\pplication of <'\ single I·IVIA thrust technique was of a simil<'\r m<'\gnitude.7) Practitioners using non-impulse <'\nd mobiliZ
UPPER CERVICAL INSTABILITY TIle bony anatomy of the atlanta-axial joint favours mobility rather than stability,111 with the atlanta-axial joint being more vttlnerable to subluxation than other segments of the celvical spine. 79 'Ille transverse and alar ligaments have an integral role in maintaining stability in the upper cervical spine. Instability of the upper cervical spine may compromise related vascular and neurological structures and in these circumstances would be <'\ contraindicatjon to the use of 1fVlA techniques. Instability must be differenti<'\ted from hypermobility.80
-9
5 _.'
------
Congenital Incompetence of the odontoid process • Sep<,\rate odontoid - 'os odontoideum' • Free: apical segment - 'ossiculum terminale' • Agenesis of odontoid base • Agenesis of apical segmem • Agenesis of odontoid process Incompetence of the transverse atlantalligament
• Idiopathic • Down's syndrome Inflammatory Incompetence of the odontoid process • Osteomyelitis Incompetence of the transverse atiantailigament
• • • • •
Bacterial infection Viral infection Granulomatous change Rheumatoid anhritis Anh.)'losing spondylitis
Neoplastic Incompetence of the odontoid process • Primary tumour of bone • Metastatic tumour of bone
Traumatic Incompetence of the odontoid process • Acute bony injury • Olfonic bony change Incompetence of the transverse atlantalligament
• Acute ligamentous damage associated \'I1th fTacture and trauma • Chronic ligamentous change
Symptoms and signs of upper cervical instability Symptomatic instability of the upper cervical spine is rare. Instability occurs most frequently in patients with rheumatoid
33
HVLA thrust techniques - an osteopathic perspective
arthritis and is also \\1£11 documented in Down's syndrome'l 8S and in patiems subsequent to relropharyngeal inflammatory processes.1l6 Ligamentous laxity following an infectiOUS process in the head or nttl< occurs most frequently in children, but it is a rare complication. Adult cases have also been reponed." Between 7% and 30% of all individuals with Down's syndrome show adantoaxial instability with most of the patients with radiographic evidence of instability being asymptomatic../f1 Upper cervical ligamentous injuries and instability can also result from tTauma- (Fig. A..5.9).lU The ability to recognize symptoms and signs that may indicate upper ce.rvka.1 instability is essentiaJ for safe practice. These symptoms are extremely variable and might include:1I • • • • • • • • • • • • •
Neck pain Limitation of neck movements Torticollis Neurological symptoms Ileadache Dizziness Buzzing in the ears Dysphagia Neurological signs Ilyper.rellexia Cait disturbances Spasticity Pareses
4. Nystagmus produced by active or passive neck movements
Currently the most reliable methcxl for detecting increased mO\'l':ment in the upper cervical spine is by the use of imaging techniques. 'Ine atlanto-denlal interval is the distance between the most anterior point of the dens of the axis and the back of the anterior arch of the atlas. "I1Us is measured on lateral radiographs of the cervical spine in flexion, neutral and extension positions. An adamo-dental interval >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
34
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
Figure A.S.l0 ·Stabilization.
Transverse atlantalligament stress test The Sharp-Purser test was designed to demonstrate aillerior instability at the atlanto-axial segment in patients with rheumaloid arthritis and ankylosing spondylilis.~·" A modif1ed Sharp-Purser test analyses the onset of symptoms and signs following head and neck flexion and the reduction of signs and symptoms accompanying posterior Lranslatioll of the occiput and atlas on the axis.
Figure A.S.11 ·Stabilizatk>n." Plane of force (operator).
Patient position Sitting with the he
Operator position Stflllding to the right of the p
Stress opplled The occiput and atlas are uanslated posteriorly by applying pressure on the forehead with your right arm (Fig. A5.1l).
Positive test A positive tell occurs when:
1. Onset of symptoms and signs with head and ncc.k flexion 2. Reduction of Symptoms
Alar ligament stress tests There are many teslS thai purpon to stress the alar ligaments and identify alar ligamem instability. A comprehensive testing regime might include the following three tests. I. Patient silting with the ncc.k in a neulral
position. Ensure that lhere is no sidebending of the head and neck. 'rne operator stabilizes the spinous process and \~ebral arch of the axis with thumb and index finger. Passively rotate the occiput and atlas to the right
35
HVLA thrust techniques - an osteopathic perspective
Figure A.S.13 ·Stabilizatkln.
Figure A.5.12 ·Stabilization. • .. Direction of 00dy movement.
36
(Fig. A.S.12). There should be: no more than 20-30· rotation. Repeat the procedure to the left. A positive test is characterized by the onset of symptoms or signs and/or a range of passive rotation greater than 30· at the Lipper cervical segmenlS. 2. Patient sitting with the neck in a neutml position. Ensure the head is straight and there is no rotation of the neck. 'l'he operator stabilizes the spinous process and venebral arch of the axis with thumb and index finger while placing the other hand on the patient's venex (Fig. A.S.13). Attempt to passively sidebend the head to the lert and then thl" right (Fig. A.S.14). Therl" should be: minimal moveml"nt in either diTl"'Ction. 'Illis test must be rl"peated with thl" neck in flexion (Fig. A.S.IS) and extension (Fig. A.S.16). A positive test is charaetrn7..ro by the onset of symptoms or signs and/or an increased ranS'" of passive sidebending in all positions of nrum!, flexion and extension.
Figure A.5.14 ·Stabilization. • .. Direction of body movement.
Figure A.S.15 *Stabilizatton.
Safety and high-velocity low-amplitude (HVLA) thrust techniques
__.r'o
Figure A.S.16 ·Stabilization. 3. Patient supine with the head and neck beyond the end of the couch and in a neutral position. Ensure the head is straight and there is no rot.ation of the ned<. The operator stabilizes the spinous process and vertebral arch of the axis with thumb and index finger while placing the other hand on the patient's vertex (Fig. A.S.I?). Both hands support the weight of the patient's head. Attempt to passively sidebend the head to the left and then the right. There should be minimal movement in either direction. This lese must be repeated with the neck in flexion (Fig. A.S.18) and extension (Pig. A.5.19). A positive test is characterized by the onset of symptoms or signs and/or an increased range of passive sidebending in all positions of neUiral, flexion and extension.
Figure A.5.18 ......-~•• Direction of body movement.
Figure A.S.19
Transverse atlanta I and alar ligament stress tests have been developed 011 the premise that patients at risk from manipulation to the upper cervical spine may be identified using physical examination techniques. There is a need for continuing research to investigate the reliability and validity of upper celVical instability tests in identifying those patients at risk.
Infonned consent Figure A.S.17
Informm consent may be defined as: 'the voluntary and Te\QCable agreement of a
37
HVLA thrust techniques - an osteopathic perspective
Infonncd consent
I
competent individual to participate in a therapeutic or research procedure, basro on an adequate understanding of its nature. purpose and implications'.n Informed consent comprises four elements, each of which should be present to a satisfactory degree if consent is to be valid (Fig. A.5.19)." When a health practitioner provides information to a patient it should be free of any controlling or coercive influences. The infonnation should also be presented in a relevant and meaningful manner that is both intellectually and emotionally comprehensible to the patient. 99
Information exchange The traditional meth<Xl of communication in the clinical encounter is verbal, but this form of communication can be enhanced by wriuen information. To be effective. the written information should be both legible and readable. 100 Videotaped material has also been shown to be effective in patient education p
lhc following have been identified as key elements for obtaining informed consent in clinical pradice;l1J
38
• Discussion of the clinical issue and the nature of the decision to be made • Discussion of the alternatives • Discussion of the benefits and risks of alternatives • Discussion of uncenainties associated with the decision
• Assessment of the patient's understanding • Asking the patient to expr£ss their preference. A suggested checklist prior to applying a HVLA thrust technique is outlined in Box A.5.2. Box A-'i.2 Infanned consent - practitioner checklist • Discuss the dlnlcal findings • Discuss manipulation and why this treatment is recommended • Demonstrate manipulation treatment using videotaped material • Discuss alternative treatment approaches • Discuss the benefits and risks of manipulation and treatment altematives • Discuss the uncertainties that arise from the conflicting evidence as to the benefits and risks of manipulation and the treatment alternatives • Assess the patient's understanding of the information provided • Discuss the patient's preference for treatment • Ask the patient to sign a consent form
CONCLUSION It is often stated that manipulation of the spine is a therapeutic technique associated wtth a high level of risk. The potential benefits100l,10!> for the patient must be weighed against the risks associated with manipulation of the cervical spine. There are currently no high quality data to enable accurate estimation of the risk of stroke following cervical manipulation
i"
Safety and high-velocity low-amplitude (HVLA) thrust techniques
•
or establish causation. lOll While there is a temporal relationship it may not be a causal relationship. If there is a potential for serious sequelae, the risk appears to be extremely 10W.lm,10ll
The evidence review accompanying the national c1inkal guidelines on acute and recurrent low back pain indicates that the risks of manipulation for low back pain are very low provided patients are assessed and selected for treatment by trained practitioners.lOR.IIO In a review of the literature relating to the risk of neurovascular compromise complicating cervical spine manipulation Rivett concluded that an analysis of the risks and benefits supports the continued judidal use of CE!Mcal spine manipulation by a prudent and appropriately trained practitioner. 'W An extensive review of the literature indicates that the key to safety is dependent upon appropriate training, a thorough patient history and physical assessment prior to the applkation of any manipulative procedure, Appropriate training in the use of manipulative thrust techniques and subsequent skill refinement through regular practice are key e~ments for safe practice and professional competence.'"
References
2
3
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5
Carey 1'. II rl'pon on the occurren<:e of cerebral vascul:lr acridel1!s in chiropractic practice. J Can Chiropractic As.wc 1993; 37: 104-106. Ollbbs V, Laureni W. II risk as.'iE'S.'lment of cervical manipulation vs NSIIIDs for the treatment of neck pain. J Manipulalive Physiot '111l'r 1995; 18:530-536. Do.'Or.1k J. Orctli n I low dangerous is manipulation to the arvic.11 spine~ I Man Me
7
• 9
'0
II
12
13
14
15
•• 17
"
19
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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, <:arlini We. McConnidc CF. AIbeB CW Neurologic: complicalions following chiropractic manipulalion: a SUf\'q' of California neurologiw. Nalrology 1995; 45:1213-1215. !'aliin ). Complications in manual medicine: a review of the literature. J Man Mcd 1991; 6:89--92. Rn.-ett DA.. Milburn PA. 1\ prospl.'Cth-e study of cervKaI spine manipulalioo. J M.an Mcd 1996; 4:166--170. Rk~l D, Reid O. Risk of stroke for cervical 5Pine manipulalion in New zeaJand. N Z J PhysiolheJ 1998; 26:14-17. Coulter ID. Ilurwiu £1.. Adams AH. et aJ. 1ne Approprialeness of Manipulation and Mobilil'.ation of the Cervical Spine. Santa Monica. CA.: RAND; 1996. Reid 0, I ling W. AlP r'Onlm: l>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.
HVLA thrust techniques - an osteopathic perspective
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
21
22
23
24
25
26 27
28
29
30
31
32
33
34
40
35 36
37
38
39
40
41
42 43
44
45
46 47
48
49
50
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, Mol
Safety and high-velocity low-amplitude (HVLA) thrust techniques
51 7..aina C. ennt It lohnson Co Dansie B, TaylOf I, SpyropoloUli P. The effect of cervical rOlalion on blood flO\\I in the contralateral \mebral artery. Man ·nler 2003; 8(2}; 103-109.
"
Arnold C. Boura.-.sa It l.;tngeT 1; Stoneham G. Doppler studies eYalualing Ihe effed of a ph)'SiOlI therap)' screening protocol on \utebral artery blood flow. Man 'fher 2004; 9( 1):13-21.
53 TlliSington-Talklw Vi, Bammer I-I. Syndrome of vertebral anery rompra.liion. Neurology 1957; 7:331-340.
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Toole I. Tucker S. Influence of head position on cerebral drcuJalion. Arch Neural 1960; 2:616-623. ~ructure of the cuvical spine with referma 10 pathology of manipuialKm compliGltions. 1 ~ian Moo 1991; 6:93-101.
55 Schmin II. Anatomical
56 Ste\"ft15 A. Puooional Doppler sonography of the vertebral anery and some ~iderations aboul manual techniques.. I Man Moo 1991; 6:102-105. 57 liaynes M. Doppler slwies comparing the effects of cervical rotation and laternl Ile.xion on \U1ebral artery blood flow. J Manipulath-e I'hystol'I'her 1996; 19;378-384. 58 Mitchell I. Changes ill \-enebral artery blood flow following normal uxation of the cervkaI spine. I Manipulative Ph)'Siol Ther 2003; 26(6);347-351. 5. Ucht r. Chrls1ensen II, Ilojgaard p. IloilWldCarlsen P. '1 ril)lex ullrawund of \'encbral anery flow during cervical rolalion. I ManipuJalh-e Physiol "Iller 1'.1'.18; 21:27-31.
GO Ucht 1', Chrislenscn II. I loilund-C..arlscn 1'. Vertebrnl anety volume Ilow in human beings. 1Manipulatiw Physiol Ther 1999; 22:363-367. 61 Ueht P, Chlhtcnsell II, Hoilund-C'.arlsen P. Is there a role for pre-manipulath'e 1l.1ltinS before cervical milnipulalion. I Manipulath'e Physiol ·Iher 2000; 23:175-179.
6'
I laynetl M, Milne N. Color duplex sonographic findings in human \~nebral ancries during c:ervkal rotation. I Qin Ultrasound 2000: 29:14-24.
63 Ilaynes M. Cala I, Melsom 1\ Malitaglia I: Milne N, McCeac:hie J. Venebral aneries and cervical TOlation: Modding and magnetic re!'iOnance angiography studies. J Ma.nipulam'E': I'h)'Sio1 "I11er 2002; 25(6):370-383.
r. Stick r. Lord R. Failure of clinical leslS to predk:t cercbr31 i5chaernia before neck ma.nipulation. 1ManipuJath-e Ph)-siol The.1989; 12:304-307.
64 Bolton
65 lhielll, Wallace K. Donal!. Yons,fling K. Flfect of various head and n«:k po5ilions on vertebral artery flow Oin IUotnechanlcs 1994; 9;105-110. 66 Cote p. Kreiu. 8. Ca5sKl)' I. Thid II. '11M- valkiil)' of the extension-rolation lelil as a dinical !iOeening procedure before neck manipulation: A secondary anal)'Sis. 1 Manipulath't" Physiol 'I"her 1996; 19(3);159-164. 67 Cole r. Kreiu. R. Cusidy J, 'Ibiel H. The.- validity of the alttWon·rocation tl'$l as a dinkal !iOeening procedure before neck manipulation: secondaJ:y anal)'Sis. J ManipulaU\'t" rh)'Sioi Ther 1996: 19:159-164. 68 Rn-ro 0, Milburn r. O1apple C. Nega.U\'t" premanipulali\'t" \'ertebral artery lesting dapite complete occlusion: a CISIe of faJse negaU\'ity. ManThe.- 199& 3(2):102-107. 6' ucht P. Ouistensm II. Iloilund-Cu-l5eJl P. Carotid anery blood flow during prernanipulall\'t" Il'$ling. J ManipulatiYe Ph~ol Ther 2002; 25(9);568-572. 7U \\'euiIW3y M. Stratford P. SymOt\$ 8. l>abenf'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'is by computerized tomography. J Bolle)t Surg (American Volume) 1984; 66:708-714. 93 Dickman C, Greene K. Sonntag V. Injuries involving the transverse atlantalligamcnt:
aassification and treatment guidelines based upon experience wi!h 39 injuria Neurosurgery 1996; 38(1):44-50.
9. Sharp I, Purser D. Spontaneous atlantoaxial dislocation in ank}iosing spond}1itis and rheumaLOid arthritis. Ann Rheum Dis 1%1; 20:47-77.
95 Uitvlught G, Indenbaum S. Clinical as...essment of atlantoaxial instability using lhe SharpPurser test. Arlhritis Rheum 1988; 31 (7):370-374. 96 Meadows I. 'Ine Sharp-Purser Test A useful
clinical tool or an exercise in futility and risk? J Man Manipulalive ·Iner 199B; 6(2):97-100.
97 Sim I. InfOfmed consent: Ethical implicatiOflS for ph)'Siotherapy. Physiotherapy 1986; 72:584.
98 Sim I. Informed consent and manual therapy. f"tm 1ber 1996; 2: 104-106.
99 Delany C. Informed consent: Broadening the fOCl£ Austl Physiother 2003; 49:t59-161. 100 Alben 1; Chadwick S. How readable are practice leaflets. BMJ 1992; 305(6864): 1266-1268.
'01 Gagliano M. A literature revkw on the efficacy of video in patient education. J Med F.duc 1988; 63(10):785-792.
102 Delany C. CcrviClI manipulatiOn - How might informed consent be obtained before treatment? I Law Med 2002; 10(2):174-186.
103 Braddock C. Fihn S. llvinson W, lonsen A. Perlman R Ilow dooms and patients discuss routine dinical decisions. Informed derision making in the out-patient setting. I Cen Intern Med 1997; 12(6):339-345. 104 Spitzer W, Skovron M, salmi L Cassidy J, Duraneeau I. Suissa S, Zeiss E. Monograph of the Quebec task force on whiplash..,associated disorders: redefining whiplash and its managemenL Spine 1995; 20:85. 105 Hurwitz F.. Aker 1', Adams A, Meeker W, Shekelle P. Manipulation and mobilization of the cerviGiI spine: A systematic review of the literature. Spine 1996; 21(151:1746-1760.
10. Brern A Manipulation of the r«k and stroke: time for mQfe rigorous 2002; 176:364-365.
~'idence.
Med I Amit
107 Ri\'ett D. Neurovascular compromise: complicating cervical spine manipulation: What is the risk? I Man ManipulatnY 'Iller 1995; 3(4):144-151. 108 Clubb D. CervlcaJ manipulation and vertebral anery injUl)': A literature review. J Man Manipulative 'Iller 2002; lOt 1):11-16. 109 Royal College of General Practitioners. Clinical guidclinC5 on anlte and fecurreRl low back
Safety and high-velocity low-amplitude (HVLAI thrust techniques
pain. London: Iw)'aJ Colltge of ~neral I'raclilioners; 1996: 01. 2. 110 Waddell C. The Back Pain Re\'olution. Edinburgh. llK: Churchill Uvings1one; 1998: Ch.16. III Vide D, f\1CKay C. Zengcrle C. The safety of manipulali\'e UeaLmttll:: ~cw of the
literal urI' from 1925 to 1993.1 Am Qsteop;lLh AMoc 1996; 96(2}·113-IIS.
112 Adams Ie. Ilamblen DI_ Outline of Onhopaedics. Edinburgh. UK: Churchill (jvin&\lone; 2001: Ch 9
43
Rationale for the use of highvelocity low-amplitude (HVLA) thrust techniques
'liglH,Ielocity 1000.,r-amplitude (HVlA) thrust techniques are \"ide1y used in patient caTe with increasing evidence of !.heir effectiveness. 1100\'e\'l?:T. the use of HVLA thrust techniques musllx considered within
the context of a compre:~ive patient management plan. which may include the application of other osteopathic: manipulative tech.niques and adjunctiVf' therapies. Various authors have described specific indications for the use: of HVlA thrust techniques (Box A.G.I).
80x A.6.1 SpeclfK Indications for HVtA techniques as listed by various authors
• • • • • • • • • • • • •
OSTEOPATHIC TREATMENT MODELS Scientific validation for the use of manual and manipulative approaches. including IIVlA techniques. is limited. Consequently. praetitionf:lS must rely upon theoretical and clinical models to justify the: use: of I IVlA thrust techniques in clinical practice:. Osteopaths use five LIe:atment and clinical reasoning models": 1. Biome:chanical 2. Neurological a. autonomic nervous system b. pain c. neuroendocrine 3. Respiratory/circulatory 4. Bioene:rgy
5. Psychobe:havioural.
Hypomobiliti~ H
Motion restriction Joint fixalion6.7 Acute joint locking J ,II,9 Motion loss with somatic dysfunction '0." Somatic dysfunction'),,'· Restore bony alignmenr U Meniscoid entrapment'.14.7.16 l7 Adhesions Displaced disc fragment lll Pain modulation ' .5.9.'9.X1 Reflex relaxation of muscles1.u,-n Reprogramming of the central nervous system lJ • Release of endorphins:M
Biomechanical (postural/strudural) This model is based upon the concept that mechanical and slmctural dysfunaion can r€Sult from single incidences of trauma or from microlfauma occurring over time and as a result of poslUral imbalance or occupational and environmental stresses. Cumulative microtrauma can lead to a breakdm...n of the body's nonnal compmsatory mechanisms with resultant de-.Tlopment of dysfunaion and pain. nu~ biomechanical model requires the practitioner to restore maximum function
to the neuromuscu)oskeJetal $)'Stem wilh enhanarnel1l of the body's ability to
4S
I
_ _ _ _ _1
HVLA thrust techniques - an osteopathic perspective
compensate for external mechanical stresses and any primary or secondary postural imbalance. Therapy is directed to'vards restoring as near nonnal motion and/or funaion to joints; ligaments; muscles and fascia. The aim is to regain optimal fWIction within the musculoskeletal system.
Neurological ,11is model is based upon the concept that neural mechanisms may be influenced by the ll'>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
HVLA thrust techniques - an osteopathic perspective
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 mobiliZ
of RCfs published since 1995, relating to a range of complementary therapies for nonspecific back pain, concluded that spinal manipulation has real but modest benefiL<; for acute and chronic low back pain and that the risks of lumbar manipulation are low,SoI Willem et al. noted that all national guidelines on the management of low back pain included the use of spinal manipulation. However, the data upon which national recommendations are based has been interpreted differently leading to conflicting guidelines between COWllries for the use of spi.nal manipulation in the management of both acute and chronic back pain. 56 A !>ystematic review of the efficacy of spinal manipulation for chronic headache concluded that spinal manipulative therapy has an effect comparable to commonly prescribed prophylactic tension headache and migraine medications. 63 Waddell, on reviewing the evidence in relation to acute Im'l back pain and disability, commented that there are numerous symptomatic treatment options other than manipulation but there is little scientific evidence that they are effective and states that the evidence supports the use of manipulation as a treatment option for symptomatic relief. 64 'Ine United Kingdom Back Pain Exercise and Manipulation (UK BEAM) randomised trial concluded thaL spinal manipulation over a 12-week period produced statistically significant benefits relative to best care in general practice at both 3 and 12 months. tiS Manual therapy approaches, including HVLA thrust techniques, have been negatively impaded by poorly designed and implemented research studies. Studies have been compromised because patients with spinal pain are not a homogeneous group, which makes comparison of like with like extremely difficult. Practitioners of manipulative therapy are also not a homogeneous group having differing levels of training and skill in the application of manipulative techniques. Future research will need LO use classification systems that allow accurate identification of the sub-
Rationale for the use of high-velocity low-amplitude (HVLA) thrust techniques
groups of spinal pain patients that might benefit from manipulative therapy.
CLINICAL DECISION MAKING IU our pre>ent state of kno\,,Iledge. what
model should guide our clinical decision making to incorporate IIVlA thrust techniques within a treatment regiTT'lE'? All hea.lthcare practitioners utilize a clinical decision-making process prior to the application of a therapeutic intelWJ1tion, e_g. 11VlA thrust technique (Box A6.2). Do. A.6.2 Clinical decision making
• Exclude contraindications (red flags) • Determine influence of yellow flags • Identify presence of a treatable lesion somatic dysfunction • Decide upon appropriate intervention
Exclude contraindications (red flags) Although the majority of patients who present with spinal pain wlll not have serious pathology, it is imperative thaI practitioners maintain vigilance in excluding red flag conditions (see col1lraindicalions. page 27). ·rne following may indicall:~ the presence of red flags: • Patient younger than 20 or older than 50 with first onset of spinal pain • Pain following trauma • Constant and worsening pain • Past or present history of malignancy • Long-term corticosteroid use • Ceneral malaise • Night sweats/pyrexia • Weight loss • Neurological symptoms and signs ·,ne identification of red nags requires further investigation and specialist referral.
Detennine influence of yellow flags Yellow flags are ps}uosodal risk faaors associated with d'lTonic pain or disability.
'nley are subjroi\'e and include negative coping Str'3tegies. fear avoidance behaviour, anxiety, depression and distress. If yellO\" nags are identified treatment should aim to reduce dependency on medication and Othe.r passive fonns of treatmenl, including manipulative therapy, and e.ncourage the deve.lopment of self-manageme.nt skills. 'lne identification of yellow nag; requires a shih in the focus of care.
Identify the presence of a treatable lesion - somatic dysfunction A number of treatment models use elements ofT~A·R·T as the basis for the selection of manipulative techniques including 11\fLA. thrust techniques. U.ll.14,Z1.6Ml
Box A.6.3 Diagnosis of somatic dysfunction
• S relates to symptom reproduction • T relates to tissue tendemess • A relates to asymmetry • R relates to range of motion • T relates to tissue texture changes
Decide upon appropriate intervention Broadly speaking. manipulati...e techniques will be selected based upon one or more of the following: • Evidence • Convention • Training and exPffience
49
-
HVLA thrust techniques - an osteopathic perspective
•
Within manual medicine, there is an ongoing debate about the specific effects of individual manipulative teclmiques. including HVlA thrust techniques. While there is ~rch evidence demonstrating the effects of HVLA thrust techniques in increasing range of motion, JI-M altering pain pe.rception)4·68 and altering autonomic ~fJex activity,65I this research does not infonn practitioners of when to apply any given manipulative technique including HVLA. thrust techniques. In clinical praclice, lhe trealment of spinal pain and dysfunction commonly combines several interventions, e.g. maJlipulation, mobili7..3lion and exerdse with evidence supporting a multi-modal approach. lIl- n '111ere is currently no evidence to guide the dinician with regard to lhe following aspects of manipulative treatment interventions: I. Direction of thrust 2. lhe combination of manipuJative
techniques that will be most effective 3. "l'he most effective sequencing of technique within a multi-modal approach In the absence of research evidence. the decision regarding these aspects of treaunent GIn only be made upon the basis
of convention and practitioner uaining and experience.
CONCLUSION
50
Practitioners rely upon theoretical and clinical models to justify the use of HVlA thrust techniques in dinical practice. Best practice also requires incorporating the results from clinical and epidemiological research with the individual clinical experience and expertise of the practitioner while taking account of patient preferences. Osteopaths have used HVl..A thrust techniques for the treatment of somatic. dysfunction for many years. Clinical decision making retating to the use of these
techniques requires the Ktentification and exdusKln of red Rags, recognition of the impact of yellow flags upon patient presentation and prognosis and the KtentiflCation of a treatable lesion. There is conflicting evidence for the use of tM.A thrust techniques in clinical practice, with no dear direction as to which manipulative approach would be effective. As a consequence, decisions relating to direction of thrust, which combination of manipulative techniques and the sequencing of technique in a multi-modal approach will continue to be made upon the basis of convention and the individual practitioner's training and experience.
References
c:
Kenna Murtagh J. Back Pain and Spinal Manipulation, 200 Ed1\. Oxford: Bunerworth· Heirwmann; 1989. 2 Bruc:knes- P, Khan K. OinKaJ Spons Medidne. t'ew York. NY: M.cCnw-l-lill; 1994. 3 l.t:wit K. Manipulathoe 'f1'M!npy in Rehabililation of the I.ocomotor S)'$tem. 2nd Oxford: Buuerworth-Heinnnann; 1991. <1 t.laigne R Diagnosis and Treatment of I"'Mn of Venebral Origin. Baltimore. MD: Williams " Wilkins; 1996. 5 Brodeur R The audible release iWOdated with joinl manipulation. J Manipulall\Y l'hysiol Ther 1995; 18(3):155-164. 6 F..der M, Tilscher H. Chiropr.tClk Thempy. Diagnosis and Treatmelll. Gaithersburg. MD: Aspen; 1990. 7 Sammut F.. Searle-Barnes I~ Osteopathic Diagnosis. O..ehenham: Stanley 'nlOffit':!l; 1998. 8 Gainsbul)' I. High-\oelocity thru!il and pathophysiology of segmental dysfunction. In; Glasgow E,. Twomey I~ Sallie E,. "1t')'flhans A. ldc:zak R. eds. Asp«:ls of Mauipulati\Y Therapy. 2nd edu. Melbourne; Churchill Livingstone; 1985:0\. 13. 9 Zusman t..i.. What does manipulation dol The net'd for basic research. In: Boyting J. P:tla.sWl;il M. eds. GrinY'S Modem Manual Therapy, 2nd edn. New York Chwchill Uving.stone; 1994;01.47. 10 Kuchen ,v, Kuchera M. Osteopathic Princip&es in l'r.Ktke. Kirksville. M(); KCOM; 1992.
ron.
Rationale for the use of high-velocity low-amplitude (HVlA) thrust techniques
Kappler R. lones I. 'nnust (higll-\~locityl low-amplitude) techniques. In; "'
-'he
Greenman PE. Principles of Manual Medicine. 3rd edn. Philadelphia. PA: lippincott Williams & \'lilkins; 2003. IS Nyberg R. Basmajian J. Rationale for the: use: of spinal manipulation. In: Basmajian " Nyberg R. eds.. Rational Manual ·Ille:rnpies. Baltimore, MD: \'/iJliams & \'/iUdns; 1993:01, 17, 16 Bogduk N, Twomey L Cinical Anatomy of the Lumbar Spine 2nd txl.n. Melbourne: Churchill Uvingslone; 1991.
27
28 Wal50n r. Mollan R. Cinerddiography of a cracking joint. Ilr J Radiol 1990: 63:145-147.
29
Mierau 0, Cassidy J, I\o\ven V, Dupuis I~ Noftall t.lanipulation and mobilization of lhe third metacarpophala~ljoinr. a quantitarn,oe radklgraphic and range of motion study. Man Moo 1988; 3:135-140.
30
Darner G, Gregerson 0, Knudsen I, Hubbard B, Usw L. GmlU I. The effects of side-jX)Stwe positioning and spinal adjusting on the': lumbar Z joints.. Spine 2002; 27(22):2459-2466.
31
Howe DH, Newcombe RG, Wade Mr. Manipulation of the cervical spine: a pilOl study. I R Coil Ge:n PTact 1983; 33(254):574-579.
J2
Nan.sel D, Cremata E, Carlson I, Sl'lazak M. Effect of unilateral spinal adjusunenlS on goniometricaJlyassessed tttVical Iateral-f1aion e:nd-r". asymmetries in otherwi~ asymptomalic sub;eas.. J Manipulali\'E' P~iol Ther 1989; 12(6);419-427.
33
Nansel 0, l'eneff A. Carlson I, Szlazak M. TIme course ronsider.uions for the effects of unilateral lower cervical adjustments wilh !\'SpecliO the amelioralion of cervkal lateralflexion passi~ end-range asymmeuy. I Manipulatiw Physiol Ther 1990; 13(6):297-304.
3.
Cassidy JD, Quon JA. l.afrance (J, Yong-Ying K The erfl'Cl of manipulation on pain and range of mOlion in the cervical spine: a pilot study. J Manipulaliw I'hysiol'l1ler 1992; 15(8):495-500,
35
Nansel D, Peneff A. Quitoriano D, Effecti\'eness of upper \'er'5US lower cervical adjustments with !\'Spec! to the ameliOrdlion of passive rolalional \~rsu.s latel
36
Nilsson N, Chrislenson JlW, Hilnrigson J. Lasting changes in passive range of motion after spinal mllnipuli!tion: a rnndomised, blind controlled trial. J Manipulath"l'. I'hysiol Ther 1996; 19(3):165-168,
14
17
18
19
20
21 22 23
2'
25
26
Sloddard A. Manual of Osteopathic Practice. London: Hutchinson; 1969, Cyriax I, 'fextbook of Orthopaedic Medicine. 6th OOn. I.ondon; Baillibe Tindall; 1975:\U1. I. 'Ierrett A. Vernon H. Manipulatlorl and pain tolerance. A cOfluolled slUdy on the effect of spinal manipulation on paraspinal CUlaIleOUS pain tolerance levels. Am I Ptlys Med 1984; 63:217-225. Hoehler r, Tobis j, Buerger A. Spinal manipulation for 10\"" back pain. 1Am Moo Assoc 1981; 245:1835-1838. Kucher" W, Kuchera M. Osleopathic Principles in Prdetice, OH: Grey<.len Press; 1994:292. Neumann I r. Introduction to Manual Medicine. Berlin: Springer; 1989, Fisk J. A cOlllroliOO tn;l! of manipulation in a selected sroup of (XllienlS wilh low back pain favouring one side. N Z Med J 1979; 90:288-291. Vernon H, Dharrni I, Howk')' T, Annett R. Spinal manipuilltion and betil-endorphin: a controlled study of the effect of iI spinal manipulation on plasma beta-endorphin lE"A'ls in normal males. J Manipulali\'e Physiol Ther 1986; 9:1l5-123. ROSIon J, Haines R. er"cking in the metarnrpophalangeal joint. J Anat 1947; 81:165-173. UllS\vonh A. Dawson D, Wright V, Cracking joints: a bioengineering study of ca\~tation in the metacarpophalangeal joinl. Ann Rhewn Dis 1972; 30:348-358.
Meal G, Scott R. "ualysis of the join! crack by simultaneous recording of sound and tension. ManipulativE' Physiol 'nlel" 1986; 9: 189-195,
I,
37 Surkitt D, Gibbons p, Mcl.o1ughlin I'. High velocity low amplilUde milnipulatioll ofthE' allanto-axial joint: Effect on atlanto-axial and cervical spine rotation asyml1lelJ}' in ilsymplomatic subjects. , Osteopath Moo 2000; 3(1):13-19. 38
r. Mclaughlin I'. lhe amel.ioration of atlanlo-axial asynlmelry using
aeme:n1S 8. Cibbons
51
I
HVLA thrust techniques - an osteopathic perspective
high \It':locity )0\'" amplilude manipulation: Is Ihe direction of thrusl importanl1 J Osteopalh Moo 2001; 4(1):8-14. 39
Slodolny J, Chmielewski H. Manualthef"clpy in the treatment ofpatiems with cervical migf",tine. Man Med 1989; 4:49-51.
40
Nordemar It 'l1lomer C. TrealJl'M.'nt of acu!t: «:rvical pain: a comparalhl~ group sludy. Pain 1981; 10:93-101.
41
I-lynn'l; r.,.itt J, Wainl'M.'1' It Whitman J. The audible pop is noc nettSSary !Of .successful spinal high-\'docity thrust manipulation in individuals with 10\'" back pain, Arch l'hys t.1ed Rehabil2003; 84:1057-1060. RqgaB J, Pollard H_ Analysis of Z)"giIpophyseal )oim cracking during chiropractic manipulation. J Manipulali\~ Physiol'£ber 1995; 18(2):65-71Beffa R. Malhr:ws R. Does lhe adjustmenl Gl\'itate the tatgt'ted ;oina An imatigalion into the iocaIion o( C'.Mtaooo sounds. J Manipublh'e 1"hysioI'£ber 2004; 27(2):e2.
42
43
44
Sweuy It Swezey S. The consequences of habitual knllCkle cr.Kking.. West J Moo 1975; 122:377-379.
Castellal'lOli J, AWrod D. Effect of habitual knuckle crncking 00 hand (unction. Ann Rheum Dis 1990; 49:308-309. 4G Sacketl D. Richardson W; Rosenbetg W, Haynes R. Evidena Based Medkine. How to l"rania & 'leach r.BM. New York Olurchill Ij\";'ngstone-; 1997. 47 Pedersen'J: C'Juud C. Gottsche P, Maum P, Wille-Jorgensen P. W1uII is evidena--based medicine? lIgeskr l..aeg 2001; 163(27): 3769-3772.
45
4.
49
50
52
Bronfon G. Hass M, Evans It Bouler L Effieaty o( spinal manipulation and mobilization for low back lind nttk pain: A SYSlemlltic review and best evidence synthesis. Spine 2004; 4(3):335-356. Koes B, Assendelft W, Ileijden G van det BoUler L. Spinal manipulation (or low back pilin. An updated ~)'Stematic review of randomi¥.ed dinicaltrials. Spine 1996; 21(24):2860-2871. van Thlder M Koes B, Bouter L. Consef\'ati\'e Ireatment of aCUle and chronic nonspecific 10\'" back pain. A S)'SIematic revif'W o( randomized controlled lrials of the mO!it common inteJ\'enlions. Spine 1997; 22( 18):2128-21 56.
51
Bronfort C. Spinal manipulation: cunttll Slale of research and its indications. Neurol Oin 1999; 17(1):91-111.
52
r't'JTei.ra M, f-enei.ra I~ Lalimer ), Herbert It Maher C. Does spinal manipulali\'e t1-.erap)'
help people with chronic 10\'" back pain1 Ausc , PhysiotlM.'r 2002; 48(4):277-284. 53
1\>rIgeIII, t.taher C. Ref.shauge K Sy.sIenUttic review of conM'rvati~ inlef\'entions for Mlbacute low bad: pain, Oin Rehabil 2002; 16(8):811-820.
54
Olerkin D, Sherman K. Deyo It. Shekelle I~ A review of Ihe evidena for the effecti\'ftles5, 5ilfely. and 0051 of ilCUpunctun'.. massage Iherapy. and spinal manipulalioo for back pain. Ann Intern Med 2003; 138(11):898-906,
55
I,"rreira M. Prmira I~ Lalimer J. Herben It Maher C. Efficacy of spinal manipulati\'e t1M.'rclP)' (or low back pain ofless Ihan lhree monlhs' duration. I Manipulath.'e l'hysiol Ther 2003; 26(9):593-601.
,.
Willern J, AumdeUt \~ Morton S. Yu I!., Suuorp M. St~lIe P. Spinal manipulau\'e therapy for low back pain. A meta-anal}'5is of dTeoi\'t'OeU relath't: to Olher therapies.. Ann Intern Med 2003; 138( II ):871-881.
57 AssendeUt W, Mortoo S. Yu F~ Sunorp M. Shekelk P. Spinal manipubli\'e lherapy for low back pain, Cochrane Database Sy.sI Rev 2004; 1:<:0000447, 5.
Mior S. Manipulalion and mobili7.ation in the lreatment of chronic pain. Oin 1 Pain 2001; 17(4);570-876,
59
Bron(on Co Haas t-I, Evans R. Bouler L F..fficacy ofspinal manipulalion and mobilization for low back pain and neck pain: a S)'SIemalic review and !)t'$1 evidence sylllhesis. Spine 2004: 4(3):335-356.
60 Gross A, HO\Iing I, Haines'l: Goldsmith C. Kay T, AXer I~ Bronfon G. A Cochmne review of manipulalion and mobili"'.iuion for mechanical neck disorders. Spine 2004; 29( 14):1541-1548. 61
GI"06S A. K.'l)' T. I londras M, el ill. M.mual therapy (or mechaniC'cll neck disorders: a li)'Sl.ematic review Manual 'n-.erapy. 2002; 7(3):131-149.
G2
Hurwitz E. Aker I~ Adams A. Meeker W. Shekelle P. Manipulalion and mobilization o( Ihe cervical spine. A S)'lilematic review of the Iitercllure. Spine 1996; 21 (15): 1746-1759.
63 Bronfon C, Assendelfl \'i, F.v,tns It l-faas M, Bollier 1_ Effic-clC)' of spinal manipulalion for chrooic headache: a syslemalic review. J Manipulali\'e I'hysKll "Cher 2001; 24(7):457-66. 64
Waddell G. lbe Back I~in Re\'Qlulion, 2nd 000. Edinburgh. UK: OlurchiIJ U'l1ngslone; 2004.
65
UK BfA\t Trial 'learn. United Kingdom Back Jl'ain Exercise and Manipulation (UK BEA.M) randomised lriaJ: l-.ffecth'Ult'SS of physical treatments (or back pain in primal)' care. Brit Med J 2004; 329(7479):1377.
Rationale for the use of high-velocity low-amplitude (HVLA) thrust techniques
66
67
DiGiovanna El. Schiowitz S. An Osteopathic Approach to Di
70
lull G. Trott I~ POller H, et at A randomized colllrolled lIial of exercise and manipulaliw therapy for cervicogenic headache. Spine 1002; 17( 17}:1835-1843.
Mitchell F. The Muscle Energy Manual. EaSt
71
Gross A, Kay 1; Kennroy C. et al. ainiGl.I practice guideline on the use of manipulation or mobilization in Ihe treatment of adults with mechanKaI neck disorders. Man lher 2002; 7(4}:193-2OS.
72
Grunnesjo M, Bogekldl S, Svardsudd K. Blomberg S. A randomized controlled dinK:.al trial ofstay-aetiw care \'oeI'SUS manual thetapy in addition 10 slay-aeth-e care: f-unctional variables and pain, I Manipulalhoe Physiol Ther 2004; 27(7):431-441.
Lansing. MI: Ml:.T; 1995. 68 Vernon H, Aker r. Burns S. Viljakaanen S, Shon L Pressure pain threshold evaluation of the effect of spinal manipulation in the treatment of chronic neck pain: A pilot study. J Manipuhlli\oe Ptlysiol'l1ler 1990; 13( 1):285-289. 69
Gibbons I', Gosling C. Holme; M. 11le shon term effects of cervical manipulation on edge light pupil cycle time: a pilot stud)'. I l>-tanipulatnoe I"tlysiolTher 2000; 23(7}:46S-469,
S3
Validation of clinical practice by research
Responsibility for the scientific credence thai can be afforded osloopathic medicine rests largely within its own disc:ipline. "Ille osteopathic profession is obligated to question the value of teaching unsubstantiated doctrines, except \~thin their historical perspecth'e. Students and the profession should be encouragro 10 engage in active research. Research is nerned both 10 establish the clinical efficacy of osteopathic therapeutic inteT'\~tion and to elaborate the biological basis and physiological mechanisms that lU1derlie the osteopathic principles of practice. Patient satisfaction is also an important measure of the quality of care. I If there is to be a commitment to researclt. where should the osteopathic profession focus ils research funds and activities?
WHY UNDERTAKE RESEARCH? Civen the tinallcial constraints placed upon health expenditure and Ihe increasing pressure upon thjrd-pany payers to rationali7£ and limit costs,. one can expect that health professionals will be required to demonstrate efficacy of treaunenL It will no longer be acceptable to claim that therapy is beneficial solely because individual patients report improvement after treatment. The challenge is to demonstrate that symptom improvement is a direct outcome of specific intervention rather than nalural Il'CO\'ff}' and that this inlervemion is moll' effecti\T and cost-effective. than marketplace competitors. Bogdulr argues that research is
not an indulgence or academics. but constitutes the basis of best prncLicf' and quaJityassurance Various osteopathic authors ha,,~ acknO\\'ledged the need for research and the importance of rominwng to search for ne\v
knowledge. J-S ,11e need for research should be indisputable. but where shouJd the osteopathic profession's resources be concentrated? Bogduk and Mercer" express a view thai it is more valuable to demOl1su
ss
I
HVLA thrust techniques - an osteopathic perspective
.
promoted without evidence of their effectiveness.'
WHERE SHOULD RESEARCH BE FOCUSED? Research effort should be directed towards designing and implementing effective therapeutic mals that could demonstrate the efficacy or othenvise of therapeutic interventions.6 Validation of osteopathic practice b}' outcome studies could be a way forward. Management of patients utilizing outcome measures has the benefit of establishing baselines. documenting progress and assisting in quality assurance. II Osteopathic practice is diverse. Individual practitioners. depending upon their style of practice and interests, treat a wide variety of different complaints. Osteopaths see and treat a significant number of patients presenting with spinal pain. n. l ' Outcome studies on patients presenting with spinal pain and disability are an obvious area for osteopathk research. Despite this faa. there is a paucity of osteopathic outcome studies. Various authors"'),'· highlight the point that there are significant difficulties associated with clinical research in the osteopathic area StoddardI' emphasizes that clinical research in osteopath)' is hampered by the complexity and diversity of the presenting problems and the difficulties associated with patient allocation to syndrome groups that vary constantly over lime. Ilowevcr, similar problems associated with clinical research exist for other disciplines practising manual therapies. Despite the difficulties, other disciplines are panicipating in an increasing number of research projects.
PATIENT CLASSIFICATION
56
A possible spearum of research designs would include com-entional and unconventional group designs. ethnomethodological designs and single case studies. IS Each research method has
advantages and limitations, with varying applicability. differing ranges of validity and ethical conSLraints and will generate differing sets of data Which approach would be most useful for outcome sttKiH's in osteopathic medicine? The nature of the research question should guide the selection of research design. One of the major problems associated wilh clinical trials related to spinal pain lies in the area of diagnosis. I~ The aetiology of most low back pain is unknown,I7 with the pathological or structural diagnosis uncertain in 80-90% of patients presenting with disabling back pain. la-XI Assessment procedures used may not be able to diagnose the pathology involved or may be incorrectly interpreted.:n Problems associated with poor inter-observer reliability for clinical findings further confound the picture. Palpatory findings are integral to the establishment of an osteopathic diagnosis. r"OT palpatory diagnosis to be useful for classification purposes,. good inter..-aaminer reliability needs to be demonstrated It is well documented that there is poor interobserver reliability for palpatory findin~ .h · pl"O\'OCatlon. . 1J-U .-or r ,._WIt out pam '10;::.0::: reasons. current osteopathic diagnostic labels cannot be used effeah.oely in clinical trials of spiJlal pain 3Jld disability and an alternative means of classification needs to be identified. The Quebec Task r-orce 16 reeogni7..oo the lack of uniformity in diagnostic temlinology used for spinal disorders and proposed a classification that does not depend upon pathological entities. but reflects the clinical presentations encountered in practice. A modified form of this classification am be utilized for conducting research. This classification system can be used by all clinicians. regardless of discipline.. to categorize patients with spinal pain in the clinical setting and links patient symptomatology with dunnion of symptoms and working status (Table A.7.1). The Quebec Task Force classification consists of 11 categories with classification based
Validation of clinical practice by research
Table A.7.1 Classification of activity-related spinal disorders Classification
1
2 3 4 5
6
7
8 9
10 11
Symptoms
Duration of symptoms from onset
Pain without radiation Pain + radiation to extremity, proximally } Pain + radiation to extremity, distally Pain + radiation to upper/lower limb + neurological signs Presumptive compression of a spinal nerve root on a simple roentgenogram (Le. spinal instability or fracture) Compression of a spinal root confirmed by: - specific imaging techniques (Le. CAT, myelography or MRI) - other diagnostic techniques (e.g. electromyography, venography) Spinal stenosis Post-surgical status, 1-6 months after intervention Post-surgical status, > 6 months after intervention 9.1 Asymptomatic 9.2 Symptomatic Chronic pain syndrome Other diagnoses
Working status at time of evaluation
a «7 days) b (7 days-7 weeks)) W (working) c(>7 weeks) I (idle)
W (working) I (idle)
Source: Quebec Task Force.16
upon historical markers and clinical and paraclinical examinations. Some categories are further subdivided by stage. i.e acute. subacute and chronic. and whether the patiem is able to work. A number of authors have suggested different methods of patient classification. 36•37 DeRosa and PonerfieJd37 modified the Quebec Task rWC£ classification for spinal pain, making it more appropriate for physical therapy diagnosis rrable A.7.2). Dtegorizing patients using the Quebec Task Force or a similar system of classification enables outcome studies 10 be performed on groups of patients with spinal pain without the need for a specific
osteopathic or mechanical diagnosis. '111is does not obviate the need for the practitioner to Wldertake a full and thorough assessment of each patient, but does allow classification of patients into groups for the purpose of research. lhis form of classification removes the obstacles to research associated with a lack of standardization and validation of diagnostic tenninology in spinal disorders. The Quebec Task Forrel8 published a similar classification for whiplash-associated disorders. This classification of whiplash 'provides Gl.tegories that are jointly exhaustive and mutually exclusive, clinically meaningful, stand the test of common sense and are "user friendly" LO investigators,
57
HVLA thrust techniques - an osteopathic perspective
Tabll! A.7.2 Modified physical therapy diagnosis classification
Category
Definition
1
Bad. pain without radiation
2 3 4 5 6 7
Back pain w;th referral to extremity, pfOximally Back pain with refenal to extremity, distally Extremity pain greater than back pain Back pain w;th radiation and neurological signs Post-surgical status months or >6 months) Chronic pain syndrome
«6
Source: DeRosa and Porterfteld.v
clinicians, and patients'. A classification system exists that \\IOuld also allow outcome studies on 'whiplash' patients to be undertaken. 'lowever, if the measurable outcome from a therapeutic intervemion is likel}' to be small, i.e. small effect size, then studies using these classification systems need to be undertaken on populations of sufficient size to demonstrate a statistically significant change.
MEASURING OUTCOMES Consideration needs to be given as to what instruments might be used to measure patient outcomes arising from osteopathic intervention. 'Ine process of selecting appropriate measuring instruments can be broken down into three stages. 1. The researcher muSt identify what he or she wishes to measure, e.g. spinal pain and disability. 2. What is to be measured mUSt be defined in quantifiable terms, e.g. the intensity of pain suffered by the patient. the impact the pain and disability have upon the patient's activities of daily living. etc. 3. Selection of appropriate data collection and recording instruments that will give reliable and valid results.
58
Broadly speaking. outcome measures attempt to quantify pain, physical impairment. limitation of activity, impact
upon work and leisure and p.!>ychosocial ftlctors. While patient records tire easily accessible to the practitioner, there are problems associated wilh this fonn of data collection for the purpose of outcomes assessmenL Recording in palient records lacks slandardization and is often incomplete and what is recorded may nOt reOect what has acrually occurred.» Practitioners also record physical examinalion findinp;;,. but the large variability in normal values and poor interexaminer agreement limit the use of such tests in research. A variety of easily used tools has been developed that allO\... praetilionen; 10 assess specific outcomes resuJting from lherapeutic interventions. Leibenson and Yeomans lO have identified eight categories of available outcome approaches Crable A.7.3). As lhe range of questionnaires and pain raling scales is diverse. researchers must be confident that they have selected the most appropriate measurement tools for their dinical trials. A different approach and rating instrument would be selected for assessment of chronic spinal pain, with the possibility of a strong affective component. as compared with arute spinal pain. Clinicians undertaking research must be cogni7.an1 of both the advantages and disadvantages of individual outcome assessment insnurnenls. Once the mosl appropriate measurement tools have been
Validation of clinical practice by research
Table A.7.3 Outcome approaches category based on assessment goals OUtC.OmH assessment instrument 1. Pain level
1 Numerical pain scale (NPS) 2 Visual analogue scale (VAS)
3 Mc.GilVMelzac::k Pain Questionnaire 2. Regionlcondition-specific disability
4 Oswestry low Bad< Pain Disability Questionnaire
questionnaires
LBP
5 Roland-Morris low Back Pain Disability Questionnaire
Neck Headache
6 7 S 9
Dallas Pain Questionnaire low Back Pain 'TyPE' Neck Disability Index (NOI) Headache Disability Index (HOI)
3. General health
10 Dartmouth COOP charts 11 Health Status Questionnaire 2.0 12 Short Form (SF)-36
4. Psychometrics
13 14 15 16
Health Status Questionnaire (HSQ) 20 5F-16 waddell's Non-organic LBP signs Modif.ed lung Questionnaire 17 Modified Somatk Perception Questionnaire 18 Beck's Depression SCale 19 Fear Awidanc.e ~iefs Questionnaire 20 SCL~
5. Patient satisfaction
21 Patient Satisfaction Questionnaire 22 Visit 5pedfK Questionnaire 23 Chiropractic Satisfaction Questionnaire
6. Job dissatisfaction
24 APGAR
7. General disability
25 Vermont Disability Questionnaire 26 Vermont Disability Questionnaire: brief form
27 Functional Assessment Screening Questionnaire 28 Fear Avoidance 8efiek Questionnaire
8. Job demands
29 Job Demands Questionnaire
Source: Adapted from Leibenson and Yeomans. 10
selected, they should be used throughout the period of the study. Different scales and questionnaires are nOt interchangeable. In relation to spinal pain and disability, there is evidence that appropriately designed questionnaires have at least equal scientific validity to practitioner measurements. 40.~ Specific questionnaires can measure a patient's presenting level of pain and disability and be used to reflect changes in that pain and disability after treatment and
o\'er time. '111e Oswestry Low Back Pain Disability Questionnaire·~-M and Ihe Roland-Morris low Back Pain Disability Questionnaireu h3\'e been shown in randomized controlled trials to have validity and reliability in measuring results for patients with back pain. A modified Oswestry low Back Pain Disability Questionnaire demonstrated superior measurement properties and higher levels of test-retest reliability and responsiveness
59
·1------....;....-......;-.;......;,------HVLA thrust techniques - an osteopathic perspective
1 100 mm )wI No pain 1-1- - - - - - - - - - - - - - - 1 1 Excnriating pain Figure A.7.1 Visual analogue scale.
No pain
0
1
2
3
4
5
6
7
8
9
'0
Excruciating pain
Figure A.7.2 Numerical rating scale.
60
when compared with the Quebec Back Pain Disability Scale.46 ~ liken modified venion of the Roland-Morris Disability Questionnaire has shown greater sensitivity to change over time than the original version. 47 Vernon and Mior'" demonstrnted a high degree of test-retest reliability and internal consistency for the Neck Disability Index. 'Ihis index was modified from the Oswestry Low Back Pain Disability Questionnaire. A whiplash specific disabijjty questionnaire has also been developed that has shown internal consistency and validity.d Of the large number of scales available to measure functional disability and impairment in back. pain patients, the most widely accepted are the Roland Oswestl)'. Million and Waddell scales. 50 These scales have been demonstrated to reliably detect changes in the level of disability and impairment O\Ier time and are reproducible and acceptable to patients. Some questionnaires include items that may nOt be directly relevant to a particular patient. "lie patient-specific functional questiolUlaire allows the measurement of patientgenerated and -specific activities that are of concern to them.S!."i2 'ille subjective sensation of pam can be self-rated by patients using a number of different measures.. 'l1le mOSt commonl)' used include the visual analogue scale. numerical rating scale and the verbal rating scale. With the visual analogue scale (Fig. A.7.1). the patient records the level of pain by making a single perpendicular line along
the 100 mm scale. This can be repeated at second and subsequent visits. 11le researcher measures the pain level for all visits by measuring from the left end of the 100 mm line. As the line is 100 mm long. all measurements can be expressed as a percentage. Iloweve.r, even with this simple scale. experience has demonstrated that patients need oral reinforcement and supervision in addition to wrillen instructions in cm;e they use a circle or a cross to indicate level of pain rather than a perpendicular line. Such responses would render the rating imprecise and invalid. Modifications to refine the use of the visual analogue scale to indude pain level at present. a..-erage pain grade and worst pain grade. have been Suggested.53 If applied in a c1iniGlI setting. it is recommended that the scale be used every 2 weeks. 54 'llle numerical rating scale is similar to the visual analogue scale. but offers the patient more defined pain categories to mark. 'llIe patient is asked 10 rate the severity of pain by marking one box on the scale in Figure A,7.2, With the verbal rating scale. the patient must select an adjective. from a standardized list, that best describes the pain. 'lllere are many verbal rating scales with the level of pain severity being represented in the questionnaire varying from as few as 4, to 14 (Fig. A.7.3). 'lllere is evidence that tissue tenderness is also measurable. 'Ilie American College of Rheumatology recommends a five-grade classification of tenderness (Box A.7.1 ).ss
Validation of clinical practice by research
Not noticeable Just I"IOticeable
Very v.eak Weak
7 I
_ _ _ __-------.J
chronic pain. The Depression, Anxiety and Positive Outlook Scale (DAPOS) has been developed in an attempt to measure these factors in patients that present with chronic . pam. ~
Mild Moderate Strong
Very strong
Intense Very intense
s.-. Excru:::iating Figure A.7.3 Twelve-point verbal rating scale.
lox A.1.1 Standardi;zed palpation of tenc:lerr'lPSs (Wolfe et all99()Cl') Using 4 kg of pressure (enough to blanch the tip of the thumbnail if you pressed on a table): Grade 0 Grade I
No tenderness Tenderness with no physical
Grade II
Tenderness with grimace and/or
"'po",.
flindl Grade III
Tenderness with withdrawal (+ jump sign) Grade IV Withdrawal to non·noxious stimuli
Many practitioners will encounter patients with chronic spinal pain in clinical practice. II is nOw recognized that a biopsychosocial model is useful in helping manage these patients.56 '111e Distress & Risk Assessment Method (DRAM) has been developed as an easily applied and nonthreatening tool that allows a practitioner to determine if a patient requires a more comprehensive psychological eva.luation.~7 Questionnaires measuring depression and other mood states are available but have been criticized as they were not developed in patient populations suffering from
CONCLUSION There is a need for the osteopathic profession to undertake dinical research. Establishing the effectiveness of osteopathic treatment was rated highly in a study of responses from a group of osteopathic professiooals.S!I Structured questionnaires and pain rating scales have been shown to be valid and reliable research instruments to evaluate the efficacy of any given therapy in attering pain and disability. Biopsychosodat factors are of significance in the management of patients with chronic spinal pain and questionnaires allow quantification of these factors. The use of standardized classification systems enables comparison of efficacy of treatment between professions and of therapeutic approaches within a profession.
References Oonab«lian A. The quality of care: how Qn it be asscssed~ lAMA 1988; 260:1743-1748. 2 Bogduk N. Editorial. Scientific monograph of the Quebec Task force on whiplash·associated disorders. Spine 1995; 20(8S):8-9. 3 Moor D. Aspects of clinical research in osleop.1thy. Au~t I Oslcopmhy 1992; 5( I ):6-14. 4 Ward RC. Myoho;cial relea..c conccplS. In; Ba~majian IV, Nyberg R, cd~. R<1lional Manual Therapies. Baltimore. MD: Williams &. Wilkins; 1993:223-241. 5 Spallro K. Northup and loki ~pet..'(hc~ round out research conference. DO 1984; 24:81-82. 6 Bogduk N, Mercer S. Sck,<:tion and application oftrcatmcllL In: Re[~hauge K. Ca~ E. eds. Musculoskeletal Physiotherapy, 1st 0011. Oxford.: Buuerwonh·lleinemann; 1995:169-181. 7 Nalional Health &. Medical Research Council (NHMRC). Evidence Based Management of Acute Musculoskeletal Pain. National Health & Medical Research Council: 2003:httrr.J/www.nhmrC-.p.au!publicalions/:>y IlOpsesJcp94syn.hun. 1
6'
HVLA thrust techniques - an osteopathic perspective
8
•
I. 11
CrQM A. Kay'r, Kennedye. et aI. Clinical prnc1ice guidclines on lhe ~ of manipulalion or mobilil'.lllion in the lreatment of aduhs with mechanical ncc::k disorders. Man Ther 2002; 7(4):193-205.
23
Maryas'l;t.. Bach 1M. The: ndi
2'
Mior SA. King RS, McGregor M, Bernard M. lnlra- and inler-ocamine:r reliabilit}' of moljon palpation in lhe cervical spine. I Can o.iropractic t\5SOC 1985; 29:195-198. lo\oe RM. Brodeur RR. Inlel- and imraexaminer reliabilily of motion palpation for the thorarolumbar spine. I Manipulaliw: Ph}'~ioI Ther 1987; 10:1-4.
McGuirk 8, King \\I, Govind J. lowfy I. Bogduk N. Safety, efficacy. and C05t effectiveness of lMdence·base<J guideline5 for the managemenl of anile low back pain in primlll}' care. Spine 2001; 26(23):2615-2622.
25
Leibenson e. )'eomans S. OutCOR1f5 ~l in musculoskeletal medicine. Man Ther 1997; 2(2):67-74.
2.
Boline PO, Kealing}C, Brist J, Denver G. lnterexaminer reliability of palpalOry evaluatjon of the lumbar 5f)ine. .... m I Otiropr.tetic Mm 1988; 1:5-11.
27
Ktoating JC. Bergmenn 1F. Iambs GE, Finer BA. lawson K Inlerexaminer reliability of eighl ewalualh"l" dimensions of lumbar segnte!:ntal abnormality. I ManipuJath"l" Ph}'5iol Ther 1990; 13:463-470.
Jamison III
12 Burton AK Back pain in osu:opalhic ptaetice. Rheumalol Rdtabil 1981; 20:239-246. ~ating Ie. Seville I. t.iuker We. looaac RS. Quitoriano 1.1\, Dydo M, Leibd DP. Inuasvbject aperimemal dnigm in OfilOOpalhic medicine;
"
appUcllions in dinica.1 practice. In: Bea.I Me. ed. The Principles of PalpalOry Diagn05is and Manipulative'IKhnlque. Newarlc ....merican Acadwly of Ostoop.alhy: 1990;205-214,
28 IJ\imm llJM Van. ~jn I. 0CkhU}~ AI.. "ortman 81. 1he ,,,,,Jut: ofsome clinical lestS
29
14 SlOddard ..... Manual of
30
1969:281-282. IS
Aldridge O. Single-case research designs. Compleme:l1lary Met! Res 1988; 3(1);37-46.
••
Force qr. SCientific apprO"lCh 10 the assessmem and n13nagemenl of activity.related spinal disorders. Spine: 1987; 12(75): 16-21.
.7 SChultz. AB, Warwick ON. IJe:rkson MH,
31
32
Na<:hemwn i\L Mechanical properties of human lumb.1r spine motion seg~nts. J Riomed Eng 1979; 101:46-52.
'8
I'
62
Ca.'iS EM. The challenging role for physiolhernpy in chronic musculoskeletal diwrders. In: He["hauge t<. Cas." E, eds. Mu."Culoskelet.1l Physiolherapy, Oxford: 13uuerworth-lleinemann; 1995:206-217. Nadll~msol1 AI_ 'nlt' nalura! course of low back pain. In: While AI\, Gordon eds. American Academy of Orthopaedic Surgeons Symposium 011 Idiopathic tow Back Pain. SL Louis. MO: Mosb}~ 1982:45-51,
sc.
2.
Dillane JB. Fry I, KallOn G. Acute back syndrome - a sludy from genera! pract.ice. BMJ 1966; 2:82-84.
21
Don'ligny RL Fw1Ction and pathomechanics of lhe: sacroiliac: joinL Phys Ther 1985; 65:35-43.
22
Connella e. Paris S. Kutner M. Reliability in evaluating ~ive intel>WlebraJ motion. Ph}~ 1her 1982; 62:436-444.
33
34
35
3.
Oflhe sacroiliac joinL Man Med 1990; 5:96-99. Illln'q' O. Byfield O. Prelimiruuy Mudies "'ilh a mechanical model for lhe evaluation of spinal mOlion palpatioo. elin 8iomecltanks 1991; 6:79-82. Panzer OM. The reliability of lumbar mocion PllpatiOft. I Manipulaliw Physiol1her 1992; 15(8};S18-524. lewit t<. Uebmson C. Palpation - problems and implicaLions. J Manipulative Physiol 1'her 1993; 16(9):586-590. Nyberg R. Manipulation: definition. types,. applicaLion. In: I~majian IV. Nybe:rg R. eds. Raliomll Manual Therapies, BaiLimore. MO: Williams & Wilkins; 1993:22-47, 1.a..~leli /l.i, William.~ M. The reliability of seleclcd pain provocalion 1e:';1$ forsacro-iliac joint palhology. In: Leemillg A. Mooney V, Dorman'l: Snijders C. cd!l, The Integrated Funrlion of lhe Lumbar Spine and Sacroiliac Joint. ROlterdam: ECO; 1995: 485-498, Vinc:elll-$mith 13, Giblx)I1s P. Inler-examiner aud illlra-examiner reliability of palpalO!}' findings for lhe slanding flexion lest. Man TIler 1999; 4(2):87-93. O'llaire C. Gibbons P, 111Ier-examiner and intra-e:xaminer reliability for assessing sacroiliac: analomicallandmarks using palpalion and observation: .... pilot study. Man Ther 2000; 5(1):13-20. DC}'O RA. Clinical ConceplS in Regional Musculo-ske1etal 1I1ness. London: Crune & Stratton; 1987:25-50.
Validation of clinical practice by research
37 DeRosa CP, Poneriield JA,. A pll)'Sical wrapy
38
3. 40
41 42
43
44
45
46
47
48
model rOJ the lreaunent or low back pain. Ph)'S Ther 1992; 72(4):261-269. Force QT. Scientific moJlOgJ3pll of the Quebec 1Ilsk Force on whiplash-assodated diliorder$: redefining 'whiplash' and its maO¥JT'Ie'nL Spine 1995; 20(8S):1O-73. Fowkes feR. Medical audit cycle. Med F..duc 1982; 16(4):228-238. McDowell I. Newell C. Measuring Ilealth: A Guide to Rating SCale:- ilnd Questionllain!S. New York; Oxford Pra~ 1987. lX}'O R. Measuring the funcLional status of p<\lienlS with low back pain. Arch Phys Med Rehabi1198B; 69:1044-1053. Fairbanks J, Davit'S J, Couper I, O'Brien J. The OSWC5IJ)' Low Back Pain Disability Que:slionnaire. Physiotherapy 1980; 66:271-272. Meade 1W, Dyer S. 8rowne \'I; Townstnd I, Frank AD. Low back pain of memaniG\l origin: randomi7.ed compari<;On of chiropr;lCtic and hospital OUlpatiUlllreaunem. 8MI 1990; 3OO:t431-1437. Iisieh 0, Phillips RH, Adams AH, Pope MIl. Functional outcomes of low back pain: comparison of four treatment groups in a Tilndomi7.cd colllrolled trial. J Manipulativt" Physio! Ther 1992; IS( I ):4-9. Roland M, Morris R A Study of (he natural hiStOf)' of back pain. Part I: development ofa reliable and. sensitive measure of disability in low-back pain. Spine 1983; 8:14t-I44. Fritz 1M, Irrgang JI. A comparison of a modified Oswesuy low Back Pain Disability Questionnaire and the Quebec Back Pain Disability Scale. Phys 1hef" 2001; 81(2):776-788. \\lakhe D, ftlddifTe J. Pain beliefs and perceived physical disability of patients with chronic!ow bock pain.I"ain 2002; 97:23-31. Vernon H, Mior S. TIle Neck Disability Index: a slUdy of reliability and valid.ily. J Manipuliluve Physio! Ther 1991; 14(7):409-41S.
4. l>infOld M, NN.ore K O'lnry F. I loving J, Green
SO
51
52
53
54
55
56
57
58
5.
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'
r.
63
PART
HVLA thrust • techniques - spine and thorax SECTION 1 Cervical and cervicothoracic spine 69
Note: Before reviewing up-slope and down-slope lIVLA rllnl5l techniques, the Introduction on CD-ROM should be viewed.
"ie
1.1
Atlanto-occipital joint (0-C1: contact point on occiput; chin hold; patient supine; anterior and superior thrust in a curved plane 71
1.2
Atlanto-occipital joint (0-(1: contact point on atlas; chin hold; patient supine; anterior and 5uperiOf thrust in a curved plane 77
1.3
Atlanto-axial joint (1-2: chin hold; patient supine; rotation thrust
1.4
Atlanto-axial joint (1-2: cradle hold; patient supine; rotation thrust
1.5
Cervical spine (2-7: up-slope gliding; chin hold; patient supine
1.6
Cervical spine 0-7: uJHlope gliding; chin hold; patient supine - variation
1.7
Cervkal spine 0-7: ulHlope gliding; cradle hold; patient supine
1.8
Cervical spine 0-7: up-slope gliding; cradle hold; patient supine; reversed primary and secondary leverage 101
1.9
Cervical spine 0-7: up-slope gliding; patient sitting; operator standing in front
81
85
89 93
97
107
1.10 Cervical spine 0-7: uJ)'"slope gliding; patient sitting; operator standing to
the side
111
1.1J Cervical spine C2-7: down-slope gliding; chin hold; patient supine
115
1.12 Cervical spine C2-7: down-slope gliding; cradle hold; patient supine
121
J .13 Cervical spine C2-7: down-slope gliding; patient sittIng; operator standing to the side 127
1.14 Cervicothoracic spine C7-n: rotation gliding; patient prone; operator at side of couch 131 J .15 Cervicothoracic spine 0-n: rotation gliding; patient prone; operator at head of couch 135 1.1 G Cervicothorack spine C7-n: rotatton gliding; patient prone; operator at head of
couch - variation
139
J. J 7 Cervicothoracic spine 0-TI: sidebending gliding; padent sitting
143
I. J 8 Cervicothoradc spine C7-TI: sidebending gliding; patient sitting; ligamentous myofasdal tension locking 147
HVLA thrust techniques - spine and thorax
1.19 Cervicothoradc spine O-T3; sidebending gliding; patient side-lying
151
, .20 Cervicothoraclc spine 0-T3: sidebending gliding: patient side-lying; ligamentous
myofascial tension locking
1SS
1.21 Cervicothoracic spine Cl-T3: extension gliding; patient sitting; ligamentous myofascial tension locking 159
SECf/ON 2 Thoracic spine and rib cage 163 2. J
Thoracic spine T4-9: extension gliding; patient sitting; ligamentous myofasciat tension locking 167
2.2
Thoracic spine T4-9: flexion gliding; patient supine; ligamentous myofasdal
tension locking
171
2.3
Thoracic spine T4-9: rotation gliding; patient supine; ligamentous myofascial tension locking 177
2.4
Thor-acic spine T4-9: rotation gliding; patient prone; short lever technique
2.5
Ribs Rl-3: patient prone; gliding thrust
2.6
Ribs R4-10: patient supine; gliding thrust; ligamentous myofascial tension locking
2.7
Ribs R4-10: patient prone; gliding thrust
197
2.8
Ribs R4-10: patient sitting; gliding thrust
201
SEC110N
3
183
189
Lumbar and thoracolumbar spine
193
205
Note: Before retliewing side-lying HVLA dttlLSr rechnu,ues in rhe lumbar mul dlClr"acolumoor spine. rhe hlt.TlXluaitm on the CO-ROM 51tould be viewed. 3. J
Thoracolumbar spine Tl ~12: neutral positioning; patient side-lying; rotation gliding thrust 209
3.2
Thoracolumbar spine Tl o-l2: flexion positioning; patient side-lying; rotation gliding thrust 213
3.3
lumbar spine ll-S: neutral positioning; patient side-lying; rotation gliding thrust
217
3.4
lumbar spine ll-S: flexion positioning; patient side-lying; rotation gliding thrust
221
3.5
lumbar spine 11-5: neutral positioning; patient sitting; rotation gliding thrust
3.6
lumbosacral joint l5-$1: neutral pOSitioning; patient side-lying; thrust direction is dependent upon apophysial joint plane 229
3.7
lumbosacral joint L5-51: flexion positioning; patient side-lying; thrust direction is dependent upon apophysial joint plane 233
225
Introduction Part B includes 36 manipulative techntques applied to the spine from the atlanto-occipital to the lumbosacral joint. Ml techniques are described using a variable hetght manipulation couch. 66
This part of the bl:x)k relates to spedftC highvelocity low-amplitude (HVlA) thrust
techniques applied to spinal joints. HVlA thrust techniques are also known by a number d different names, e.g. adjustment, high-velocity thrust,. mobilization with impulse, grade V mobifization. Despite the different nomenclature, the common feature in techniques of this type is that they are
Introduction =:....._-~ designed to achieve a joint cavitation (pop or cracking sound) within synovial joints of the spine. The cause of the popping Of cracking sound is open to some speculation. Information gained from a thorough history. c1iniccM examination and segmental analysis will direct the practitioner towards any possi~ somatic dysfunction and/or pathology. The use d HVlA techniques is dependent on a diagnosis of somatic dysfunction. Somatic dysfunction is identified by the 5-T-A-R-T of diagnosis:
• S relates to symptom reproduction • • • •
T A R T
relates to tissue tenderness relates to asymmetry relates to range of motion relates to tissue texture changes
The manual is designed in a format that presents a standardized approach to each region of the spine. If the instructions are follOVoled conscientiously, the novice manipulator will be well placed to achieve a positive outcome from the procedure. The nature of manipulative pl"aetice is such that there are many different ways to achieve joint cavitation at any given spinal segment. Many clinicians achieve extremely high levels of expertise and competence in the use of HVLA thrust techniques. This Is the result of many years of individual clinical experience and practice.
This manual is designed to be a safe and effective starting point upon which practitioners can build basic. and then more refined. technical skills. The text lays out the primary and secondary joint leverages required to facilitate effective localization of forces to a specific segment of the spine prior to application of the thrust. If the instructions are followed. the resultant thrust is likely to achieve joint gliding and cavitation with the use of minimal force. The joint to be thrust should not be locked by facet apposition, but remain free so that the practitioner can direct a gliding thrust along the joint plane. Appropriate pre-thrust tension is then developed by positioning the joint towards
the limit of its available range and not at its anatomical barrier. No text can teach the subtle nuances of HVlA thrust techniques. For example. the sense of appropriate pre-thrust tension is difficult to describe and acquire. Experienced practitioners often use compression as an additional lever. Extensive practice under the supervision of skilled and experienced clinicians is strongly recommended. The majority of techniques are described using facet apposition IoclOng. In broad terms, facet apposition kxking uses combinations of sidebending and rotation. An understanding of the biomechanics assodated with coupled movements of the spine in different postures allows the operator to decide on optimal leverages. While rotation and sidebending are the principal leverages used, the more experienced manipulator may include elements of flexion, extension. translation. compression or traction to enhance localization of forces and patient comfort. Patient relaxation is an essential prerequisite for effective HVlA thrust techniques. This may be facilitated by the use of respiration and other distraction methods. After making a diagnosis d somatic dysfunction and prior to proceeding with a thrust.. it is recommended that the following checklist be used for each of the techniques described in this section: • Have I excluded all contraindicatlons? • Have I explained to the patient what Iam going to do? • Do I have informed consent? • Is the patient well positioned and comfortable? • Am I in a comfortable and balanced position? • Do I need to modify any pre-thrust physical or biomechanical factors? • Have I achieved appropriate pre-thrust tissue tension? • Am I relaxed and confident to proceed? • Is the patient relaxed and wilting for me to proceed?
67
Cervical and cervicothoracic spine
SECTION
CERVICAL SPINE HOLDS AND GRIPS The hold or wrist position selected for any paniOllar techniqu~ is that which enables the operator to effectively locali7..e forces to a specific segment of the spine and deliver a high-velocity low-amplitude (HVLA) thrust in a controlled manner. Patient comfort mllSt be a major consideration in selecting the most appropriate hold.
Chin hold • Operator's left forearm must be over, or slightly in fronl of, the patient's left ear. • Operator's fingers lightly clasp lhe patielll's dlin. • Operator's cltest should be in (on tad with the vertex of the patient's head. • Operator's right hand applies applicator to (on tad point.
69
_ _ _ _ _------=-1
.
HVlA thrust techniques - spine and thorax
,
Cradle hold
Wrist position
• Patient's left ear resting in the palm of opc..>rator's left hand. • Operator's left hand spread oul for maximum conlact. • Operators right hand applies applicator to contact point and gives support to the patient's OCcipuL • The \veight of the patient's head and neck is balanced between the operator's left and right hands.
Operators can select from either the pistol grip or wrist extension grip.
Pistol grip Note: radius in line with first
metacarpal.
Wrist e.xtension grip Note: wrist extension.
70
Atlanta-occipital joint (0-(1 Contact point on occiput Chin hold Patient supine Anterior and superior thrust in a curved plane
Assume somatic dysfimcliolJ (S-T-A-R-T) is identified and)'ou wisl1 to use a tllmsl in the plane of the CO-Cl apophysial joim to produce caviWtiOll 011 til. rigllt (Fig. BI. 1.1)
Figure 81.1.1 1. Contact point
KEY
RighI posterior occiput. Medial and posterior to the mastoid process.
>t: Stabilization
2. Applicator
Laleral border, proximal or middle phalanx
•
Applicator
of the operator's right index finger.
-
Plane of thrust (operator)
3. Patient positioning
E::>
Direction of body movement (patient)
Note: The dimensions for the arrows
are not a pictorial representation of the amplitude or force of the thrust.
Supine: \vith the neck in a neutral relaxed position. If necessary. remove pillow or adjust pillow heighL The: neck should not be in any significant amount of flexion or extension.
4. Operator stance Head of couch. feet spread Slighlly. Adjust couch height so lhat the operator can stand
71
HVlA thrust techniques - spine and thorax
...1--------..:..;,.....:....;.,;",.........;..;,..--------as erect as possible and avoid crouching over the patient. as this will limit lhe tt.'Chnique and restrict delh!ff)' of lhe thrust.
conlro)kd by balancing forces bel....'t'eTl lhe right palm and left forearm. Maintain lhe applicator in position.
S. Palpation of contact point
8. Vertex contact
Place fingers of both hands gently under lhe occiput. Uft the head slightl),. and gently rotate it to the left. taking the weight of the head in your left hand. Remove )'Our right hand from the occiput and palpate the contact point on lhe occiput wilh the tip of your index or middle finger. Ensure lhat you an:..;nediaLtp, and not on,.the mastoid procns. Slowly but firmly slide your right index finger. in close approximation to the suboccipital musculatur~ downward (towards lhe couch) along the occiput until it approximates the middle or proximal phalanx. Severnl sliding pressures may be necessary to establish close approximation to the contact point. It is imponant to obtain a contact point as far along lhe underside of lhe occiput as possible and into lhe suboccipital musculature. 1bis thrust uses a cwved plane of movement to produce a cavitation and this positioning ensures that the applicator will not slip during the thrLl5t.
MO\'e your body forward slightly so that your chest is in contact with the vertex of the patient's head. The head is now securely cradled between the left forearm. the flexed left elbow, the right palm and )'Our chest. Vertex contact is often useful in a heavy, stiff or difficult case but can. on occasions. be omitted.
6. Fixation of contact point
Keep your right index finger firmly pressed on the contact point whiJe you flex the other fingers and thlUllb of lhe right hand so as to clasp the back of the occiput and head, thereby locking the applicator in position. You must now kE..'€p 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
72
Keep )'our right hand in position and slide the left hand. slowly and carefully. forwards until lhe fingers lightly clasp the chin. Ensure that your left forearm is over or slightly anterior to the ear. Placing lhe forearm on or behind the ear polS lhe neck into too much flexion. The head is now
9. Positioning for thrust Step to the right and stand across the right corner of the couch. keeping lhe hands firmly in position and taking care not to lose pressure on the contact poinL Gently introduce a little rotation of the head to the left. Straighten your right wrist so that the radius and first metacarpal are in line. While maintaining firm applicator pressure,. allow lhe right index finger to roll slightly on lhe comaa point as you move your right elbow towards the patient's right shoulder. This facilitates optimal alignment for the thrust, which is in a curved plane because of the shape of the apophysial joint. It is important that your applicator is well beneath the OCcipUl so that you do not slip when applying the thrust along a curved facet plane. Keep your right elbow close to the couch in order to keep the contact point on the occiput (Fig. 81.1.2). Add extension and slight side~nding to the right to provide a feeling of tension at the contact point. 'Ihe extension and right side~llding are introduced by pivoting slightly via lhe legs and trunk so that your trunk and upper body rotate to the left. Do not attempt to introduce sidebending by moving the hands or arms as this will lead to loss of contact and inacrurate technique. "Ibis technique does not use facet apposition locking. "Ihe pre-thrust tension is achieved by positioning lhe occipito-atlantal joint towards the end range of available joint gliding while avoiding excessive rotation
Cervical and cervicothoracic spine
Figure 81.1.2
and sid€bending J€\'efages. ExtensiV€ praClic€ is necESSary to d€V€lop an appreciation of th€ required tension. 10. Adjustments to ac:hieve appropriate pre-thrust tension Ensure the patient remains relaxed. Maintaining all holds, make any necessary minor changes in flexion, extension, sidebending or rOlation until you can sense a stat€ of appropriate tension and leverage at th€ contact point. TIle paoem should not be aware of any pain or discomfort. You should introduce these finaJ adjustments by slight movements of the ankles, knees, hips and trunk, nOl by altering the position of your hands or arms. 11. Immediately pre-thrust Relax and adjust your balance as necessalY. Keep your head up; looking down impedes the thrust and can cause embarrassing proximity to the patient. An effective HVlA thrust technique is best achieved if the
operator and patierll are relaxed and not holding themselves rigid. This is a common impediment to achieving effective cavitation. Ensure th€ patient's head and neck remain on the pillO\" as this facilitates the arrest of the technique and limits excessive amplitude of thrust.
12. Delivering the thrust This is a difficult technique to master, as the thrust mU~1 be appli€d aJong a curved plane. Apply a HVLi\ thrust to the occipUl, using both hands, in an ant€rior and superior direction along a curved plane which follows the shape of the occipito~atlalHaJ articulation (Fig. 81.1.3). The thrust, although V€ry rapid, must never be ex((.'SSiv€ly forcible. llle aim should be to use the absolute minimum of force necessary to achi€ve joint cavitation. A common fault arises from the use of excessive amplitude with insufficient velocity of thrust.
73
HVlA thrust techniques - spine and thorax
Figure 81.1.3
74
Cervical and cervicothoradc spine
SUMMARY Atlanta-occipital joint (0-(1 Contact pOint on occiput Chin hold Patient supine • Contact point: Right posterior occiput • 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: Ensure that you are medial to, and not on, the mastoid process • Fixation of contact point • Chin hold: Ensure your left forearm is over or slightty anterior to the ear • Vertex contact Optional • Positioning for thrust: Step to the right and stand across the right corner of the ~. Optimal alignment for the thrust is in a curved plane. Keep your right Ibow close to the couch in order to keeeJhe contact ~int on the ~
0/
oe ~
ciput (Fig. Bl.1.2)
• Adjustments to achieve appropriate pre::thruslte.nsioo /
t\f'{}
• Immediately pre-thrust: Relax and adjust yo~ balance • Delivering the thrust: The thrust must be applied, using both hands, along a curved plane that follows the shape of the occipita-atlantal articulation.(Fig. B1.1.3)
75
I
Atlanto-occipital joint CO-C1 Contact point on atlas Chin hold Patient supine Anterior and superior thrust in a curved plane
Assume somatic dysfunction (S-T-A-R-T) is identified and you wish to use a thrust in the plane of the CO-Cl apophysial joint to produce cavitation on the right':
1. Contact point
KEY
Right posterior arch of atlas. ~ Stabilization
2. Applicator
•
Applicator
Lateral border, proximal or middle phalanx of operator's right index finger.
-
Plane of thrust (operator)
~*
r;)
Direction of body movement (patient)
Note: The dimensions for the arrows are not a pictorial representation of the amplitude or force of the thrust.
3. Patient positioning
Supine with the neck in a neutral relaxed position. If Of.."Ct'Ssary, remove pillow or adjust pillow height. "The neck should not be in any significant amount of flexion or extension.
4. Operator stance Head of coud" feet spread slightly. Adjust couch height so that the operator can stand
77
HVlA thrust techniques - spine and thorax
as erect as possible and avoid crouching over the patient as this will limit the technique and restria delivery of the thrust.
cradkxl. between the left foreann, tht: flexed left elbow, the right palm and your chest. Venex contact is essemial in this technique.
5. Palpation of contact point
9. Positioning for thrust
Place fingers of both hands gently lmder the occiput. Uft the head slightly and gently rotate it to the left. taking the \veight of the head in your left hand. Remove )'our right hand from occiput and palpate the contan point on the right posterior arch oflhe atlas with the tip of your index or middle finger_ Slowly but firmly slide YOUT right index finger. in dose approximaLion to the suboccipital musculature,. downwards (to\vards the couch) along the posterior arch of the atlas unlil 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 finnly in position and taking care not to lose pressure on the COntact point. Gently introduce a little rotaLion of the head to the left. Straighten )'OUT right wri~1 so that the radius and first metacarpal are in line. While maintaining finn applicator pressure allow the right index finger to roll slightly on the comaa point as you move your right elbow to\vards the patient's right shoulder_ This facilitates optimal alignment for the thrust. which is in a auvro plane because of the shape of the apophysial joint. It is important that your applicator has a firm contact on the atlas so that you do not slip when applying the thrust along a anved facet plane. Keep )'OlIr right elbow dose 10 the couch in order to keep the contad point on the atlas (Fig. B1.2. J). Add extension and slight sidebrnding 10 tlle right to provide a feeling of tension at tlle contact point. The extension and right sidebending are introduced by pivotjng slightly via the legs and trunk so your trunk and upper body rotate to tht: left. Do not attempt to introduce sid~bending by moving the hands or anns, as this will lead to Joss of contact and inaccurate tt:chnique. This technique does not use facet apposition locking. 11lt: pre-thrust tension is achieved by positioning the occipito-atlantal joint towards the end range of available joint gliding while avoiding excessive rotation and sidebending leverages. Extensive practice is necessary to deveJop an appreciation of the required tension.
6. Fixation of contact point
Keq> your right index fiJlgeT finnly pressed on the cOlltaa point while )'OU flex the other fingers and thumb of the right hand so as to clasp the back of the occiput and head. thereby locking the applicator in position. You must now keq> 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
Cervical and cervicothoracic spine
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
HVLA thrust techniques - spine and thorax
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
Lateral border, proximal or middle phalanx of operator's right index finger.
-
Plane of thrust (operatOf)
3. Patient positioning
¢
Direction of body movement (patient)
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
10. Adjustments to achieve appropriate pre-thrust tension
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
HVLA thrust techniques - spine and thorax
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
Lateral border, proximal or middle phalanx of operator's right index finger.
-
Plane of thrust (operator)
3. Patient positioning
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
HVLA thrust techniques - spine and thorax
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 e<'lr. Placing the forearm on or behind the elr puts the ned< into 100 much flexion. The head is now controlled by balancing forces between the right palm and lell foreann. Maintain the appl icator in position. 8. Vertex contact
90
MCJ\.·e your body forw:ard slightly so that your chest is in contact with the \,ertex of the patient's head. The head is now securely cradled between your left forearm, the (]exed left elbow, the right palm and your chesL Vertex contact is often useful in a
Step to the right and stand across !.he right comer of !.he couch. keeping the hands finnly in position and taking care not to lose pre5SUre on !.he contact poinL Straighten the right \\'nst so that the radius and first metacarpal are in line. Maintaining applicator pressure, allow lhe right index finger to roll slightly on lhe contact point to align your right wrist and foreann wilh !.he thrust plane, which is upwards and towards 11le midline in Ihe direction of !.he patient's left eye. Keep the right elbow dose to the couch in order to maintain the COntad point on 11le posterolateral aspect of the articular pillar. (a) Primary leverage of roration. Maintaining all holds and contact points, complete lhe rotation of the head and neck 10 the left until tension is palpated at lhe contact point (Fig. 81.5.3). Do not lose finn pressure at the contact point. A common mistake is to use insufficient primary 1C\'ttage of head and neck rotation. (b) &coruIary lezlfmJge. Add a very small degree of sidebending to the right. down to and including C4. The operator pi\'Oting slighdy, via the legs and trunk, introduces the right sidebending. so that the lrunk: and upper body rotate to !.he lefl. enabling llle hands and anus 10 remain in position (Fig. HI.5A). Do nOI attempt to introduce sidebending by moving the hands or arms as this will lead to loss of contact and in(lcomue technique. 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 lC\uage. The patient should not be aware of any pain or discomfort. You make these final adjustments by slight movemenls of your
Cervical and cervicothoracic spine
1.5
Figure 81.5.3
Figure 81.5.4
ankles, knet'S, hips and trunk, not by altering the position of the hands or arms. 11. Immediately pre-thrust
Relax and adjust your bal
12. Delivering the thrust
Apply a HYl.A thrust to the right articular pillar of C4. l1"le thmst is up\vards and towards the midline in the direction of the patient's left 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 inaease the sidebending leverage (Fig. BI.S.S). The increase of rotation to the left is accomplished by slight supination of the left wrist and foreann. The thrust is induced by a very rapid contraction of the flexors and adduetors of the right shoulder and. if necessary. trunk and lower limb movement. The thrust.. although very rapid. must never be excessiveiy forcible. The aim
91
:
HVLA thrust techniques - spine and thorax
should be (,0 use the absolute minimum force necessary to achieve joint cavitation. A common fault arises (rom the use of excessive amplitude with insufficient velocity of thrusL
Hgure 81.5.5
SUMMARY Cervical spine (2-7 Up-slope gilding Chin hold
Patient supine • Contact point: Posterotateral aspect of right (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 contad 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. Introduce primary leverage of rotation left (Fig. 81.5.3) and a small degree of secondary leverage of ~ndio.9.right: Keep the right elbow close to the couch in order to maintain the contact point on the posterolateral aspect of the C4 articular pillar (Fig. 815.4) • 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. 81.5.5)
92
Cervical spine C2-7 Up-slope gliding Chin hold Patient supine - variation
Assume somatic dysfunction (S-T-A-R-T) is identified and yOIl wish to use an upward and fonuard gliding thnlSt, parallel to the apophysial join! plane, to produce cavitnr:ion at C4-5 on the right
,. Contact point
KEY
Posterolateral aspect of right C4 articular pillar.
.~,"
Stabilization
•
Applicator
Lateral border, proximal or middle phalanx of operator's right index hnger.
-
Plane of thrust (operator)
3. Patient positioning
<>
Direction of Ix>dy 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
HVLA thrust techniques - spine and thorax
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
HVLA thrust techniques - spine and thorax
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
-
Plane of thrust (operator)
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
Lateral border, proximal or middle phalanx of operator's right index finger.
3. Patient positioning
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
HVLA thrust techniques - spine and thorax
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
Cervical and cervicothoracic spine
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
HVLA thrust techniques - spine and thorax
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
Lateral border, proximal or middle phalanx of operator's right index finger.
•
Plane of thrust (operator)
3. Patient positioning
.~
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
HVLA thrust techniques - spine and thorax
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.
9. Positioning for thrust
'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 <'Inns. When treating the lower cervical segments. the middle or distal phalanx may be used as the applicator. 102
8. Vertex contact None in this technique.
Figure 81.8.1
Cervical and cervicothoracic spine
trunk so that the trunk and upper body rOlate to the left, enabling the hands and arms 10 remain in position. Do not lose firm COntact with your comacl point on the anicular pillar of 01. A common mistake is to use insufficient primary leverage of head and neck sidebending. (b) Seamdary 'eJ>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
HVLA thrust techniques - spine and thorax
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.
----------
Cervical and cervicothoracic spine
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.
•
Plane of thrust (operator)
3. Patient positioning
q
Direction of body movement
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
HVLA thrust techniques - spine and thorax
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
---------
Cervical and cervicothoracic spine
8. Adjustments to achieve appropriate pre-thrust tension Ensure your patient remains relaxed. It is important to keep your e1bO\\IS dose to your sides. Maint.aining all holds, make any necessary changes in flexion, extension. sidebending or rotation until you can sense ill state of appropriate tension and leverage. 11le patient should nOt be aware of any pain or discomfon. You make these final adjustments by slight mO\'emenlS of yOUr l~ and tnmk. not by altering the position of the hands or arms. 9. Immediately pre-throst
Figure 81.9.3
Relax and adjust your balance as necessary. Keq> 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
HVLA thrust techniques - spine and thorax
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
-
Plane of thrust (operator)
¢
Direction of body movement (patient)
Note: The dimensions for the arrows
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
'"
.
HVLA thrust techniques - spine and thorax
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
Cervical and cervicothoracic spine
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)
3. Patient positioning
c:>
Direction of body movement (patient)
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 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
HVLA thrust techniques - spine and thorax
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
9. Positioning for thrust
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
116
Figure 81.11.1
b Cervical and cervicothoracic spine
(a) Primary leverage of sideIH!JJdirlg. Maintaining all holds and contan points, sidebend the patient's head and neck to the right until tension is palpated at the contad point (Fig. B1.11.1). lhe operator pivoting slightly, via the legs and trunk, introduces the right sidebending. so that the trunk and upper body rotate to the left., enabling the hands and anns to remain in position. Do not attempt to introduce sidebending by moving the hands or anns alone, as this will lead to loss of contact and inaccurate technique. Do not lose firm contact with your contad point on the articular piUar of C4. A common mistake is to use insuffident primary Iew:rage of head and neck sidebending. (b) S«ondary lerremge. Add a little rOlation to the left. dO\vn to and including C4 (11881.11.2). lhis requires extensive pntetice 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 yOli can sense a state of appropriate tension and leverage. 'n,e
'.--~_
... ' .
,'-;::.. 1 17 '-. ' ";'
t
~'
patient should not be a\vare of any pain or discomfort. You make these final adjustments by slight movements of your ankles. knttS, 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\vn impedes the thrust and can cause embarrassing proximity to the patient. An effecthre HYLA thrust technique is best achiC\--ed if both the operntor and patient are relaxed and not holding themselves rigid. This is a common impediment to achieving effeal\,re cavitation.
12. Delivering the thrust
Apply a IIVLA thrust to the right anirular pillar of C4. The directtcm of thrust is caudad in the direction of the patient's left shoulder and dO\vmvards to\vards the couch, parallel to the apophysial joint plane. Simultaneously. apply a slight. rapid increase of sidebending of the head and neck to the right but do nOt increase the rOlation leverage (Fig. 81.11.3). The increase of sidebending is induced by a slight rotation of the operator's trunk and upper body to the left. A "cry rapid contraction of the flexors and addudOrs of the right
117
Figure 8 1 . 1 1 . 2 : J
_ _ _ _ _1
HVLA thrust techniques - spine and thorax
Figure 81.11.3
shouJder joint induce the thrust; if necessary, lrunk and lower limb rnO\'ement may be incorporated. The thrust, although \'eI)' rapid, must 11e\'er be excessh'ely forcible. The aim should be to use the absolute minimum
118
force necessary 10 achieve joint cavitation. A common fault arises from the use of excessh'e amplitude with insufficient velocity of thrust.
Cervical and cervicothoracic spine
SUMMARY Cervical spine C2-7 Down-slopegliding Chin hold Patient supine • Contact point: Lateral aspect of the right (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 • Chin hold: Ensure your left forearm is over or slightly anterior to the ear • Vertex contact: Optional but often useful Positioning for thrust: Step slightly to the right. Introduce primary leverage of sidebending rtght (Fig. B1.11.1) and a small degree of secondary leverage of rotation left (Fig. 81.1 1.2). Align your body and right arm for the thrust plane, which is caudad in the direction of the patient's left shoulder and downwards towards the couch • 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 shoulder and downwards towards the couch. Simultaneously, apply a slight, rapid increase of sidebending of the head and neck to the right with no increase of rotation to the left (Fig. B1.11.3)
119
---Cervical spine C2-7
1.12
Down-slope gliding Cradle hold Patient supine
Assume sammie d}'S[1mcLioPl (5-T-A·H-T) is identified and )'OU wish CO use a dOlll11ward and backward gliding tlrmsl, parallel co tile apophysial joint plnlle, to produce cavitiltion at C4-5 on tire right:
1. Contact point
The: lateral aspect of the right anirular pillar ofC4.
KEY .:+,.
Stabilization
2. Applicator
•
Applicator
Lateral border. proximal or middle phalanx of operator's right index finger.
..
Plane of thrust (operator)
3. Patient positioning
,:)
Direction of body movement (patient)
Note: The dimensions for the arrows are not a pictorial representation d the amplitude or force of the thrust.
Supine with the neck in a neutral relaxed position. If necessary. remove pillow or adju.st pillow· height. The 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
121
I
HVLA thrust techniques - spine and thorax
as possible and avoid crouching over the patient as this will limit the technique and restrict deliwry of the thrust. S. Palpation of contact point
Place fingers of both hands gently under the occiput. Rotate the head to the left. taking its weight in )'Our left hand Remove your right hand from the occiput and palpate the right anicular pillar of C4 with the tip of your index or middle finger. Slowly but finnly slide your light index finger downwards (towards the couch) along the anicular pillar until it approximates the middle or proximal phalanx. Se\.·eraI sliding pressures may be necessary to establish dose approximation to the contact point. 6. Fixation of contact point
Keep the light index finger finnly pressed on 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 posilion, return the head to the neutral position.
9. Positioning for thrust
The elbows are held dose to or only slightly away from )'Our sides. 'Ihis is an essential feature of the cradle hold method. Stand easily upright at the head of the COUdl and do not step to the right as in the chin hold method. (a) Pri"IIU}' leverage of sidelxmdillg. t\laimaining all holds and contact points, gently imroduce sidebending of the head and neck to the right until tension is palpated at the contact point (Fig. 61.12.1). To imroduce the righl sidebending. the operator pivots slightly via the legs and trunk so that the Hunk and uJ>PE':r body rotate to the left. enabling the hands and arms to remain in position. Do not lose firm contact with )'Our contact point on the articular pillar of CA. A common mistake is to use imuffident primary levernge of head and neck sidebending. (b) Seamdaf}' IClJeTage. Add a little rotation to the left, down to and including CA (Fig. 81.12.2). This requires exte.nsi'\T pracLice before one develops a refined 'tension sense'. Movement of )'Our hands and forearms introduces the rotation.
7. Cradle hold
Keep the left hand under the head and spread the fingers out for maximum contact; kE.'Cp the paticlU's ear resting in the paJm of the your left hand. Hex the left wrist, allowing you to cradle the paticlll's head in your palm, nexed wrist and anterior aspect of forearm. Keep your right index finger firmly on the contad poilU and press the right palm against the occiput The weight of the patient's head and neck is now balanced between your left and right hands. with the cervical positioning convolJed by the converging pressures of your two hands and arms. When veating the lower cervical segments,. the middle or distal phalanx may be used as the applicator.
8. Vertex contact 122
None in this technique.
Figure 81.12.1
Cervical and cervlcothoracic spine
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 umil you can sense a state of approprioue tension and levernge. The 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
•
Figure 81.12.2
Figure 81.12.3
Relax and adjust your balance as necessary. Keep }'Our head up; looking dO\'\fIl impedes the thrust and can cause embarrassing proximiry to the patient. An effective IIVLA thrust technique is best achieved if both the operator 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 piUow as this facilitates the arrest of the technique and limits excessive amplitude of thrust Note that the final thrust is directed in a dO\'\fIl\vard and backward direction parallel to the facet joint plane. the thrust is directed to\varos the patient's left shoulder as iUustrated. 1lle primary leverage is sidebending to the right and the secondary (lesser leverage) is rotation to the left.
123
HVLA thrust techniques - spine and thorax
12. Delivering the thrust Apply a HVLA thrust to the right art~rular pillar of <:4. 'Ibe direction of thrust IS caudad in the direction of the patient's left shoulder and downwards towards the couch, parallel to the apophysial joint plane (Fig. B1.12.3). 'Ibe operator rotaling the trunk and upper Ixxly to the left. enabling the hands and anns to remain in position on the cervical spine,. generates the thrust.
124
l
Simuhaneou'ily, apply a very slight, rapid increase of sidebending of the head and neck to the right but do not increase the rotation leverage. 1be thrust. although very rapid must nC\'et" be excessively forcible. "be aim should be to use the absolute minimum force necessary to achieve joint cavitation. A common fault arises from the USE': of excesshoe amplitude with insufficient "clodly of thrust.
-
Cervical and cervicothoracic spine
. .
1.12
SUMMARY Cervical spine C2-7
Down-slope gilding
Cradle hold Patient supine • Contact point: lateral 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 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 s}des. Introduce primary leverage of sidebending to the right (Fig. 81.121) and a small degree of secondary leverage of rotation left (Fig. 81.12.2). Maintain the contact point on the lateral aspect of the right (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 shoulder and downwards towards the couch. Simultaneously, apply a slight, rapid increase of sidebending of the head and neck to the right with no increase of rotation to the left (Fig. 81.12.3)
125
Cervical spine C2-7 Down-slope gliding Patient sitting Operator standing to the side
Assllm. somaLic dysfullClioll (S-T-A-R-T) is ideruiji£d alld )'011 wisl. 10 use a downward lind oockwnrd gliding lhniSl.. parallel to tile apopllysinl joint. plane, to produce cavilillioll at C4-5 on the riglll:
,. Contact point Lateral aspect of the right anicular pillar of
KEY
C4. l"
Stabilization
•
Applicator
•
Plane of thrust (operator)
Q
Direction of boc1y movement (patient)
Note: The dimensions for the arrows
are not a pictorial representation of the amplitude Of force of the thrust.
2. Applicator Palmar aspect, proximal or middle phalanx of operator's left index or middle finger.
3. Patient positioning Sining with the neck in a neutral relaxed position. °llle neck should not be in any signifiGlflt amounl of flexion or extension. 4. Operator stance Stand to the left of the patient. feet spread slightly. Adjust couch height so IDal )'Ou can stand as erect as possible and avoid
127
I--
H..V.:L;.A thrust techniques - spine and thorax
FIgure 81.13.2 Figure 81.13.1
crouching over the paLient as !.his will limit the technique and restrict delivery of the thrust (Fig. 81.13.1).
5. Palpation of contact point
Place the fingers and palm of your right hand over the left side of the patient's head and neck, gentJy covering the left ear. Reach in front of the patient with your left hand and palpate the right anicular pillar of CA with the tip of your lefl index or middle finger. SIO\\lly bUI timlly slide your applicator along the anicuJar pillar of C4 until it approximates the proximal or middle phalanx. Several sliding pre;sures may be necessary 10 establish dose approximation to the COntact point. 6. Fixation of contact point '28
Keep your left index or middle finger firmly pressed upon the contact point while you
spread the other fingers and thumb o( the left hand to securely support the head mandible and neck. thereby locking the applicator in position. You must now keep the applicator on the contact poim until the technique is complete. 1he weight o( the head and neck is now balanced between your right and left hands. with the cervical spine positioning controlled by the converging pressures o( your two hands. 7. Positioning for thrust
The elbO\vs are held dose 10 or only slightly away (rom your sides. (a) Primary leuerag£ Ensure that the patient's head is securely supported between your two hando;. Maintaining all holds and contan points sidebend the head and neck to the right unlil tension is palpated at the contact point (Fig. 81.13.2). Do not lose contact between your applicator and the artiOllar pillar o( C4. Do not force sidebending; take it up fully but carefully. A common mistake is to use insufficient
Cervical and cervicothoracic spine
sides. Maintaining all holds. make any necessary changes in flexion. extension, sidebending or rotation until )'Ou can sense a state of appropriate tension and I~rage. The patient should nol be aware of any pain or discomforL 9. Immediately
pr~thrust
Relax and adjusl your balance as ntn'SSary. Keep )'Our head up; looking down improes the thrust and can C3US4!: embarrassing proximity to the patient. An effecth'e IIVLA 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 effective cavitation. 10. Delivering the thrust
Figure B1.13.3
primary leverage of head and neck sidebending. (b) S«tmdllr)' letlCTt/Se. Add a ve:ry small degree of rotation to the left, dOMl 10 and including C4. Slight movements of the operator's hands and arms imroduce the rotation. 8. Adjustments to achieve appropriate pre-thrust tension
Ensure your palienl remains relaxed. II is imponam 10 keep your elbows dose to your
Apply a HVLA thrust to the right anicular pillar of C4. The thrust is caudad and lowards the patient's left shoulder, parallel 10 the apophysial joint plane (Fig. 1l1.13.3). Simultaneously. apply a slight. rapid increase of sidebending 10 the right but do not increase rotation leverage. This is a HVLA 'flick' type thrust. Coordination between the leC! and right hands and arms is critical. The thrust, although ve:ry 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 lhe use of excessive: amplitude with insufficient velocity of thrust.
129
HVLA thrust techniques - spine and thorax
SUMMARY Cervical spine C2-7
Down-slope glldmg
Patient sitting Operator standing to the side • Contact point: lateral aspect of the right (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 left of the patient. feet spread slightly (Fig. 81.13.1) • 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 sidebending to the right (Fig. 81.13.2) and a small degree of secondary leverage of rotation left. Maintain the contact point on the lateral aspert of the right (4 articular pillar • Adjustments to achieve appropriate pre-thrust tension • Immediately p~thrust: Relax and adjust your balance • Delivering the thrust: The thrust is caudad and towards the patient's left shoulder. Simultaneously, apply a slight. rapid increase of sidebending of the head and neck to the right with no increase of rotation to the left (Fig. B1.13.3). Coordination between both hands and arms is critical
,130
Cervicothoracic spine C7-13 Rotation gliding Patient prone Operator at side of couch
As.sume somatic dysfunction (5-T-A-R- T) is identified and )00 wish to use a rolation gliding thrust, parallel to the apophysial joint, pume, to produce cavilation at the 12-3 apophysial joi,,, (Figs 81.14.1, 81.14.2)
Figure 81.14.2
Figure 81.14.1
1. Contact point
Right side of spinous process ofTI.
KEY ~;
2. Applicator
Stabilization
lllUmb of right hand. •
Applicator
-
Plane of thrust (operator)
¢
3. Patient positioning
Patient lying prone with the head and neck turned to the left and arms hanging over the edge of the couch or against the patient's
Direction of body movement (patient)
Note: The dimensions for the arrows are not a pictorial representation the amplitude or force of the thrust.
or
sides (Fig. B1.14.3). Illlroduce a small amount of sidebending to the right by gently moving the patienl's head 10 lh~ right while in th~ rotated position. Do not introduce 100 much sidebending. 131
--------
HVLA thrust techniques - spine and thorax
Figure 81.14.3
Figure 81.14.4
4. Operator stance
6. Positioning for thrust
Stand on the right side of the patient facing towards the head of the couch.
Keeping your position at the side of the couch, gently place your left hand against the left side of the patient's head. This hand will control the rOtation and sidebending leverages. Increase rotation of the patient's head and neck to the left by applying gentle pressure to the patient's head until a sense of tension is palpated at the contact point. Move your right foreann so that it lines up with your thumb against the spinous process of'1'3 and forms an angle of approximately 90° at the elbow (Fig. 81.14.5).
5. Palpation of contact point
132
Locate the spinous proc~ of 1'3. Place the thumb of your right hand gently but firmly against the right side of this spinous process. Spread the fingers of )'OUr right hand to rest over the patient's right lrape7jus muscle with your fingertips resting on the patient's right davicle (Fig. 81.14.4). Ensure that )UU have good contact and will not sLip off the spinous process ofT3 when you apply a force against it. Maintain this contact point.
Cervical and cervicothoracic spine
7. Adjustments to achieve appropriate pre-thrust tension Ensure the patient remains relaxed. MaiOlaining all holds. make any necessary c:hanges in 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 discomfort. Make these final adjustmE"nts by altering thE" pressurE" and direction of forces between the left hand against thE" patient's head and }'Qur right thumb at thE" contaa point.
B. Immediately pre-thrust Relax and adjust )'OUr balance as necessary. Keep your hE"ad up and ensure that your contacts are firm and your body position is well c:ontrolled. An effective IIVLA thrust technique is best ac:hieved if thE" operator and patiE"nt are relaxed and not holding lhemselws rigid. This is a common impedimmt to achieving effeeth'e cavitation. 9. Detivering the thrust
Figure B1.14.5
Figure 81.14.6
Apply a IIVlA thrust to the spinous process of13 in thE" direaion of the patient's left shoulder joinl. Simultaneously. apply a slight. rapid inc:rE"ase of hE"ad and neck rotation to the left with }'OUr left hand (Fig. B1.14.6). The thruSl induces local rotation of the T3 venebra. focusing forces at the 1'2-3 segment. You muSl not overemphasize
133
HVLA thrust techniques - spine and thorax
the thrust with your left hand against the patient's head. Your left hand stabilizes Ihe leverages and maintains the position of the head against the thrust imposed upon the contact point. The thrust is induced by a wry rnpid contraction of the shoulder adductors.
Th€" thrust. although \'ery rapid. must never be excessively forcible. The aim should be to use the absolute minimum force necessary 10 achieve joint cavilalion. A common fault arises from the use of excessivt' amplitude ,.,ith insufficient velocity of thrust.
SUMMARY
Cervicothoracic spine C7-T3
Rotation gilding
Patient prone
Operator at side of couch • Contact point: Right side ofT3 spinous process • Applicator: Thumb of right hand • Patient positioning: Prone with the head rotated to the left and arms hanging over the edge of the couch or against the patient's sides (Fig. 81.14.3). Introduce a small amount of sidebending to the right Do not introduce too much sidebending • Operator stance: Right side of the patient facing towards the head of the couch • Palpation of contact point: Place the thumb of your right hand against the right side of the spinous process ofD. Spread the fingers of your right hand to rest over the patient's trapezius muscle and clavicle (Fig. 81.14.4) • Positioning for thrust: Place your left hand against the left side of the patient's head. Increase rotation of the head and neck to the left until a sense of tension is palpated at the contact point. Move your right forearm so that it lines up with your thumb against the spinous process ofD and forms an angle of approxImately 90° at the elbow (Fig. 81.14.5) • Adjustments to achieve appropriate pre-thrust tension • Immediately pre-thrust Relax and adjust your balance • Delivering the thrust Thrust is directed towards the patient's left shoulder joint. Simultaneously, apply a slight rapid increase of head and neck rotation to the left with your left hand (Fig. 81.14.6). You must not overemphasize the thrust with your left hand against the patient's head 134
Cervicothoracic spine C7-T3 Rotation gliding Patient prone Operator at head of couch
I
Assume somatic dysfullaion [S-T-A-R-T) is identified and you wi511 Lo use a rotarion gliding thrust. parallel to the ap6physial joint. plane. Lo produce cavitacion at the 12-3 apoph)'sUll joint.:
1. Contact point
KEY
Transverse process of '1"3 on the: left.
.;f"
Stabilization
•
Applicator
2. Applicator
Ilypothenar eminence of left hand. 3. Patient positioning ..
Plane of thrust (operatOf)
':> Direction of body movement (patient) Note: The dimensions fOf the arrows
are not a pictorial representation of the amplitude or force of the thrust
Patient prone with the point of the dlin resting on the couch and the anns hanging over the edge of the couch or against the paliem's sides. Introduce a small amount of sidebending 10 the right by gently Hrling and moving the patient's chin 10 the right (Hg. B1.I5.1). Do nO( introduce tOO mudl sidebending. 13S
HVLA thrust techniques - spine and thorax
Figure 81.15.1 4. Operator stance
I lead of the couch, fet::t spread slightly. Stand as erect as possible and avoid crouching (wer the patient as this will limit the technique and restrict delivery of the thrust. 5. Palpation of contact point
Locate the transverse process ofT3 on the left. Place the hypothenar eminence of your left hand gently but firmly against the transverse process of 1'3 on the left. Ensure that you have good contact and will not slip across the skin or superficial musculature when you apply a caudad and dO'ovnward force towards the couch again.'it the transwrse process of1'3. Maintain this contact point. 6. Positioning for thrust
136
Keeping your positjon at the head of the couch, gently place your right hand against the left side of the patient's head and neck with your fingers pointing to\vards the
patient's right shoulder. While maintaining the right sidebending introduced earlier, begin to rotate the cervical and upper thoracic spine to the left by applying gentle pushing pressure to the left side of the patient's head and neck with your right hand (Pig. B1.15.2). Maintaining all holds and pressures, complete the rotation of the patient's head and neck until a sense of tension is palpated at your left hypothenar eminence. Keep firm pressure against the contact point. 7. Adjustments to achieve appropriate pre-thrust tension
Ensure the patient remains relaxed. Maimaining all holds. make any necessary changes in extension, sidebending or rotation until )IOU 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 altering the pressure and direction of forces between the right hand against the patiem's head and neck and
Cervical and cervicothoracic spine
your left hypOlhenar eminence against the contact point. 8. Immediately pre-thrust
Helax and adjust your balance as necnsary. Ke€p your head up and ensure that your
7.15
COnlacts are firm and that your body position is well controlled. An eITectiw IIVl.J\ thrust technique is best achieved if the operator and patiem are relaxed and nOt holding themselves rigid. This is a common impedimcm 10 achieving effective cavitation. 9. Delivering the thrust
Apply a I M..A lhrust to the left tranlo",'et'Se process of 1'3 down tQ\Y
Figure 81.15.3
137
HVlA thrust techniques - spine and thorax
SUMMARY
Cervicothoracic spine C7-T3 Rotation glidmg 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 sidebending to the right (Fig. B1.1 s.l). Do not introduce too much sidebending • Operator stance: Head of the couch, feet spread slightly • Palpation of contact point: Place your hypothenar er,ninence 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. Rotate the cervical and upper thoracic spine to the left by applying pushing pressure to the left side of the patient's head and neck with your right hand until a sense of tension ;s palpated at the contact point (Fig. 61.15.2)
• 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. B1.1s.3). You must not overemphasize the thrust with your right hand against the patient's head
138
Cervicothoracic spine C7-T3 Rotation gliding Patient prone Operator at head of couch - variation
~
Assume somaric dYSfu'u:tion (S-T-A-R-7J is identified and )"u wish
10
use a rotation gliding thrust, parallel to the apophysial joint plane, to produce Ciliritati5!!J at tile 12-3 apopll)'sial jainl~
1. Contact point
KEY
Transverse process of1'3 on the left.
.:t~
Stabilization
•
Applicator
•
Plane of thrust (operator)
':>
Direction of body movement
2. Applicator
Ilypolhenar eminence of left hand. 3. Patient positioning
(patient) Note: The dimensions for the alTows are not a pictorial representation of the amplitude or force of the thrust.
Patient prone wilh the pOint of 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. No"., introduce a small amount of sidebending 10 the right by gently lifting and moving the patient's hf'ad to the right (Fig. 81.16.1). 139
HVLA thrust techniques - spine and thorax
Figure 81.16.1
4. Operator stance
To the right of the head of me couch. feet spread slightly. Stand as erect as possible and avoid crouching over the patient as this will limit the technique and reslria delrvery of me Ihrust. 5. Palpation of contact point LOGue Ihe transve~ process ofT3 on the left. Place the hypothenar eminence of your left hand gently but firmly against the transverse process of1'3 on the left. Ensure that you have good contad and will not slip across the skin or superficial musculature when you apply a caudad and downward force towards the couch against me transverse process ofD. Maintain this contad point. 6. Positioning for thrust
140
Keeping yOUT position at the head of the couch. gently place your right hand against the left side of the patient's head and neck with your fingers pointing towards the couch. While maim3ining the right
Figure 81.16.2
sidebending introduced earljer, begin to ralate the cervical and upper moracic spine to the left by applying gentle pulling pressure to the left side of the patient's head and neck with your right hand (fig. 81.16.2). Maintaining all holds and pressures, complete the rotation of the patient's head and neck until a sense of tension is palpated at your left hypothenar eminence. Keep finn pressure against the contad point. 7. Adjustments to achieve appropriate pre--thrust tension
mUTe the patient remains relaxed. Maintaining all holds, make any necessary changes in flexion, extE'.nsion, sidebending or rotation until you can sense a state of appropriate tension and It"\'erage.. 1he patient should nol be a\voue of any pain
Cervical and cervicothoracic spine
~;:7.76 .----
or discomfon. You make these final adjustments by altering the pressure and direction of forces bet ....·een the right hand against the p_nient's head and neck and your left hypothenar eminence against the COntaa point. B.lmmediately pre-thrust Relax and adjust your balance as necessary. Keep your head up and ensure that your , / contacts are firm and that }~y - - position is w€':l1 controlled. An effective IIVlA thrust technique is best achiewd if the operator and patient are relaxed and not holding themsel~ rigid. This is a common impediment to achieving effectivt> 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
HVLA thrust techniques - spine and thorax
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
-
Plane of thrust (operator)
¢
Direction of body movement (patient)
3. Patient positioning
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
HVlA thrust techniques - spine and thorax
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 b
Cervical and cervicothoracic spine contan point and the right hand and forea-nn against the patient's head and neck. 8. Immediately pre-thrust He.lax and adjust your balance as necessary. Keep ),our head up and ensurt' that )'Our contacts are firm and that the patient's body weight and position art' v.-ell controlled. An effective HYlA thrust technique is best achieved if the operator and patient are relaxed and not holding themselves rigid. "Jllis is a common impediment to achieving effective cavitation. 9. Delivering the thrust Apply a HVlA thrust to the: left side: of the spinous process ofTI in the direction of the patient's right axilla. At the same time. slightly increase head and neck sidebending to the left with your right arm (Fig. 81.17.4). 'rbe thrust on the spinous process of12 and the slight increase in neck sidebending to the left focus forces at the
Figure 81.17.3
-
Figure B1.17.4
145
HVLA thrust techniques - spine and thorax 1'2-3 segment and causes cavitation at that level. 'l11e thrust is induced by a wry rapid contraction of the shoulder adductors. The thrust, although very rapid, must never be excessively forcible. The aim
should be to use the absolute minimum force necessary to achieve joint cavilation, A common fault arises from the use of excessiVE' amplitude with insufficient velocity of thrust.
SUMMARY Cervicothoracic spine (7-13 Sidebendlng gliding Patient sitting Contact point: left side of the T2 spinous process • Applicator: Thumb of left hand • Patient positioning: Patient sitting with back towards the operator • Operator stance: Behind the patient • Palpation of contact point: Place your left thumb against the left side of the T2 spinous process. Spread the fingers of your left hand to rest oller the patient's trapezius muscle and clavicle (Fig. B1.17.1) • Positioning for thrust: Place your right hand and forearm alongside the right side of the patient's head and neck (Fig. Bl .17.2). Use your left hand to slightly rotate the patient's trunk to the left whilst using your right hand to introduce head and neck rotation to the right (Fig. B1.1 7.3). Introduce left sidebending to the cervical spine, localizing forces to the T2-3 segment Ensure that your applicator thumb forms a straight line with your left forearm • 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 axilla. Simultaneously. apply a slight, rapid increase of head and neck sidebending to the left (Fig. B1.17.4)
146
Cervicothoracic spine C7-T3 Sidebending gliding Patient sitting Ligamentous myofascial tension locking
Assu"", sommie d)'sfuncriOl1 (5-T-A-R-T) is identifi£d and )'OU wis/. to use a sideberzding gliding thrust, parallel to the apophysinl joint plane, to produce cavitntion at the 12-3 apopl1ysial joint:
V ...... . ~ -W.
..
i ~
'~' .... ; : N i
.
1. Contact point
KEY
Left side of me spinous process of1'2.
.,;~
Stabilization
•
Applicator
2. Applicator 'l11umb of left hand.
3. Patient positioning -
Plane of thrust (operator)
Patient sitting with back tmvards the
operator.
<>
Direction of body movement (patient)
Note: The dImensions for the arrows are not a pictorial representation of the amplitude or force of the thrust.
4. Operator stance
Stand behind the patient. 5. Palpation of contact point
Locate the spinous process or1"2. Place the lhumb of your left hand gently but finnly
147
_ _ _ _ _1
HVLA thrust techniques - spine and thorax
Figure 81.18.1
6. Positioning for thrust
Figure 81.18.2
148
against the left side of this spinous process. Spread the fingers of your left hand to rest over the patient's left trnpezius musde with your fingertips resting on the patient's left davide (Fig. B1.18.1). Ensure that you have good contact and will not slip off the spinous process of1'2 when you apply a force against it. Maintain this contact point.
Keeping your position behind the patient, place }'Our right hand and foreann alongside the right side of the patient's head and neck and gently rest the palm of )'Our hand O\'er the top of the patient's head (Fig. BI.18.2). Ensure that )'Our forearm remains anterior to and just over, the patient's ear. lhis hand will introduce and control the rotation and sidebending leverages.. Use )'Our right hand to introduce a small amount of head and neck extension (Fig. Bl.18.3). Now introduce cervical sidebending to the left by allowing the patient'S body weight to full slightly to the right. Keeping the patient's head centred over the sacrum, guide the neck into left sidebending with your right ann against the right side of the patielll's head. A venex compression force can be added to assist in localizing forces to the 1'2-3 segment. Ensure that your applicator thumb forms a straight line with your left forearm. 7. Adjustments to achieve appropriate pre-thrust tension Ensure the patient remain... relaxed. Maintaining all holds, make any necessary changes in flexion. extension, sidebending or rotation until you can sense a Slate of appropriate tension and le\'erage. 'Ille patient should not be 3'\13re of any pain or discomfort. Make these final adjusunents by balancing the pressure and direction of
Cervical and cervicothoracic spine
Figure 81.18,3
Figure 81.18.4
forces between lhe left hand against the contact point and the right hand and forearm a~inst the patient's head and
emplll1Sis on lJ>e exJJggeralUm of prinwry leverage tlmn i5 d>e case with faut apposition IocIring rechniques. Apply a IlVlA thrust to the left side of the spinous process of1'2 in the direction of the patient's right axilla. At the same time. increase head and neck sidebending to the left with your right arm (Fig. R1.18.4). 'the thrust on the spinous process of1'2 and lhe increase in neck sidebending to the left focus forces at the 1'2-3 segment and causes cavitation at that level. 'I"e thrust is induced by a very rapid contraction of the shoulder adductor'S. 'Ihe thrust. although very rapid. must n£'Ver be excessively fcrable. 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.
neck. 8. Immediately pre.thrust Helax and adjust your balance as necessary. Keep your head up and ensure that your contacts are finn and that the patient's body weight and position are well controlled. An effective IiVLA thrust technique is best achieved if the operator and patient are rela.xed and nOI holding themselves rigid. 'I"is is a common impediment to achieving effective cavitation. 9. Delivering the thrust
This feclmiqlle uses Iigamt!7ltous myofascinl tension foching and nOf facet apposition Iocl.'ing. This approacll generally requires a gretJter
1.18
"9
HVLA thrust techniques - spine and thorax
SUMMARY Cervicothoracic spine C7-T3 Sidebendlng glIding Patient sitting Ligamentous myofascial tension locking Contact point: Left side of the T2 spinous process • Applicator. Thumb of left hand • Patient positioning: Patient sitting with back towards the operator • Operator stance: Behind the patient • Palpation of contact point: Place your left thumb against the left side of the T2 spinous process. Spread the fingers of your left hand to rest over the patient's trapezius muscle and davide (Fig. B1.18.1) • Positioning for thrust: Place your right hand and forearm alongside the right side of the patient's head and neck (Fig. B1.18.2). Use your right hand to introduce a small amount of head and neck extension (Fig. 81.18.3). Introduce left sidebending to the cervical spine localiZing forces to the T2-3 segment. Ensure that your applicator thumb forms a straight line with your left forearm • 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 axilla. Simultaneously, apply a rapid increase of head and neck sidebending to the left (Fig. 81.18.4)
150
Cervicothoracic spine C7-T3 Sidebending gliding Patient side-lying
Assume somatic d).function (S-T-A-R-TJ is identified and)'OU wish to use a sidebending gliding tJl11lSt, parallel to the apophysial joint plane,
w produce Cl1vitalion
at the T2-3 apophysial joint:
1. Contact point
KEY
Right side of the spinous process orn.
*
Stabilization
•
Applicator
3. Patient positioning
•
P1ane of thrust (operator)
Patient lying on the left side. Flex the patient's knees and hips for stability.
¢
Direction of body movement (patient)
2. Applicator 'Ihumb of left hand.
Note: The dimensions for the arrows
are not a pictorial representation of the amplitude or force of the thrust.
4. Operator stanc:e Stand facing the patient and gently place your right arm under the head. lightly spreading your fingers around the patient's OCcipUL "be head should now be cradled in your right arm with your upper arm against the patient's forehead and your foreann and hand supporting the head and neck.
151
HVLA thrust techniques - spine and thorax
Figure B1.19.1
Figure B1.19.2
s. Palpation of contad point
Locate the spinous process ofTI. Place the thumb of your left band gently but firmly against the right side of this spinous process. Spretl.d the fingers of your left hand to entl.ble firm conttl.ct of your thumb. This will ensure that you have good contact and will nOI slip off the spinous process when you apply a force against it. Maintain Ihis contact point but do not press too hard, as it can be uncomfonable. 6. Positioning for thrust
152
Using your right arm, sidebend me patient's head and neck to the right until a sense of tension is palpable at the contact point. lbis sidebending is achieved by gently lifting the
patient's head, within the cradle of )'OUf right arm (Fig. 81.19.1). Gently introduce cervical rotation to me left ulllil a sense of tension is palpated at the contact point (Fig. B1.19.2). If necessary, you may add a compression force to Ihe patient's shoulder girdle:, fcom your chest, to stabilize the upper torso before applying the thrust. 7. Adjustments to achieve appropriat@ pr@-thrusttension Ensure the patient remains relaxed. Maintaining all bolds. make any necessary changes in flexion. extension, sidebe:nding or rotation until you can sense a Slate of appropriate tension and leverage at the
Cervical and cervicothoradc spine
1.19
Figure 81.19.3
contact point. ]ne patient should not be aware of any pain or discomfon. Make these final adjusunents by balancing me pressure and direction of forces between the left hand against the contact point and the right hand and forearm against the patient's head and neck. 8. Immediately pre-thrust
Relax and adjust your balance as necessary. Keep your head up and ensure that your conlacts are firm and that your body position is well controlled. An effeoive 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
direction of the patient's left shoulder. 'Ine thrust is accompanied by a simultaneous downward application of force with your chest to the patient's right shoulder girdle, AI. the same time, introduce a slight increase in head and neck sidebending to the right with your right arm (Fig. BI.19.3). The thrust on the spinous process of 1'2 and slight increase in neck sidcl>ending 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
HVLA thrust techniques - spine and thorax
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
3. Patient positioning
-
Plane of thrust (operator)
Palienllying on the left side. Plex !.he paLienl's knees and hips for stability.
Q
Direction or I:x>dy movement (pattent)
Note: The dimensions for the arrows are not a pictorial representation of the amplitude or force of the thrust.
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
HVLA thrust techniques - spine and thorax
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
Cervical and cervicothoracic spine
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
HVlA thrust techniques - spine and thorax
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
-
Plane of thrust (operator)
Q
Direction of body movement (patient)
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
HVLA thrust techniques - spine and thorax
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.
6. Adjustments to achieve appropriate pre-thrust tension
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.
Cervical and cervicothoracic spine
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
HVLA thrust techniques - spine and thorax
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
HVLA thrust techniques - spine and thorax
•
Figure 82.0.3
Figure 82.05
164
Figure 82.0.4
Thoracic spine and rib cage
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
-
Plane of thrust (operator)
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
HVLA thrust techniques - spine and thorax
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
------------
Thoracic spine and rib cage
\\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.
8. Delivering the thrust
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
HVLA thrust techniques - spine and thorax
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
170
Thoracic spine T4-9 Flexion
gJ.idi~-~
Patient supine Ligamentous myofascial tension locking
Assume sOIMtic dysfimetiOll (5-T-A-R- T) is identified and )"u wish 10 use a flaimJ gliding thrust, parallel to the apop/l)'sial joint plane, lO produce joim cavitarion al T5-6~
1. Contact points
KEY
(a) TransYelse processes of '1'6 (b) Palient's elbows.
•:t:.
Stabilization
•
Applicator
-
Plane of thrust (operator)
Q
Direction of body movement (patient)
2. Applicators
(a) Palm of the operator's right hand. held in a clenched position (b) Operator's lower sternum or upper abdomen.
3. Patient positioning Note: 1lle dimensions for the arrows are not a pictorial representation of the amplitude or force of the thrust.
Supine with the arms crossed over the cht'St and hands passed around the shoulden. "l1l.e arms should be firmly clasped round the body as fae as the patient can comforubly reach (Fig. 82.2.1).
171
HVLA thrust techniques - spine and thorax
Figure B2.2.1
Figure 82.2.2
4. Operator stanceA~
If>'-~
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
Thoracic spine and rib cage
. -
.
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
HVLA thrust techniques - spine and thorax
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
Thoracic spine and rib cage
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
-
Plane of thrust (operator)
(b) Operator's lower sternum or upper abdomen.
..)
Direction of body movement
(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.
HVLA thrust techniques - spine and thorax
Figure 823.1
Figure 82.3.2
4. Operator stance
Stand on the right side of the patient. facing the couch.
5. Positioning for thrust
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
Thoracic spine and rib cage
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.
6. Adjustments to achieve appropriate pre-thrust tension
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
HVLA thrust techniques - spine and thorax
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..
Thoracic spine and rib cage
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
-
Plane of thrust (operator)
¢
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
HVLA thrust techniques - spine and thorax
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
Thoracic spine and rib cage
-
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
HVLA thrust techniques - spine and thorax
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
Thoracic spine and rib cage
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
-
Plane of thrust (operator)
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
HVlA thrust techniques - spine and thorax
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
Thoracic spine and rib cage
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 ne
191
HVlA thrust techniques - spine and thorax
SUMMARY Ribs R1-3 Patient prone Gliding thrust • Contad point: Angle of the right second rib • Applicator: Hypothenar eminence • Patient positioning: Patient prone with the chin resting on the couch and arms hanging over the edge of the couch. Introduce sidebending to the left (Fig. 82.5.3). 00 not introduce too much sidebending • Operator stance: Head of the couch. feet spread slightly • Palpation of contad point: Place your hYFXlthenar eminence against the angle of the second rib on the right. Ensure that you have good contact and will not slip across the skin or superficial musculature when you apply a caudad and downward force towards the couch against the angle of the second rib • Positioning for thrust: Place your left hand against the right side of the patient's head and neck. Rotate the cervical and upper thoracic spine to the right. by applying pressure to the right side of the patient's head and neck with your left hand until a sense of tension is palpated at the contact FXlint (Fig. 82.5.4)
• Adjustments to achieve appropriate pre-thrust tension • Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: The thrust to the angle of the second rib on the right is directed downwards towards the couch and also in a caudad direction towards the patient's right iliac crest. Simultaneously, apply a slight. rapid increase of head and neck rotation to the right with your left hand (Fig. 82.5.5). You must not overemphasize the thrust with the left hand against the patient's head and neck
192
Ribs R4-10 Patient supine Gliding thrust Ligamentous myofascial tension locking
Ass"'''e solllalic dysfunClitm (S·'FA'/l-T) is identified .,UJ )'OU 1I1is/. 10 produce caviratioll lit tile coSlOlmmver5e joim of lhe sixth rib on the left (Fig. 82.6./):
Figure 82.6.1
1. Contact p~nts
KEY
(a) Sixth rib on the left, just lateral to the transverse process ofT6 (b) Patjent's elbows and left forearm.
;:;:.
Stabilization
•
Applicator
-
Plane of thrust (operator)
(a) Hypolhemu eminence of the openuor's right hand (b) Operntor's lower sternum or upper abdomen.
<;;)
Directton of body movement (patient)
3. Patient positioning
2. Applicators
Note: The dimensions for the arrows
are not a pictorial representation of the amplitude or force of the thrust.
Supine with the arms crossed over the dlt~SI and the hands passed around the shoulders. The left arm is placed O\'I':f the right arm. The arms should be finnly clasped around the body as far as me paliel1l call comfortably reach.
193
HVlA thrust techniques - spine and thorax
Figure 82.6.2
Figure 82.63
4. Operator stance
Stand on the right side of the patient, facing the couch.
s. Positioning for thrust
194
Reach over the patient with your left hand to take hold of the left shoulder and gently pull it to..."ards you. With your right hand, locate the sixth rib on the left. Now place the hypothenar eminence of your right hand against the rib just lateral to the transverse process ofT6 (Fig. 62.6.2). Keeping contact with the rib, begin rolling the patient back to the supine
position (Fig. B2.6.3). Continue until the patient's elbows are directly over your hypothenar eminence. This introduces additional rotation, which is a critical elemelll in Lhe technique. Hest your lower Sternum or upper abdomen on the patient's elbows and left foreann. Initially. a slow but finn pressure is applied with your lower sternum or uppt>r 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
.
Thoracic spine and rib cage
-..
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.
8. Delivering the thrust
This technique I~ ligllment01lS mrofllSdal temiml locking and nor faat apposirion locking.
195
.,
J
HVLA thrust techniques - spine and thorax
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
•
Plane of thrust (operator)
¢
Direction of body movement (patient)
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
HVLA thrust techniques - spine and thorax
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.
6. Positioning for thrust
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
Thoracic spine and rib cage
tension is achieved by positioning the of the sixth rib to\vards the end f3.n~ of av
CO'ltotf3.llS~rse joint
7. Adjustments to achieve appropriate pre-thrust tension
Ensure your patient remains relaxed. Maintaining all holds. make any neCfSSal)' changes in extension, sidebending and rotation until )'Ou sense a state of appropriate tension and levera~ at the costotr.:lnsverse joint of the sixth rib. The patient should not be aware of any pain or discomfort. 8. Immediately pre-thrust Relax and adjust your balance as necessary. Keep your head up and ensure that your contaclS are firm. An effective HVLA lhrust technique is best achieved if the opern.lor and patient are relaxed and not holding themselves rigid. 'J11is is a common impediment [0 achieving effective cavitation.
9. DeUvering the thrust
Figure 82.7.3
Apply a IIVLA thrust directed in a downward and cephalad direction against the angle of the sixth rib. It is important to achieve fixation ofT6 by maintaining a finn dow'oward pressure against the tr.:lnsverse process ofT6 on the righL The thrust is generated by your right hand in contact with the sixth rib (Fig. 82.7.4).
Figure 82.7.4
199
HVLA thrust techniques - spine and thorax The thrust. although very rapid. must
never be excessiVl"ly forcible. ·me aim should be to use the absolute minimum force necessary to achieve joint cavitation.
A common fault arises from the use of
excessh", amplitude with insuffident velocity of thrust.
SUMMARY Ribs R4-10 Patlent prone Gliding thrust
•
I
J
• Contact points: Angle of left sixth rib (right applicator). Right transverse process ofT6 (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 angle of the patient's left sixth rib and establish a firm contact (Fig. 82.7.1). Place the hypothenar eminence of left hand against the right transverse process of T6 (Fig. 82.7.2) • 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. 82.7.3). Appty an additional force directed cephalad with the right hand against the angle of the sixth rib • 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 angle of the sixth rib. It is important to achieve fixation of T6 by maintaining a firm downward pressure against the transverse process of T6 on the right. The thrust is generated by your right hand in contact with the sixth rib (Fig. 82.7.4)
200
Ribs R4-10 Patient sitting Gliding thrust
Assume somatic dj~fu"ctioll (5-T-A-R- T) is idenrified alld )"u wish to produce cavit.ation at. t.he costotransverse join! of the rig1lt sixth rib (Fig. B2.8.1):
Figure 82.8.1 1. Contact point
KEY
*
Angle of right sixth rib.
Stabilization
2. Applicator
Ilypothenar eminence of right hand. •
Applicator
3. Patient positioning •
Plane of thrust (operator)
f.::>
Direction of body movement
(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'
HVLA thrust techniques - spine and thorax
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
Thoracic spine and rib cage
Figure 82.85
6. Adjustments to achieve appropriate pre-thrust tension
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
8. Delivering the thrust
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
HVLA thrust techniques - spine and thorax
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
HVLA thrust techniques - spine and thorax
Figure B3.0.2
Figure B3.03
Figure 83.0.4
206
Lumbar and thoracolumbar spine
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
•
Plane of thrust (operator)
¢
Direction of body movement (patient)
Note: The dimensions for the arrows are not a pictorial representation of the amplitude or force of the thrust.
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
HVLA thrust techniques - spine and thorax
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
HVLA thrust techniques - spine and thorax
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
1. Patient positioning
.:t: Stabilization •
Applicator
•
Plane of thrust (operator)
...,
Direaion of body movement (patient)
Note: The dimensions for the arrows
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
HVLA thrust techniques - spine and thorax
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.
Lumbar and thoracolumbar spine
----. - T .......
.....
Figure 83.2.1
215
HVLA thrust techniques - spine and thorax
•
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
..
Plane of thrust (operator)
¢
Direction of body movement (patient)
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
HVLA thrust techniques - spine and thorax
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
HVlA thrust techniques - spine and thorax
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
1. Patient positioning
*:-
Stabilization
•
Applicator
•
Plane of thrust (operator)
<>
Direction of body movement (patient)
Note: The dimensions for the arrows are not a pictorial representation of the amplitude or force of the thrust.
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
HVlA thrust techniques - spine and thorax
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
4. Adjustments to achieve appropriate pre-thrust tension
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
HVLA thrust techniques - spine and thorax
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 dy
KEY 1. Patient positioning -$
Stabilization
•
Applicator
Sitting on the treatment couch with the arms folded. The patient should be encouraged to maintain an erect posture.
-
Plane of thrust (operator)
2. Operator stance
Direction of body movement (patient)
Stand behind and slightly to the right of the patient with your feet spread. Pass your right ann across !.he front of the patienl's chest to lightly grip the patient's left thorax (I'tg. B3.5.1).
<>
Note: The dimensions for the arrows are not a pictorial representation of the amplitude or force of the thrust
3. Positioning for thrust Place your left hypothenar eminence to the right side of the spinous process of L3 and
225
HVlA thrust techniques - spine and thorax
Figure 83.5.1
Ftgure 83.5.2
226
introduce right sidebending to the: patient's thoraac and upper lumbar spine (Fig. H3.5.2). The thoracic and upper lumbar spine is now rotated to the right to lock the spine down to but not including L3. The operator maintains as erect a posture as possible. Keep your left hypothenar eminence firmly applied to the spinous process of L3 with your left arm held close to your body.
5. Immediately pre-thrust
4. Adjustments to achieve appropriate pre-thrust tension
A degree of momentum is n«cssary to achieve a successful cavitation. It is desirable for the momentum component of the thrust to be restricted to one plane of motion and this should be rotation. Rock the patient into and out of rotation while maintaining the sidebe.nding and flexion/extension positioning. When dose to full rotation. you will sense a state of appropriate tension and leverage at the 1.3-4 segment, at which poilll you apply a HVLA thrust against the spinous process of L3. Thc thrust is directed
Ensure your paticnt remains relaxed. Maintaining all holds, make any necessary changes in flexion, extension, sidebending or rotation until you can sense a state of appropriate tCl1Sion and leverage at the: 1.3-4 segmcnt. The patient should not be a\va.re of any pain or discomfort- Make these final adjustments by slight movements of the shoulders. trunk. ankles, knees and hips.
Relax and adjust your balance as necessary. An effective HVLA thrust t«hnique is best achiE:\cl if both thc operator and paticlll are relaxed and not holding themselves rigid. TIlis is a common impediment to achieving effective cavitation. 6. Delivering the thrust
lumbar and thoracolumbar spine
to the spinous process of L3 aJld accompanied by a slight exaggeration of right rotation (Fig. B3.5.3). 1be thrust, although \'el)' rapid. must never be excessi~ly forable. The aim should be to ust' the absolute minimum force necessal)' to achieve joint cavitation. A common fault arises from the use of excessive amplitude with insuffident velocity of thlU'it.
Figure 835.3
227
HVLA thrust techniques - spine and thorax
SUMMARY Lumbar spine L1-5 Neutral positioning Patient sitting Rotation gliding thrust • Patient positioning: Sitting erect • Operator stance: Behind and slightly to the right of the patient with your right arm across the front of the patient's chest (Fig. 835.1) • Positioning for thrust: Place your left hypothenar eminence to the right side of the spinous process of l3 and introduce right sidebending to the patient's thoracic and upper lumbar spine (Fig. 83.5.2). The thoracic and upper lumbar spine is now rotated to the right to kx:k the spine down to but not including l3 • Adjustments to achieve appropriate pre-thrust tension • Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: The thrust is directed to the spinous process of L3 and accompanied by exaggeration of right rotation (Fig. 83.5.3). A degree of momentum is necessary to achieve a successful cavitaUon. The momentum component of the thrust should be in the direction of rotation
228
Lumbosacral joint (LS-Sl) Neutral positioning Patient side-lying Thrust direction is dependent upon apophysial joint plane'
Assume somatic d)'s/unction (S-T-A-R-T) is identified aPld you uris11 to use a gliding thmst lO produce cavitntion at 15-51 on the right (Figs 83.6.1,83.6.2): < ,
Figure 83.6.1
D,J
v-'
"i'
Figure 83.6.2
1. Patient positioning
KEY W'
Stabilization
•
Applicator
-
Plane of thrust (operator)
1:)
Direction of body movement (patient)
Note: The dimensions for the arrows are not a pictorial representation of the amplitude or force of the thrust
Lying on th~ left side with a pillow to support the head and neck. Lower body. Straighten the patient's lower (left) leg at the knee joint while placing the 'The condition where joints are asymmetrically orientated is referred to as articular tropism. The lumbosacral zygapophyslal joints would normally be orientated at approximately 45· with respect to the sagittal plane. There is considerable individual variation and you will encounter patients wilh lumbosacral apophysial joint planes that range between sagittal and coronal orientation. The variation in apOphysial joint plane means that considerable palpatory skill is required to localize forces accurately at the lumbosacral joint and to determine the most suitable direction d thrust
HVLA thrust techniques - spine and thorax
Maintain an upright posture. fadng slightly in the direction of the patient's upper body. Keep your left arm as close to }'our body as possible. 3. Positioning for thrust
Apply your left forearm 10 the region bt'twn~n gluteus medius and maximus. Your left forearm nO\\I controls 100\lef body rotation. Your right foreann rests on the patient's right axillary area. This will control upper body rotation. First, appl}' pressure to the patient's pelvis until motion is palpated at the IS-SI segment. Relate the patient's upper body away from }"1)u using }"1)ur right ann until a sense of tension is palpated at the IS-SI segment. Finally, roll the patient aboul 10-15· towards you while maintaining the build~up of IC\~ at the 15-5lsegmenL Figure 83.6.3 4. Adjustments to achieve appropriate pre-thrust tension
left hip in approximately 20° of flexion. Flex the patient's upper knee and place the patient's right foot behind the left lower leg (Fig. B3.6.3). This position provides stability to Ihe lower body. Upper !JOtI,.. Gently extend the patient's uppe.r shoulder and place the patient's right forearm on the lower ribs. Using your left hand to palpate lhe 15-S I interspinous space, introduce right rotation of the patient's upper body down to the 15-S1 segment. This is achieved by gently holding the patient's left elbow with your right hand and pulling it towards you, but also in a cephalad direction towards the head end of the couch. Be careful not to introduce any flexion to the spine during this movement. Right rotation is continued until your palpating hand at the 15-S1 segment begins to sense motion. 'rake up the axilIaI)' hold. This arm controls the upper body rotation. 2. Operator stance
230
Stand close to the couch with your fcd spread and one leg behind the other.
Ensure your patient remains relaxed. Maintaining all holds. make any neCl'SSary changes in flexion, ext~nsion, sidebending or rotation until }UlI can sense a state of appropriate tension aJld k"\~rage at the L5-S1 segment. The patient should not be aware of any pain or discomfort. Make these final adjustments by slight movements of the should~rs. trunk. ankles. knees and hips. 5. Immediately pre-thrust
Relax and adjust your balance as necessary. Keep your head up; looking down impedes the thrust. An effenive IIVlJ\ thrust technique is best achieved if both 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 pati~nt's axillary region does not apply a thrust but acts as a stabili7..er on I}' (Fig. 83.6.4). Keep the thrusting (left) arm as dose to your bod}' as
lumbar and thoracolumbar spine
Figure 83.6.4
possible. Apply a IIVLA thrust with )'OUr left forearm against the patienl's bUllOCk. lhe: direction of lhrust is variabl~ depending on the apoph)'Sial joint plane. Common!)' the dired.ion of thrusl approximates to a line along the long axis of the palient's right femur (Fig. 83.6.5). The thrust, allhougb \~ry rapid, must never be exce:ssi\~ly fordble. ·'he aim should be 10 use the absolute minimum force necessary to achieve joinl cavitation. A common fault arises from lhe use of excessive amplitude: with insufficient velocity of thrust.
Figure 83.6.5
231
HVLA thrust techniques - spine and thorax
SUMMARY Lumbosacral Joint (L5-S1) Neutral posItIoning Patient side--Iying Thrust direction is dependent upon apophysial joint plane • Patient positioning: Left side-lying: Lower body. Left hip in approximately 200 of flexion with knee extended. Right hip and knee flexed (Fig. 83.6.3) Upper body. Introduce right rotation of the patient's upper body until your
palpating hand at the l5-S1 segment 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 patient's upper body • Positioning for thrust: Place your left forearm in the region between gluteus medius and maximus. Apply pressure to the patient's pelvis until motion is palpated at the l5-S1 segment. Rotate the patient's upper body away from you until a sense of tension is palpated at the L5-S1 segment. Roll the patient about 10-15° towards you • Adjustments to achieve appropriate pr~thrust tension • Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: Your right arm against the patient's axillary region does not apply a thrust but acts as a stabilizer only (Fig. 83.6.4). The direction of thrust is variable depending on the apophysial joint plane. Commonly the thrust is along the long axis of the patient's right femur (Fig. 83.6.5)
,
"
232
~~""" ((.t.f_-iILd lief (~ V'.. vrr" Lumbosacral'joint (LS-Sl)
.._ _
Flexion positioning Patient side-lying Thrust direction is dependent upon apophysial joint plane'
Assume somatic dysfunction (S-T-A-R-T) is identified and you wish to use a gliding thrust to produce cavilati01l at l5-S1 on the right:
"'
*~
Stabilization
•
Applicator
-
Plane of thrust (operator)
c:>
Direction of body movement (patient)
Note: The dimensions for the arrows are not a pictorial representation of the amplitude or force of the thrust.
1. Patient positioning Lying on the left side with a pillow 10 support the head and neck. tower bod)\ Straigtucn the patient's low'cr (left) Iq; at the knee join! while placing the left hip in approximately 20° of flexion. trhe condition where joints are asymmetricalty orientated is referred to as articular tropism. The lumbosacral zygapophysial joints would normally be orientated at approximatety 45" wIth respect to the sagittal plane. There is considerable Individual variation and you will enCOU'ltef patients with lumbosacral apophysial joint planes that range between sagittal and coronal orientation. The variation [n apophysial joint plane means that considerable palpatory skill is required to localize forces accurately al the lumbosacral joint and to determine the most suitable directtcm of thrust
233
HVLA thrust techniques - spine and thorax
"'ex the patient's upper knee and place: the patient's right foot behind the left lower leg (Pig. B3.7.1). 'Illis position provid€S stability to the lower body. Upper lJOd)'. Gently extend the patient's upper shoulder and place: the patient's right fore..1rm on the lower ribs. Using your left hand to palpate the LS-51 inteTSpinous space. introduce right rotation of the patient's upper body down to the l5-S1 segmenL Rotation with flexion JX>Sitioning is achieved by gently balding the patient's left eltxn\l with )'OUr right hand and pulling it towards yOU, but also in a caudad direction towards the foot end of the couch. Right rotation is continued until your palpating hand at the 15-51 segment begins to sense motion. Take up the axillary hold. This ann controls the upper body rotation. 2. Operator stance
5tand close to the couch with )'Our feet spread and one leg behind the other. Maintain an upright JX>Sture, faong slightly in the direction of the patient's upper body. Keep your left arm as dose to your Ixxly as possible. 3. Positioning for thrust Apply your left fort'<1rm to the region
234
between gluteus medius and rnaximus. Your left forearm now controls lower body rotalion. Your right fort..':I.rm rests on the patient's right tlxillary area. This will control upper body rotation. first, apply pressure to the patient's pelvis until motion is palpated
Figure 83.7.1
4. Adjustments to achieve appropriate pre-thrust tension
Ensure your patient remains relaxed. Maintaining all bolds. make any necessary changes in flexion, extension, sidebending or rotation until you 0111 sense a state of appropriate tension and leverage at the 15-51 segment. The patient should not be aware of any pain or discomfort. Make these final adjustments by slight movements of the shoulders, trunk, ankles, knees and hips. 5. Immediately pre-thrust
Relax and adjust )'Our balance as necessary. Keep )'Our head up; looking down impedes the thrust. An effective IIVl..A lhrust technique is best achieved if both Lhe operator and patient are relaxed and not holding themselves rigid. This is a common impediment to achieving effective cavitation.
Lumbar and thoracolumbar spine
.
3.7
Figure 83.7.2
6. Delivering the thrust Your right arm against the patient's axillary region does not apply a thrust but aos as a stabili7h only. Keep the thrusting (left) ann as dose to your body as possible and main!ain the left lumbar sidebending leverage. Apply a IIVU\ thrust \"';'th )'our left forearm against the patient's buttock. The direction of thrust is variable depending on the apophysial join! plane. Commonly the direoion of thrust approximates to a line along the long axis of the patient's right femur (Pig. 83.7.3). The thrust, although very rapid. must nevt:r be excessively forcible. The aim should be to use the absolute minimwn of force necessary to achieve joint cavitation. A common fault arises from the use of excessive amplitude with insufficient velocity of thl1.1st.
Figure 83.7.3
235
HVLA thrust techniques - spine and thorax
SUMMARY lumbosacral Joint (l5-S1)
Flexion positioning
Patient side-lying Thrust direction is dependent upon apophysial joint plane • Patient positioning: Left side-lying: Lower body. Left hip in approximately 20" of flexion with knee extended. Right hip and knee flexed (Fig. 83.7.1) Upper body. Introduce right rotation of the patient's upper body until your palpating hand at the l5-S1 segment begins to sense motion. Introduce 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 patient's upper body • Positioning for thrust: Place your left forearm in the region between gluteus medius and maxim us. Apply pressure to the patient's pelvis until motion is palpated at the L5-S1 segment. Sidebend the lumbar spine to the left (Fig. 83.7.2) and then rotate the patient's upper body away from you until a sense of tension is palpated at the l5-S1 segment. Roll the patient about 10-150 towards you • Adjustments to achieve appropriate pre-thrust tension • Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: Your right arm against the patient's axillary region does not apply a thrust but acts as a stabilizer only. It is critical to maintain left lumbar sidebending when delivering the thrust. The direction of thrust is variable depending on the apophysial joint plane. Commonly the thrust is along the long axis of the patient's right femur (Fig. 83.7.3)
236
PAKr
HVLA thrust techniques - pelvis
Saaoillac joint: left innominate posterior. patient prone; ligamentous myofascial tension locking 239 2
Sacroillacjoint: right innominate posterior; patient side-lying
3
Sacroiliac joint: left innominate anterior; patient supine
4
Saaoiliac joint: sacral base anterior; patient side-lying
5
Sacrococcygeal joint: coccyx anterior; patient skte-lying References
243
247
251 255
259
Introduction The sacroiliac joint as a source of pain and dysfunction is a subject of controversy.'-6
Mobility alters with age and can increase during pregnancy.
Many authors implicate the sacroiliac joint as a possibfe cause of low back pain,6-16 but there is disagreement as to the exact prevalence of sacroiliac: joint pain within the low back pain population. While many practitioners believe the sacroiliac joint is a source of pain and dysfunction and treat perceived sacroiliac lesions. there is no general agreement concerning the different diagnostic tests and theIr validity in determining somatic dysfunctton of the pehlis. I 6-29
A number of manual medicine t~ * refer to the use of high-velc:x:ity low-amplitude (HVlA) thrust technkjues to the joints of the peMs, but there is little evidence that cavitation is uniformly assoc.iated with these procedures. When an audible release does occur, its site of origin remains open to speculation. Studies undertaken to measure the effects of manipulation upon the sacroiliac joints provide contradictory findings. Roentgen stereophotogrammetric analysis was unable to detect altered position of the sacroiliac joint postmanipulatK>n 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
3. Patient positioning
(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
-
Plane of thrust (operator)
<>
Direction of body movement (patient)
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.
6. Positioning for thrust
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
HVLA thrust techniques - pelvis
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:
1. Patient positioning
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
•
Plane of thrust (operator)
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
¢
Direction of body movement (patient)
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
HVLA thrust techniques - pelvis
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
•
Plane of thrust (operator)
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.
<>
Direction of body movement
6. Positioning for thrust
(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).
Note: The dimensions for the arrows
are not a pictorial representation of the amplitude or force of the thruSL
247
HVLA thrust techniques - pelvis
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 han<\ over the palienc's shoulder girdle do not appl}' a thrust but act as stabilizers only. '111e aim of this technique is to achieve posterior rotation of the left innominate and movement at the left sacroiliac joint The direction of thrust will alter between pat.ienL~ as a result of the wide va.riat.ion in sacroiliac anatomy and biomechanics. The thrust. although very rapid must never be excessively forcible. The aim should be to use the absolute minimum force necessary.
Figure 0.3
249
HVLA thrust techniques - pelvis
SUMMARY
Sacroiliac joint
left innominate anterior
Patient supine Thrust posteriorly
• Contact points: -left anterior superior iliac spine (ASIS) -Posterior aspect of left shoulder girdle • Applicators: -Palm of right hand -Palmar aspect of left hand and wrist • Patient positioning: Supine. Move patient's pelvis towards the right. Move feet and shoulders in the opposite direction to introduce left sidebending of the trunk. Place the patient's left foot and anlde on top of the right anlde. Ask the patient to clasp fingers behind the neck (Fig. C3.1) • Operator stance: To the right side of the patient, facing the couch • Palpation of contact points: Place the palm of your right hand over the ASIS. Place the palmar aspect of your left hand and wrist over the posterior aspect of the left shoulder girdle • Positioning for thrust Rotate the patient's trunk to the right. Maintain left trunk sldebending. Apply a force directed downwards towards the couch and slightly cephalad to fix your right hand against the inferior aspect of the ASIS (Fig. 0.2) • Adjustments to achieve appropriate pre-thrust tension: Make any necessary changes in trunk rotation, flexion and sidebending. Simultaneously, adjust direction of pressure applied to the ASIS • Immediately pre-thrust: Relax and adjust your balance • DeliverIng the thrust: The thrust against the ASIS is in a curved plane towards the couch (Fig. C.3.3). Your left forearm, wrist and hand over the patient's shoulder girdle do not apply a thrust but act as stabilizers only
250
Sacroiliac joint Sacral base anterior Patient side-lying
Assume somatic dysfunction (S-T-A-R-T) is U1entified and}uu luis', to thrust Ute apex of tlte sacrum anteriorly:
,. Patient positioning
l),jng on the right side with a pillow to suppon the head and neck. Lower body. Slrnighlen the patient's lower leg and ensure that the leg and spine are in a straight line. in a neutral position. Hex the patient's upper hip and knee slightly and place the upper leg just anterior to the lower leg. The lower leg and spine should form as near a straight line as possible with no flexion at the low'er hip or knee.
Upper- body. Gently extend the patient's upper shoulder and place the patient's left forearm on the JOWl':r ribs. Using )'our right hand to palpate the l5-S1 interspinous space introduce left rotation of the patient's trunk down to and induding the 1.5-$1 segment. 'I'his is achieved by gently holding the patient's right elbow with your left hand and pulling it IOw:uds )'ou, but also in a cephalad direction to\"",rds the: head end of the couch. Be careful Ilot to ilurodua: any
flexion to the spine during this movement. Take up the axillary hold. This ann controls and maintains trunk rotation.
KEY
2. Operator stance
.:f,-
Stabilization
•
Applicator
•
Plane of thrust (operator)
¢
Direction of body movement (patient)
Note: The dimensions fOf' the arrows are not a pictorial representation of the ampJitude Of' force of the thrust.
Stand close to the couch with }'Our feet spread and one leg behind the other. Maintain an upright posture, facing slightly in the direction of the p
251
.
HVLA thrust techniques - pelvis
to "void undue pressure in the axi!1". Finally, roll the p"tient about 10_15 0 to\v"rds }'Ou while maintaining the build-up of levelilges. 4. Adjustments to achieve appropriate pr~thrust tension
Ensure your patiem remains relaxed. Maimaining all holds, make any necessary changes in flexion, extension, sidebending or rOl
Relax and adjust )'Our balance as necessary. Keep }'Our head up and ensure contacts are
Figure CA.l
252
firm. An effective IIVI.A thrust technique is best achieved if both the oper3tor and p,ujent are relaxed and not holding themseh'es rigid. This is a common impediment to achieving effective cwitation. 6.
~ivering
the thrust
Apply a I-IVlA thrust with }'Our right forearm against the apex of the sacrum in a cu.rved plane to\\'3.rds }'OU (Fig. G.4.1). Your left arm against the patient's pectoral region does not apply a thrust but acts as a stabilizer only. 'l1le aim of this technique is to achieve a counter-nutation mO\'lTJlent of the sacrum. 1he thrust. although ''elY rapid. must nE"\~ be excessively forcible. 1he aim should be to use: the absolute minimum force necessary.
Sacroiliac joint Sacral base anterior
SUMMARY Sacroiliac joint Sacral base anterior Patient side--Iying Thrust apex anteriorly • Patient positioning: Right side-lying: 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 trunk down to and including the l5-$1 segment. Do not introduce any 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: Apply the palmar aspect of your right forearm to the apex of the sacrum. Ensure that contact is below the second sacral segment Your left forearm should be resting against the patient's upper pectoral and rib cage region. Rotate the patient's trunk away from you using your left forearm until you achieve spinal locking. Roll the patient about 10-15" towards you • Adjustments to achieve appropriate pr~thrust tension • Immediately pre·thrust: Relax and adjust your balance • Delivering the thrust: The thrust against the apex of the sacrum is in a curved plane towards you (Fig. C.4.1). Your left arm against the patient's pectoral region does not apply a thrust but acts as a stabilizer only
253
Sacrococcygeal joint Coccyx anterior I~A --F""" - - - Y .. r rPatient
5id~lying
Assume somatic dysfunction (5-T-A-R-T) is identified and ),ou wisll to
thrust the coccyx posteriori)': 11le operator must exercise alT€ and attention to ensure that the patient is fully informed as to the nature of this procedure. 'f'his technique involves both assessment and treaunenl via a rectal approach. It is assumed that the operator will examine the anal and rectal region to detennine if there are any contrnindiGltions to performing this procedure. '['his technique can bE! used either as a means of gently artirulating the sacrococcygeal joint or applying a I IVI.A
thrust to the roccyx. Cocqdynia can be severe and the choice of technique depends as much upon pati~nt comfort as perceived f'.fficacy of approach. Practitioners should becoml" familiar \\'ith articulating thl" sacrococcygl"al joint beforl" attempting a thrust to the coccyx. 1. Contact points (a) Ant~rior aspect of !.hI" coccyx through thl" posterior wall of the r~etum (b) Postl"rior 3SpI"Cl of thl" coccyx.
2. Applicators (
KEY
*,
Stabilization
3. Patient positioning •
Applicator
-
Plane of thrust (operator)
Q
Direction of txx:Iy movement (patient)
Note: The dimensions for the arrows
are not a pictorial representation of the amplitude or force of the thrust.
Lying in the left lateml position with the maximal amount of flexion of the hips. knees and spine consistent with patient com fOil. 'I'he p
4. Operator stance S13.nd behind the patient. approximately at thl" In'e!. of the patient's hip joints, fadng the couch and patient's back.
255
7
•
HVLA thrust techniques - pelvis
A
/
Figure C.S.l Sacrococcygeal joint. A: The index finger is placed against the anal margIn. B: The finger Is Inserted as shown. C: After examination of the rectum, the coccyx is held between the index finger Internally and the thumb externally.
5. Palpation of contad points
256
The operator should be wearing a pair of suitable g10\'eS " ..ith lubricant smeared over the right index finger. 'llIe patient must be informed that a finger within the rectum will cause a ~nsation similar to that of opening the bowels. Ask the patient to relax and place the index finger of your right hand against the anal margin (Fig. C.S.1A). With steady pressure, insert your right index finger into the patient's anal canal in a cephalic and slightly anterior direction (Fig. C.5.1B). The finger will pass through the anal sphincter and into the rectum. If the patient has difficulty relaxing.. ask him/her (0 bear down as if opening the bowels and gently slip your finger past the anal sphincter and into the rectum. Once through the anal sphincter, the direction of the rectum is cephalic and posteriorly along the curve of the coccyx and sacrum. At this stage an examination of the rectum should be undertaken. for m.de patients this would include examination of the prostate gland. 'Ine palpatjng right index finger identifies the sacrum and coccyx through the posterior wall of the rectum. Place the distal phalanx of the right index finger against the anterior surface of the coccyx immediately below the sacrococcygeal joint. Use the thumb of
your right hand ext~mally to identify the posterior aspect of the coccyx between the buttocks. llle coccyx is nO\.., gently held between your index finger internally and thumb externally (Fig. C.S.1C). Gentle pressure is applied in a number of directions to determine undue tenderness or any reproduction of the patient's familiar symptoms. The mobility and position of the coccyx relatiw to the sacrum is also noted.
6. Fixation of contact points Keep your right index finger on the anterior aspect of the coccyx while applying pressur~ against the posterior aspect of the coccyx with your right thumb. The fIXation is gentle but linn with less pressure against the anterior surface of the coccyx.
7. Adjustments to achieve appropriate pre-thrust tension The operator should be in a position to move the coccyx through a range of motion and in different planes. Ensure your patient remains relaxed. Maintaining all holds, make any necessary changes in flexion, extension, sidebending and rotation of the coccyx until you sense a state of appropriate tension and leverage at the sacrococcygeal joint.
Sacrococcygeal joint
Coccyx anterior
B.lmmediately pre--thrust
9. Delivering the thrust
Relax and adjust )'Our balance as necessary. Ensure thai your contads are firm. An effeclive IIVLA lhrust technique is best achieved if the ope:r:ator and patiem are relaxed and nOl holding themselves rigid. This is a common impediment to achieving effective cavitation.
Appl)' a HVLA thrust Lowards you in a CUlWd plane (Fig.. G.S.2). "'he thrust. although very rapid must ne\'ff be excessively forcible. The aim should be: to use the absolute minimum force necessary.
Figure C.52
257
II
l
HVLA thrust techniques - pelvis
,--~---SUMMARY Sacrococcygeal joint Coccyx anterior Patient side-lying Thrust posteriorly
• Contact points: -Anterior aspect of the coccyx
-Posterior aspect of the coccyx • Applicators: -Lubricated index finger of operator's gloved right hand -Thumb of operator's gloved right hand
• Patient positioning: Left lateral position with flexion of the hips. knees and spine
• Operator stance: Behind the patient • Palpation of contact points.: Place the index finger of right hand against the anal margin (Fig. C.S.1 A). Insert your right index finger into the anal canal in a cephalic and anterior direction (Fig. C.S.1 B). The palpating index finger identifies the sacrum and coccyx through the posterior wall of the rectum.
Place the distal phalanx of the right index finger against the anterior surface of the coccyx. Identify the posterior aspect of the coccyx between the buttocks. The coccyx is now gently held between your right index finger internally and thumb externally (Fig. C.S.1 C) • Fixation of contact points: Keep right index finger on the anterior aspect of the coccyx while applying pressure against the posterior aspect of the coccyx with your right thumb • Adjustments to achieve appropriate pre-thrust tension • Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: The direction of thrust is towards you in a curved plane (Fig. C.S.2)
258
References
dysfunction. I 10:164_171.
References
2
3
•
Alderink CI. '11M: sacroiliac loinl; review of anatomy, mechanics, and function. I Orthop Sports Ph)'S'lher 1991; 13:71-84. Bcm;ml TN, cassidy ID. The sacroiliac joint s)'ndrOl'ne - pathoph)'siolom~ diagnosis and JrnIn~ment. In: PryrtlO)'eI" JW, ed. The Aduh Spine: Prin'S Ther 1992; 72:903-916. Dreyfuss I~ Cole AI. Pauza K. Sacroiliac joint injection techniques. 1'tl)'S Mec:I RehabiL CLin Nooh Am 1995; 6(4):785-813.
• 7
Grieve C. The saociliac joinL Physiotherapy 1976; 62:384-400.
8
WeismanteJ A. Evaluation and tIeaLment of sacroiliac joint problems. I Am I'II)'S Ther ASliOC 1976; 3(1):1-9. Mitchell F. The Muscle F.nttgy Manual, Vol I. Ease lansing.. MI; MEl" Prt'SS; 1995.
9 10
DonT'igny RL Function and pathomechania of the sac.roiliac joint. PI!)'S 'fher 1985; 65:35-43.
II
Bernard TN, Kir\.:aldy-WiI1is Wt-l. Recognil'ing !ill.."Cific characterilitia of non~lx-cific low back pain. Clin Orthop 1987; 217:266-280.
12 13
8ourdillon IF. Da)' I:A, Boohhout MR Spinal Manipulation. 5th oon. Avon: Bath Press; 1995. Shaw 11_ '111e role of the sacroiliac joint as a cause of low back pain and d)'Sfunction. Roo 1nterdi!lCiplillary World Congres.~ on Low Back Pain and itll Relation to the Sacroiliac Joint, ROllcrda.m: I;CO; 1992.
I' Schw3l"Zer AC, Aprill CN. Bogduk N. 'Ibe sllcroili:tc joint in chronic low bock pain. Spine 1995; 20;31-37.
Dr~r S, Griffin I, Hoffman I, Walsh N. l>OSith~ 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 biome
......
-
Common fautts • Insufficient primary leverage • Too much secondary Ie\.lefage - Ioddng often resorts from the over-aPPlication of secondary leverages.. This can occur dlKing the build-up of IeYerages or at the point d
thrust • loss of contact point pressure immediately pre-thru
Checklist • Primary leverage • Secondary leverages • Contact point pressure • Identification of appropriate pre-thrust tension • Direction of thrust • VelocJty of thrust • Amplitude of thrust • Force of thrust • Arrest of technique
Proctitioner postu~ Dependent upon: • Using as wide a base as possible • Not relying sok!fy upon arm strength and speed • Using your body where possib~ to generate thrust force • Not stooping or bending over the patient • Keeping your own spine erect • Optimal treatment couch height
263
Subject Index
Abbrevialion.~ used:
HVlA == high-velocity ION-amplitude Page refl,.'Il:lll:el followed by 'r or 't' rde!" 10 figura and tables/boxOO material rcsp«tiwly
Biopsych06OCiaJ model 61 Biplanar Tadi08J"3phic studies, 11-12
A Alar Hll"mcnc atlanlOoaxial stability. 33 5tfC$ tcs!. 35-37, 36[. 37[
Apoph}'Sial joiOl cavitation, 47 trophism (fattt) roupl«1 motion. 13-14 low back pain. 14 Articular uopism. 233 Asymmcuy, 6 A3ymplOnlallc 50nUtic dysfuncUoo. 6 ALlanlo-aml joint (CI-2) ccMcaJ rotation. 17
chin hold. 81-84 coupled motion. 17 cTadle hold,. 85-88 IIVlA thrusl t('Chniques, 81-88 hypermobility, )) instability. 33-31 Atlanlo-d"'11tal interval. imagir'lg. 34 AtlanlO«eipital joinl (CO-Cl) contact point on ~lIas, 71-80 COIll~CI poinl on OCcipUI. 71-15 coupled motion. 17 fnce!. Opposilion, 17-18 J IVU, thl'llStlechniqu('S, 71-80 AXel of motion, 9-10, 10/ AxialI0f<1ue. 13 Axillary hoJd. 205
B Back l>ain _low back ~in
Bed re5l, DCC'ilii\'l:, 1 Ilioeocrgy lreaunent model, 46 Iliom«hanks modifying factors, 2631 $pinal motion. 9 IrnlmCrlI model, 45-46
c Cada\uresearch. 11-13 Caudil ..quina syndrome. 28 <:aviation _ joint cavitation CnmrOYa.!CUlar /ICddenl, 25. 30 Cavialspinc (0·7). 17-19 dUn hold. 691 coupkd motion, 11-12. 17-19 cradle hold, 70( down~ glidi~
dUn hold. IIS-119 cradic hold, 121 -125 patienl sillinf,. 127-130 raut ClppOIilion locking. 18-1 ') IIVLA thrust tcchniques. 89-130 il'l$labUily j f t upPer ttrviGtI instability manipulalkJn
rompllCll!Onll. 25 vt'ncbrobasilar irusufticic.'flC)' (VBI), 30 rOUlion. 19(. 29{
sidcbendins. 12 UI)oI;lol'H~ gliding
dun hold. tl9-,)6 cradle hold, 97-100.101-105 OpetCf310r in front. 107-110
patient lilting. 107-114 podtioning. 1'Jj m~~10I-105 \1!I'tcbr.tl arltfy rd;ui()nl;mp,
28{. 30 _ abo \o'eItOOrobasib.r anel)' diMoection; \~Iar insufficiency (VBI) wri5l position. 70f Cm.icoIhontdc spine (Cl~13) txtmsiongiiding.lS')-l62 facet oppOlitton kJcking. 18-19 rotation gliding
265
Manipulation of the spine, thorax and pelvis
openuor at head, 135-138 orlel,uor at head, variation, 139-142 ope....tor at skit", 131-134 sldeberKling gliding ligamemoUll m)Ofil!cia1 tensMJo lockil* 147-150, 155-158 paticm sidc-tyi~ l51-158 patient siniJ'G 143-150 Chin hold. 69f, 81-84 Oneradiogrnphy, 34 Clinicoll dcci5kJn makiJ'G- 49-50, 491 Compre5lSion. 67 Computoo lOmognphy (CT), 34 C'.onglrilill cnvicallnMability, 33 Conjunct roUtion, 10, 13 ~Ied molion, 9-16 axes; of molion. 9-10 axiallOUtion. 12 biplanar radiognplUc studies, 11-12 conjunct rotation, 10, 13 muscular 3Oivity, 14 neutral/o:tention pos.itiooiJ'G- 20 po51U11! and posicioni"1\o 19 radiographk studJto$, 12-13 ra.earch. 12-14 .\l~ot<Jgr.lmmetry, 12 type 1 Jl\O\lU11ellts, 10, ItI. 17 type 2 mo~. ~mml5, III. 17 Cndle hokt atlanto-axial joint (Cl.2), 85-88 ctrVical spiM (0-7), 70{. 97-100, 101-IOS, 121-125
o Depn:ssiOI\ Anxiely and POliti\1: Oullook Scale (DAPOS),61 Disc dt.'gener,lIion. 14 Disc herniation, 28 Di.ma-l & Risk ASK$Smcnl Method (DRAM), 61 Diu:in~ 29, 291 Down's syndrome. 34
E Elbow hold, 205 Evidence Basal Mt.'dicine (I:BM), 47-49 Examiner reliability, 5-6
F
266
Face1 appositionlockil"G 17-27,67 cervieothoradc ,;pine. 18-19 flexion posilionhJ&. 23 tTUflk flf'.xKm, 21f F~ lI'ophism, \'CI1l.'br,'" coupled molion. 13-14 ..w.xion positioning,. 9, 20, 23, Df Fryt'lta law, 9-14
H Haod pa;:ition. thoracic: and ribcage lupinl" teehniqut'S, 165 Headache. spinal mallipulaciYe therap)', 48 High-\'do61y kJw-amplilude (IIVIA) thrust techniques aim, 47 anaiysb, 261-263 aLiarnoaxial join.. 81-88 aLianlo-ocdpital join.. n-80 av'il,nion., 46-47 arvicothoradcspine.131-162 complotio... 25-27 causes, 27 dassi6cuion. 26-27 inciderlct", 25-26 rontnindiationl, 27 diK hrnliation. 28 fail~ 261-263 indication.. 451 IUrMM sphw. 217-228 lumboaaaJ joir-., 229-236 patient variaIHa. 2631 ph)'!Oiai aod biom«hanbl modifying fanon. 2631
rncthioner variables,
2631
prNhrust checklist, 67, 238 rational(' of lR. 45-53 ribs, 189-204 sacKlCOCC)pJ joint. 255-258 sacroiliac joh.. 239-254 safety issues. 25-43 short le\~, 17 spinal poKitioning and loc:klJ'G- 17-24 thoracic spilll". 167-188 thorarolwnbar spilll". 209-216 transimt 51(\(' dT«a, 26-27 validation by rl.'l('3fCh. 55-63 Holds axillary, 205 chin hold, 69f, 81-84 cradle $N craclJ(' hold elbow, 205-207 10Wl..'f body, 205-207 p«IOra!, 205-206 sid('lying tcchniqucs. 205-207 Ullp('!' arm, 205-206 UI)perbody, 163-164,205-207
Iliac ct'C!>t 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'oMUI
Q QuebcI: Back r;.in Disability SoIk. 60 Queba: wIOorl:':, 7. 56-57 Q"csdonnairQ, JMin ratios. 58-61
R RAnSi!' of motion. 7 Res.earch, 55-63 c:oupkd mocion. 12-14
""'" 56 meawremalt. 58-61 outcOline rationale. 55-56 Rt:5piralOl)'/cimJlalOl)' treatmet1l modd 46 Rarophal)'llg,tal irllammatory processes. 34 Kheumatokl anhritil,. 33-34, 34f Ribs IlVlA thrusl techniques, 189-204 RI-3, patienl prone, 189-192 R4-IO patiClll prone, 197-200 patient sitting. 201-204 patient supine.. 193-196 Koemgm stercophOlogrnmmelric analysis". pelvi$. 237 Roland-Morris tow Back Pain Disability QiH'stionnaire.
59-60
s SocnxOCC)'lpl joint. 255-258
Sa<:roi1iac ;OInt innominate antcnOf. 247-250 left innominate I'll»terior, 239-242 lOw back pain, 237 manil>utation. cavitAtion. 47 mobility, 237 pre-lhrust checklist. 238 right innominate posteri(W, 243-246
1m
romq;en steroophOlogrammelric analysis, 237
268
sacral base anterior, 251-254 Safety L'lSues. 25-43 Sciatica. 14 Scoliotic cun~ 10 Self raling scalC5, 60 Sharp-Purser te5ot. 35-37
Sidebendill@ ceMcal spine, 9.17-19 limits. 18, 19[ Si,inal rotational rl/!Iationdtip. 10-14 thor.Jcic and lumbar splOl'.. 19-20 Sidetying l«hniques. body holds. 205-207 Somatic dysfunction asymmetl)'. 6-7 asymptoma!ic, 6 ddinil ion. 5 diagnosis. 5-7, 61. 49. 49[ mt«:Jpalhk manipuJathor techniqua. 7-8 ranse of motm 7 l)'TTIplom reproduction,. 6 tissue lendet-nmI. 6 1is6ue texture changel, 7 UellJnftlt apPfoachel, 71 Spinal toni comprcssm 34 Spinal disordm aetivity-relaloo. d-.lOOtion, 57t ~ic tenninoklgy. 56 Qul'b«Touk Foret da55ifia.tion.. 7. 56-58 lhnapeutic objoo.i\a. 7 SpiNI klc:king, 17-24. 67 IigiUllen~ myo(-.:ial tm5ion" 17 Spinal manipulative Ihtrapy, 48 dUe: haniatK>n" 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
Type 2 ll'lO\'e!I!t:IlIS
llallnJ/cxtmsion
JXl5ilionh~ 22/
w
u Unil..od Ki"bodorn llack Pain l:Xen::ise and Manipul,lloo (UK 1lt'..AM) crial. 48
Whiplam iU50Ciatcd dillordcn,. 57-58 Wrist atcllll)oo grip, 70, 70f Wrist pl)'ition. 70, 70f
269
