__Manipulation_of_the_Spine__Thorax_and_Pelvis__An_Osteopathic_Perspective

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 <liS <lIvthors of this work has been asserted by them in accordance with the Copyright, ~ns and Patents Act 1988 No PJlrt of this publication may be f1!P«lduced. storec:I in a ,~ system. e- transmitted in any ronn or by any meam,. e\\eCtJOriC. mKhcv1ica~ photoccpying. recording or ot~. without the' prior permiWon of t~ Publislwrs. Permissklrui may be sought directly from Elsevie(s ~ Sdet'la!s Rights 0epiIIrtment. 1600 JdlI'l F. ~ Boulevard. Suite 1800, PhiladPlphe. PA 19101-2899. USA: phone: {+112IS 239l804; fax: 1+ IJ 215 239 3805; 01, e-mait: ~~sevit!a:om. You may abo COfTIPIete)'OOI request on-Iinl! via the ~ hom!page {http://Www.ekevieu:om).by Sl!Ieding ~ and coroct' and then 'CopyT5ght and Pftrnssion'. 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. The Pubttsher Working together to grow -...---.-'\".. libraries in developing countries \",*,_\"'la www.e1sevier.com I www.bookaid.org I www.sabre.org I Printed in China

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 following symbol . To look at the video for a given technique. clid. on the relevant icon in the 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 5 3 Kinematics and coupled motion of the spine 9 4 Spinal positioning and locking 17 5 Safety and I-M.A thrust techniques='--'2::S'--' 6 Rationale for the use of HVLA thrust technques 45'-___ _ __ 7 Validation of clinical practice by research 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 77 1.3 Atlanto-axlal joint Cl-2: chin hold; patient supine; rotation thrust 81 ~ttan~~xial joint Cl-2: cradle hold; patie~ supine; rotation thrust 85 ~~rvical spine 0-7: up-slope gliding; chin hold; patient supine 89 1.6 Cervical spine 0-7: up-slope gliding; chin hold; patient supine- --==var'i-a-tio..n:..9:3 - - - - - 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 v in front 107 -----

Manipulation of the spine, thorax and pelvis 1.10 CeNfcat spine 0-7: u~slope gliding; patient sitting; operator standing to the side 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'-s:p-i-n-e-: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; - -lig-ament-ou-s m-y-ofasdal 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''-----,-_ 2.3 Thoracic spine T4-9: rotation gliding; patient supine; ligamentous myofasdal tension locking 177 2.4 Thoracic spine T4-9: rotation gliding; patient prone; short lever technique 183 2.5 Ribs R1-3: pa-tient prone; gliding- thrust 189 2.6 Ribs R4-1O: patient supine; gliding thrust; ligamentous myofasdal tension locking 193 2.7 3ibs A4-10: patient prone; gliding thrust 197 2.8 Ribs R4-10: patient sitting; gliding thrust 201 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 243 3 Sacroiliac joint left innominate anterior; patient supine'---:-24_7 _ 4 Sacroiliac joint sacral base anterior; patient side-tying 251 5 Sacrococcygeal joint coccyx anterior; patient side-iying --=:25::5'--- _ References 259 PAKT 0 Technique failure and analysis 261 Index 265 vii

Foreword This second edition builds upon the expanded reference lisL Coupling of spinal strengths of the firsL The aumors focus motion continues to be difficult to upon high-velocity low-amplitude (HVLA) understand and current research has cast thrust technique. It continues to be one of some doubts about some of me original the mOSt widely used forms of meoret.ical const.ruets. The authors h3Vl\" manipulation by many health care cogently bridged the original concepts with professions. The book is again divided into me results of current research. aiding me four parts: (A) HVlA thrust techniques. an reader's understanding of complex concepts osteopathic perspective; (8) HVl.A thruM and preparing their undemanding for me techniques. spine and thorax; (C) HVLA technique chapters that follow. thrust techniques. pelvis; and (D) technique failwe and analysis. Chaptet\" 5 on Safety and high-velocity low-amplitude techniques brings an update It is in the first section that the aumors to an area of controversy. The authors have have added much to this volume. and the expanded the references by 63 new profession's understanding. of two very citations.. bringing new darity to the important areas. namely in spinal concerns previously expressed about the biomechanics and coupled motion of the safety of HVLA. They conclude that the risk spine. and in the area of safety and the is extremely low but that the key to prevention of complications. prevemion of complications is adequate training and experience. In Chapter 2, the authors have added to their diagnostic criteria for somatic The technique chapters in sections 8 and dysfunction, with S signifying symptom C are again comprehensive in their reproduction. 111e new mnemonic is S-T-A· description of the techniques and follow a R-T with S for symptom reproduction; T for standard step-by-step format for student tissue tenderness; A for asymmetry; R for learning. Several n~.... techniques are range of motion; and T for tissue texture added. changes. \"llle accurate diagnosis of somatic dysfunction is critical for me proper 'nlis second edition continues to add to application of HVLA thrust techniques. the reader's knowledge of high-velocity low-amplitude (HVLA) thrust techniques in Chapler 3 on Kinematics and coupled a dear, concise and easily readable fashion. motion of the spine has been updated with the most currelll research and with an Philip E. Greenman ix

Preface 'Ibis second edition of MaFlipulntilm of the so that practitioners can use thew Spine. T11Ora:c arul PellJis: An Osteopathic techniques safely and in the appropriate Perspec:titJe has been produced at a time of ci.rcumslances. Since the first edition. there increasing knowledge related to the use of has been extensive research published manipulative techniques in clinical practice. within peer-revie\\\\u1 journals that suppons Patient safety remains a major consideration the use of a multi-modal approach, when selecting a tteatmeOl approach. Thrust induding the use of HVLA thrust techniques have been considered potentially techniques. for the treatment of spinal pain more dangerous when compared with other and cervirogenic headache. osteopathic techniques, particularly relating to the cervicaJ spine. Recent research has fur a commonly used treatment questioned the appropriateness of a number approach. it is surprising that there are such of commonly used venebrobasilar limited resources to support learning and insufficiency protocols and the text has skill refinement in HVLA thrust techniques. been updated to embrace current research Most of the learning of HVl.A thrust finding<; and recommendations. The techniques has been dependent upon evidence base for the use of spinal personal instruction and demonstration. manipulation in patients with disc lesions 'I'here are still only a handful of osteopathic has been included, as the application of technique books and manuals and few of thrust techniques in these patients remains these relate solely to thrust techniques. controversial. 'Ibe material presented in this te:<t was ·11,c move towards an evidence·based developed in response to the learning needs of undergraduate and postgraduate students and patient-centred approach to healthcare over a 30-year period and has been requires the modern practitioner to utilize expanded 10 include additional HVLA thrust the best available evidence 10 inform techniques. Two new techniques based clinical practice, to be cognizant of the legal upon ligamentous myofascial tension, as and ethical requirements for informed opposed to facet apposition locking. are consenl and 10 use the appropriate also included. instnllllems to monitor patient progress. ·111e second edition has been updated to The novice has to acquire basic skills and re(Jea these changing requirements of experienced practitioners should reflea practice. upon their performance and conslantly refine each thrust technique. It has been our Our goal remains to present a text that experience thai the structured step-by-step will provide the necessary infonnation formal used in the text and the visual relating 10 all 3SpccL.. of the delivery of reinforcement offered by the accompanying High-Velocity Low-Amplitude (HVU\\) thrust CD-ROM have been successful in assisting lechniques in one comprehensiw volume. both initial development and subsequent

Manipulation of the spine, thorax and pelvis TE'finement of the psychomotor skills include fluoroscopic images of spinal necessary for the effeaive delivery of HVlA coupling in the lumbar spine. 'l1le principles thrust techniques, Experience has shown that the video images included on the CD- of spinal positioning and locking elaborated ROM ha\\'f' proved useful for both students in the text are clarified by the addition of and praaitioners. 'l1le second edition CD· video images on the CD-ROM, ROM has been updated with the additional thrust techniques and has been expanded 10 Melbourne 2006 Peter Gibbons Philip Tehan xii

HVLA thrust PART techniques - an osteopathic perspective I Introduction 3 2 Osteopathk philosophy and technique 5 3 Kinematics and coupled mOlm of the spine 9 4 Spinal positioning and locking 17 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 55

Introduction Manipulative techniques for the spine. An overview of the ostropathjc 3 thorn\" and pelvis are commonly utilized philosophy that underpins osteopathic for the treatment of pain and dysfunction. manipulative technique and treatment is Proficiency in their use requires training, presented in Chapter 2, Chapter 3 reviews practice and development of palpatol)' and spinal kinematics and coupled motion of psychomotor skills. lhe purpose of this the spine. Practitioners require knowledge book is to provide a resource that will aid of biomechanics and coupled motion development of the knowledge and skills characteristics in order to apply the necessary to perform high-velocity low- principles of spinallocl-ing used in amplitude (HVl.A) thrust techniques in l-fVUI. thrust techniques. 11le osteopathic practice. It is written not just for the novice profession has developed a classification of manipulator but also for any practitioner spinal motion. Chapter 4 describes type I who uses thrust techniques. While the book and type II movements and the relevance of presents an osteopathic perspeaive, it does coupled mOlion to spinal positioning and not promote or endorse any panirular joint locking. treatment model or approach. Complications of, and contraindications 'Ille term 'manipulation' is often used to, IIVLA thrust techniques are outlined to describe a range of manual thern!')' in Chapter 5. Pre-manipulative assessment techniques. 'Ihis text focuses specifically of venebrobasilar insufficiency and upper upon IIVI.J\\ procedures where the cervical instability is described and the practitioner applies a rapid thrust or use of testing protocols for vertebrobasilar impulse. l\"e aim of ItVLA thrust insufficiency is revie\\...m in light of the techniques is to achieve joint cavitation published literature. that is accompanied by a 'popping' or 'cracking sound. '111is audible release Chapter 6 examines osteopathic distinguishes IIVLA thrust techniques treatment models, reviews the literature from mher osteopathic manipulative relating to cavitation and the efficacy of techniques. IIVLA thrust techniques are spinal manipulation and outlines a d€Cision also known by a number of different making process that will assist practitioners names. e.g. adjusunent, high-velocity thrust, to determine when a I IVIA thrust technique mobilization with impulse and grade V mobilization. might be used in clinical practice. 11le book is divided into four pans. Pan Research is necessary to validate the use A comprises seven chapters that provide an of osteopathic techniques in clinical osteopathic perspective on the use of HVLA practice. including HVlA thrust techniques.. thrust techniques and reviews indications, Chapter 7 identifies stratq;ies that can be kinematics. safety and research. used by practitioners to classify patients and document patient outcomes in clinical practice.

HVLA thrust techniques - an osteopathic perspeaive .\" Parts Band C oUlline in detail spedfic The art of manipulation is very I [VIA thmst techniques for the spine. rib individual, requiring IIVIA thrust cage and pelvis. These two parts combine techniques to be adapted to the needs of photographs and descriptive text that is both practitioner and patient. While some supported by the video images of HVLA modification to the described techniques thmst techniques on the accompanying will occur with developing proficiency, the CD·ROM. underty;ng principles remain the same. lhese principles can be summari7.ed as IIVLA thrust techniques can be described follows: in terms of bone movement or joint gliding. In this text, all 41 techniques are outlined I. Exclude rontr:aindicaliollS. utilizing the principle of joint gliding. This 1. Obtain informed consent. approach has been shown to be effect.iw in 3. Ensure patient comfort. the teaching of IIVLA thrust techniques to 4. Ensure operator comfort and optimum both undergraduate and postgraduate students. posture. 5. Use spinal locking. n'le text has been designed to provide 6. Identify appropriate pre-thrust tissue a logical step-by-step format that has consistency throughout the book. Each lension. technique is described from the moment the 7. Apply IIVLA thrust. patient is positioned on the couch. through a series of steps up to and including If these principles are applied, HVlA thrust segmentallocali7..ation and delh'ery of the techniques provide a safe and effective thrust. Each individual technique is logically treatment option. organized under a number of specific headings: A common experience in the evolution of proficiency in thrust techniques is a sense • Contact point(s) offrustralion and impatience when skill • Applicator(s) development is slow or variable. • Patient positioning Experienced practitioners can similany • Operator stance experience difficulties achieving cavitation • Positioning for thmst in certain circumstances. Part D provides a • Adjustments to achieve appropriate troubleshooting and self-evaluation guide to identify those problems that may limit the pre-thrust tension effective application of llVLA thmst • Immediately pre-thmst techniques. • Delivering the thmsl Integral to the practice of osteopathic Individuals use a variety of methods to medicine is an understanding of the acquire complex psychomotor skills, with interrelationship of mind. body and structured and repeated practice a key environment. Osteopathic treatment element in the development and encompasses mOfe than joint manipulation maintenance of proficiency. Experiencing alone and this manual represents only part these both as an operator and as a model of the art and science of osteopathic can enhance the learning of 11VLA thrust medicine. techniques. 4

Osteopathic philosophy and technique Osteopathy, or osteopathic medicine. is II Box A.2.1 Philosophy underpinning 5 philosophy, II science ami an arL lis pllilosoplry osteopathic approach embraces the concept oJ the unity of body stmcture and {mulian in heaIIIl and disease. • The body is an integfilted unit Its science includes the chemical, pllysimI ami • The body is self-regulating with inherent mologiall sciences rclntell fa tlie maintenmu:e of healIIi Glut llie l,revenlion, cure and alleviation capacity for healing of disease. //$ an is the applicafitm of I/le • Structure and function are inter-dependent plliIosop/IY and /lie science it' flle practice of • Somatic component to disease osteopathic medicine mId surgery in all its • Neuromusculoskeletal dysfunction impacts lJranches and specialties. on ovefiltl health status Ilealf1l is billed 011 ti,e natural capacity of • Neuromusculoskeletal dysfunction impacts fIJe IlUman organism /0 resisl and combat on recovery from injury and disease • Unhindered fluid interchange necessary for noxinus i'lf/uences in llle elllJiromllenl Glllt /0 maintenance of health compml$o/e for II/ciT clfec/!;; to meet, willi {UIeqUlltc reserllC, IIJe flsuol stresses of daily life DIAGNOSIS OF SOMATIC and tile occasilmal severe stresses imf'osetl by DYSFUNCTION ex/remes of emJirommml mul actilli'y. ,1,e accepted definilion for somatic Disease begim w/lim I/li$ naltlral cnpllcity is dysfunction in the 'Glossary of osteopathic reduced, Dr when il is exceediuf ar overcome by terminology' is as follows: noxious hl/luences. Somatic dysfunction is an impaired or OSleot1al1lic metlicifJe recognizes /lUll many altered function of related components faC/OTs impair IIlis C/lpacil1' mui 'lie 'laturtll of the somatic (bod}' framework) Imulem:1' /owaTfls recol.rery anli IIlat among tlie system: skeletal, anhrodial and most importam of llzese faC/ors are llie local myofasdaJ structures. and related liisturlJafJces or lesions of llle musclilosuelelal vaSOJlar, lymphalic. and neural s1's/em. Osteopalhic I1lellidne is IIlerefore rlemems. 2 concerned witli liberafing anli developing all tlie T/?S()llrc£s tliat ctmstitute lile capacity far Osteopaths diagnose somatic dysfunaion by resistam::e and recovery. tlius recogrlizing tlie searching for abnonnal funnion within the validit1' of llie ancient obsenlafiO,J Illllt lize somatic system. Palpation is fundamental to pllysicum deals willi a patient as well as a structural and functional diagnosis.} llisease. I Research has explored both inter~ and lhe philosophy underpinning the inlm-examiner reliability of various osteopathic approach to patient care can be enunciated as shown in Box A.2.1.

• HVLA thrust techniques - an osteopathic perspective 6 --.;.......;....;..------- diagnostic palpatory procedures. Inter· of somatic dysfunction and/or pathology examiner reliability consists of one should be determined not only by physical assessment of all subjects by each of two examination but also by information gained or more raters, blinded to each other's from a thorough patient history and patient observations, and allows assessment of rater feedback during assessment. l11is depth of agreement. Intra~examiner reliability is diagnoslic deliberation is essential if one is detennined by repeated measurements of single individuals 10 evaluate rater seJf- to select which case may or may not be consistency. amenable to treatment and \\vhich treatment Osteopaths have shO\\vn reasonable levels approach might be the most effective while of inter-examiner agreement for passi\\'E\" offering the patient a reason€<! prognosis. gross motion testing on selected 5ubjfftS We would advocate that the current ,,,ilh consistent findings of regional motion convention for the diagnosis of somatic asymmetry.4.S One osteopathic study dysfunction - TART - should be expanded to include patient feedback relating to pain demonstrated low agreement of findings for pro\\'ocation and the reproduction of patients with acme spinal complaints when familiar symptoms. practitioners usro their own diagnostic procedures.' level of agreemmt can be Somatic dysfunction is identified improved by nt'gOLiating and selecting by the S-T-A-R-T of diagnosis specific tests for detecting patient lBox A.2.2l improVE\"mt\"nL7Standardization of testing procedures can improve boc.h inter- and Box A.2.2 Diagnosis of somatic dysfunction intra-examiner reliability.! • 5 relates to symptom reproduction In asymptomatic somatic dysfunction. • T relates to tissue tenderness high levels of inter- and intra-observer • A relates to asymmetry agreement for palpatory findings have yet to • R relates to range or motion be demonstrated. Many studies show that • T relates to tissue text...-e changes intc:r- and intra-ex.aminer reliability for palpatory motion testing without pain S relates to symptom reproduction provocation is poor.~·18 Poor reliability of clinical tests involving palpation may be While somalic dysfunction can be paniaJly explained by error in location of al>)'mplomatic, it commonly exists within bony landmarks. 19 HO\\vever, palpation as a the context. of a patient presenting with diagnostic 1001 can demonstrate high levels symptoms. Pain provocation and the of sensitivity and specifidty in del.octing reponing of reproduction of familiar symptomatic intervenebral segments.21),21 symptoms are therefore essential components of the physical examination. Traditionally, diagnosis of somatic dysfunction ,.;as made on the basis of a T relates to tissue tenderness number of positive findings. Specific criteria Undue tissue tenderness is often present in identifying areas of dysfunction were and must be differentiated from dC\\'elopro and related to the observational reproduction of the patient's familiar pain. and palpatory findings of a!loymmetry, altered range of motion, tissue texture A relates to asymmetry changes and tenderness. 111is was represented as the acronym TART (tissue DiCiovanna links the criteria of asymmetry tenderness, al>)'mmetry, range of motion and to a positional focus stating that the tissue texture changes).3.22.n 'position of the vertebra or olher bone is Pain provocation and reproduction of famiJiar l>)'mptoms should also be used to localize somatic dysfunction. The presence

, ,. Osteopathic philosophy and technique .2 asymmetrical'?2 Creenman broadens the Box A.2.3 Therapeutic objectives in the 7 concept of a~)ymmeuy by including treatment of spinal disorders functional in addition to strudural • Promote rest fOt\" the affected anatomic ~ymmetry.:U structures R relates to range ofmotion • Diminish musde spasm • Diminish inflammatton Alteration in range of motion can apply to a • Improve tissue fluid drainage single joint, several joints or a region of the • Reduce symptomatic pain musculoskeletal system. the abnormality • Increase musde strength may be either restrided or increased • Increase range of motion mobility and includes assessment of quality • Increase endurance of movement and 'end feel: • Increase functional and physical WOfk T relates to tissue texture changes capacity • Modify work and home environment The identification of tissue texture changt'S • Alter mechanical structures by surgical is important in the diagnosis of somatic dysfunction. Palpable changes may be noted intervention in superficial, illlennediate and deep tissues. • Met\" neorological structures by It is important for clinicians to recognize normal from abnormal. denervation • Modify social envil'Ol'Y1'lent The diagnosis of somatic dysfunction • Provide treatment adapted to the using the S-T-A-R:r approach should nOt be based upon a single finding but should psychological aspects d the probkom be detennined b)' the clinician identifying a number of positive findinf.;) that are Box A.2A Osteopathic manipulative consistent with the patient's clinical techniques presentation. • Articulatory SOMATIC DYSFUNCTION • Balanced ligamentous tensKMl AND OSTEOPATHIC • Chapman's reflexes MANIPULATIVE TECHNIQUES • Facilitated positional release • Fascial ligamentous release A palielll's overnll management requires • Functional the identification of broad thernpeutic • High-velocity low-amplitude thrust objectives. The Quebec taskforcE?4 • Integrated neuromuscular release and developed a Jist of objectives in the treatment of spinal disorders. Box A.2.3 is a myofasdal release modified list of these objectives. which takes • Lymphatic accollnt of an osteopathic perspective. • Muscle energy • Myofasclal trigger point Patients should be made aware of the • Osteopathy in the cranial field potential debilitation of excessivf' bed re;t, • Progresslve inhibition of neuromuscular the dangers of OVf'r medication and thf' inadvisability of surgery without strong structures preoperative indications. • Soft tissue • Strain and counterstrain Once a praaitioner has established • Visceral therapeutic objectives. consideration must be given to the specific treatment of somatic Ideally, osteopaths should embrace dysfunruon. '111ere are many osteopathic a range of different techniques and not approaches (Box A.2.4) that can be used. f.wour anyone specific approach. In practice. the most commonly used osteopathic manipulative treatment

HVLA thrust techniques - an osteopathic perspective techniques are articulatory, high-velocity 11 Connella C l'<Iris S, KlIIoer M_ Reliability in !O\\...·amplitude (1IVlA) lhnlSl, rounterslrain, e\\'illualing pas..~i\\'t': imer\\'ertrornl mor.ion. Phl's Ther 1982; 62;436-444. muscle energy, Ill}'ofascial/neuromuscular release and soft tissue techniques.u 12 Maly.l.\\ T. Bach T. 11u,: reliability of scl«tro tcchniqut':li in clinical anhrokinemaLia..Aust J Physiother 1985; 31 (5):175-195. References 13 I{a....Y)' D, nyfM:':ld D. Preliminaty studil'S with a Special Commill~ on Ostcopalhk Principles mechanical modcI fOf the evaluation of spinal and Osu,;opathicTtxhnk. Kirksville College of lllOIion palpation. Oin Biomedlania 1991; Osteopathy and SuIgCl)'. An interpretaLion of 6:79-82. the osteopathic ConCcpL Tentam'f': fonnulaLion of a leaching guide for farulty, hospital staff 14 I,ev,'il K. Liebenson C. Palpation - problems and studem bod}'. J Osteopathy 1953; 60:8-10. and implications. J fl.unipulaln~ Ph}'Sio1 Ther- 1993; 16(9): 586-590. 2 lhe Glossary Review Committee of the WucalionaJ Council on 05leop.nhk I'rinciples.. 15 P3~r DM. TIle reliability of lumbar motion Glossary of osleopathic lerminology. In: Allen palpation. I ManipuJati\\~ Ph)'Siol TheJ 1992; TW, ed. ADA Yearbook and Directory of Osleopathic Ph)\"Sirians.. O1icago: American I. IS(8):518-524. Osleopa1hk Association; L993:GlossaJ)'_ l.o\\~ RM, Brodeur R. Inler- and inlla-examillCr reliability of motion palpation for !he thoracolumbar spine J Manil~daLi\\'C Physiol Ther 1987; 10( I): 1-4. 3 Kappler RE. PaJpatOly skills and. exercises for 17 Smedmark \\~ Wallin M.. Nvidsson I. Inler- oodoping the sense of touch. In: Ward R. ro. examiner reliability in asst':liSing pas.si\\\"'l!: Foundations for OstOOJl'lthic Mrokine. inlervend>ml motton of the cervical spine. Man Philaddphia: Uppincou Williams & Wilkins; Ther 2000; 5(2):97-101. 2003: Ch. 38. 18 l-leslOOek I.. 1.ebcxuf·Yde C. Are chiroprnctic tests for the lumbo·peh<k spine reliable and • lohnslon WI.. Elkiss MI- Marino RV, Blum CA. valid? A ~'SIematic critical lilcrnwre rE':\\'i(':w. , I\"as&iw: gross ITlOI ion lesting: Part II. A study \"'ianipulali\\'C Physiol Ther 2000; of il1terexarniner agrttmmL I Am Osteopath 23(4):258-27S. Assoc 1982; 81 (5):65-69. I' O'ilaire e, Cibbons P. Inler-exarniner and 5 JohnSiOll WL I~I Me, BluTli GA.. Iiendm ,I... intra-examiner agTl':t':1ll(':1lI for assessing sacroiliac anatomical landmarks using Neff I)R. Rosen ME. Passhl': gross motion palpation and ol:6ervation; A pilot study. Man Ther 2000; S( 1):13-20. 1e5ling: Part III. Examiner agreemenl on sdooro subjects.. JAm Osleopath Assoc 1982; 20 lull C, llOgduk N, Marsland A. The accuracy of 81 (S): 70-74. manual diagnosis for cervical zygapoph)'sial joint pain syndrolTl(':S.. Med I Ami 1988; • McConnell I)G, Heal Me, Dinnar U, et al. Low 148;233-236. 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. 21 lull C:, Zilo C, Troll P, Poller II, Shirley D, 7 Beal Me.. Goodridge JP' lohnston WI. Richardson C. llller-cxaminer reliabilily to detect painful upper cerviC\"oIl ;aim McConnell DC. 11llel\"t.'Xaminer agrecmell1 on dysfundion. AIISI Physiolher 1997; patiel\\l imprOYellll':llt afler negOlialed selection 43(2): 125-129. of lestS. I Am OSleopalh Assoc 1980; 79(7): 45-53. 22 DiGiovanna EI.. Sc:hiowitl S. An Osleopathic 8 Marcoue J, Normand M.. llIack P. 'nlf: Approach 10 Diagnosis and 1)eatmel\\l.. 2nd 001\\. Philadelphia: IJppincou Williams & kinemalics of motiOll palpalion and its effect Wilkins; 1997. 011 the lellability for cetVical spine rotation. , Manipulal.ive Physiol Ther 2002; 25(7):471. 23 Crttnman rE. Principles of Manual M«!idne 3rd erln. Philadelphia: UppincQtl Williams & • Van Duersen I1.JM, Pat.ijn I, Oc.kh1l)'SCtl AL Wilkins; 2003. \\'ortman BJ. lhe value of some c!inicaltcsts of Ihe sacroiliac jOillL Man Moo 1990; 24- Quebec Task FOKe. Scienlific: approach 10 !he 5:96-99. as.sessmenl and mal~1 of aciivil)'- 10 1.ask1t M, Williams M.. The reliability of relaled spirtal disordcn.. Spine 1987; selected pain pt\"O\\\"OGIlion IesU for sacroiliac 12(7S);16-21. joim palhoklgy. In: L.ttming A, Moone)' V, 25 Johnson S, Kurtz M. Ostropathic manipulati\\~ 8 Dorman T, SnijdeB CI, cds. The Inlegr.uro treaunent Icchniques preferred by I\\.ll'lCtion of th(' Lumbar Spine and Sacroiliac colllemporaJ)' osleopathic ph)<Sicians. J Am loinl. Rotlerdam; EGO; 1995:465-498. Osteopath Assoc 2003; 103(5):219-224.

Kinematics and coupled motion of the spine Clinicians use palpatory assessment of which the anterior surface of the vertebra 9 individual intervertebral segmenls prior to mO\\'eS rather than the posterior elements. the application of a thrust technique. The osteopathic profession has used I~elte's In the dinical setting. Vertebral motion model of the physiological mO\\'ements of is described using standard anatomical the spine to assist in the diagnosis of cardinal planes and axes of the body. Spinal somatic dysfunaion and the application of motion can be described ~ rotation around, treatment techniques. FrYE.'ttel outlined his and translation along. an axis as the research into the physiological movemrnts vertebral body mO'\\'es along one of the of the vertebral column in 1918. I-Ie cardinal planE'S. By convention the \\'ertical presented a model that indicated coupled axis is labelled the y-axis; the horb.ontal axis motion ocamed in the spine and displayed is labe.Ued the x-axis; and the antere> different coupling characteristics dependent posterior axis is the z-axis (Fig. A.3.I'). upon spinal segmental level and posture. The muscle e\"eJ'XY approach is one system In biomechanical terms, flexion is of segrnenlal spinal lesion diagnosis and anterior (sagittal) rotation of the superior treaunent predicated upon Fryette's LaWs.' vertebra around the x-axis, whiJe there is Practitioners utilizing muscle energy accompanying forward (sagittal) translation techniquE.' (MET) use these Laws of coupled of the vertebral body along the z-axis. In mOlion, as a predictive model. to both extension, the opposite ocrurs and the (annulate a mechanical diagnosis and to superior vertebra rOtates posteriorly around selecl the precisely conuolled position the x-axis and translates posteriorly along required in the application of both muscle the z-axis. In sidebending. there is bone energy and thnlst techniques. Current rotation around the amero-posterior 7....axis, literature challenges the validity of Pryette's but sidebending is rarely a pure movement and is generally accompanied by vertebral UlWS. rotation. The combination, and association, of one movement with others is termed BIOMECHANICS 'coupled motion'. 1he concept of coupled mOtion is not recent. As early as 1905, Convention dictates that intervertebral Lovett~ published his observations of motion is described in relation to motion coupled motion of the spine. of the superior vertebra upon the inferior venebra. Motion is further defined in COUPLED MOTION relation to the anterior surface of the vertebral body; an example of which would Coupled motion is described by White and be the direclion of vertebral rOlation which PanjabiS as a 'phenomenon of consistent is described in rdation to the direction in association of one motion (translation or rotat.ion) about an axis with another motion

HVLA thrust techniques - an osteopathic perspective ,..... Figure A3.1 Axes of motion. (Reproduced with permission from Bogduk..l ) about a second axis'. Bogduk and 1\\....omer opposite directions (eg. sidebe:nding right, describe coupled movements as 'movements rotation left). The osteopathic profession that occur in an unintended or unexpected developed the convention of naming the direaion during the execution of a desired coupled movements as Type I and T)<pe 2 motion'. Stokes eI. aI.' simply state coupling ffiO\\'elllel1ts (Figs A.3.2 and A.3.3).IJ to be when 'a primary (or intentional) lbese concepts of vertebral motion are movement results in a joint also moving in attributed to Fryene. Fryel.te acknowledges other directions'. Where rotation occurs in a the contribution made to his understanding consistent manner as an accompaniment to of spinal movement by Lovett. Loven had sidebending it has been termed conjunct undertaken research on cadavers in order to rotation.7A Therefore. in rotation the understand the structure and aetiology of venebra should rotate around the vertical scoliotic curves. y-axis but translation will be complex Fryeue acknowledged that l...O\\'eI.t's dependent upon the extent and direction of findings for the thoracic and lumbar spine coupling movements. Coupling will cause were correct in the position Lovett had shifting axes of motion. placed the spine for his cadaveric Creenman' maintains that rotation of experiments but maintainro they would not the spinal column is ah\\T3.}'S coupled with be: true if the lumbar and thomac spine sidebending with the exception of the were placed in differeru positions of flexion atlantoaxial joint. 11le coupled rotation can or extension. Fryeue performed his own 10 be in the same direction as sidebending experiments upon a 'spine mounted in soft (eg. sidebending righL rotation right) or in rubber' and intrcx1uced the concept of

Kinematics and coupled motion of the spine Sld9bending left Sdebending left Rolarion righl Rotarion Ief1 Figure A.3.2 Type 1 movement.Sidebending Figure A33 Type 2 movement. Sidebending and rotation occur to opposite sides. and rotation occur to the same side. (Reproduced with permission from Gibbons (Reproduced with permission from Gibbons and Tehan.l~ andTehan.~ neutral (facets not engaged) and non- words, the sidebending group rotates 11 neutral (facets engaged and controlling itself toward the convexity of the vertebral motion) positioning. Fryelle sidebend, with maximum rotation at the defined neulral '10 mean the position of apex. any area of the spine in which the mcets • Law 2. Non-neutral (vertebra hypernexed are idling, in the position between the or hyperextended) rotation and beginning of flexion and the beginning of sidebending go to the same side extension'. In the cervical spine below C2, individual joints aoing alone time. the facets are considered to always be in • Law 3. Introducing motion 10 a vertebral a non-neutral position and are therefore joint in one plane aUlomaLicalJy reduces assumed to control vertebral motion. lhe its mobility in the other two planes. thoracic and lumbar regions have the possibility of neutral and non-neutral Research into coupled movement has positioning. MitcheUZ summarius F'ryelte's been undertaken on cadavers and live Laws as follows: subjects. Cadaver research has allowed precise measurements 10 be \"'ken Fryette's Laws of coupling behaviour, but has the disadvantage of being unable to reOect • Law I. Neutral sidebending produces the activity of muscles or the accurate rO(;ltion to the other side or in other effects of load on different postures. Plain

HVLA thrust techniques - an osteopathic perspective radiography has been superseded by the side-bending is then accompanied by more accurate biplanar radiographic studies rotation to the same side'. U Russell et al.U that allow' research to bE': undertaken under in a study of the range and coupled more nonnal physiological conditions. Most movements of the lumbar spine. using a research has been pe:rfonned on the lumbar 3Space lsotrak system on 181 asymptomatic spine:. volunteers aged between 20 to 69 )'ears,. Brown U•.l 2 indicates. after an extensive found mat in the erect position there was literature review, the conflicting results of strong coupling of opposite axial rotation ~1.udies into coupled motion. Many authors on lateral bending. Despite subjects being have demonstrated a coupling relationship told to make lateral flexion as pure a lateral between sideflexion and rotationlll,lJ.n movement as possible, Russell et aI. also but there is inconsistent reporting of the noted a slJong coupling of flexion as well as direction of coupling.2J Other authors opposite axial rotation on lateral bending. maintain that sidebending and rotation Other authors do not support these findings are pure:ly uniplanar mOl ion occurring and report inconsistent cOllpling.lI,n.17.19 independently of each other.2c.u Plamondon et al. llsing a Stoddard I) demonstrated radiologically stereoradiographic method to study lumbar that sidebending in the celvical spine is intervertebral motion itl llioo demonstrated always accompanied b)' rotation to the that axial rotation and lateral bending were same side regardless of cervical posture. coupled motions but reponed there \\vas Stoddard's observations in relation to the 'no strict pattern that the \\'enebra follow cervical spine are consistent with Lovett's in executing a TnO\\'emenl~17 findings and Fryette's Laws. These. findings Pearcy and Tibrewa.l 's in a three- are further supported b)' research dimensional radiographic study of nonnal undertaken using biplanar X-ray analysis. la voluntan. with no hislory of back pain In 20 nonnal male \\'Olunteers, when the requiring time off work or medical head was rotated, lateral bending occurred treatment. found that the relationship by coupling in the same directjon at each between axial rotation and laleral bending segment below the C3 vertebra. Interestingly is not consistent at different levels of the coupling was not restricted to lateral lumbar spine. Some individuals occasionally bending. At the same time. flexion took demonstrate 'mO\\\"€:ments in the opposite place by coupling at each segment below direction to the \\'Oluntary movement at the C5-6 vertebra and extension abO\\'e: the individual intervertebralleve.ls. most C4-5 leve:l. In a study of active range of commonly at L4-5 and 1.5-SI. In lateral motion in the cervical spine during daily bending. there was a general tendency for fWlCtional tasks, Bennett et aI. noted thaI 1.5-SI to bend in the opposite direction to tht' normal coupling pattern for the cervical the voluntary movement'. TIlis unexpected spine is rotation and sidebending to the finding is consistent with a study by WeiLZ.16 samt' side:.21 Panjabi et al.,\" using fresh human While there is agreement as to the cadaveric lumbar spines from L1-Sacnlm, direction of axial rotation and lateral flexion assessed coupled motion under load coupling in the cervical spine below Cl, i.e. in different spinal postures using sidebending and rotation occurring to the stereophotogrammeuy. 1'hey concluded that same side the patterns for coupling in the coupling is an inherent property of the lumbar spine are less dear. Stoddard's lumbar spine as advocated by Lovett but findings in the lumbar spine were that that in vitro coupling patterns are more 'sidebending is accompanied by rotation complex than generally believed. 'l1ley to the opposite side if the commencing demonstrated the presence of muscles is 12 position is an erea one of extension. U; not a requirement for coupled motion, but hO\\Y'{'ver, the starting position is full flexion, acknowtedged that they may significantly

Kinematics and coupled motion of the spine alter coupling behaviour. The specific effect Vicenzino and Twomey' used four 13 of physiological loading and muscle activit)' human male post-mortem lumbar spines upon coupled motion is presently from Ll to the sacrum. \\\\lith ligaments unknO\\\\ln. In a neutral posture. left axial intact and muscles removed to assess torque produced right lateral bending al Ihe conjunct rotation of the spine \\.men upper lumbar levels and left lateral bending sidebending was introduced in both a flexed at the lower 1\\\"0 I€:\\>els with 1.3-4 being a and extended position. 'Iltey found that in transition level. They concluded that the the flexed position, lateral flexion of the 'rotary coupling patterns in the lumbar lumbar spine \\vas associated with conjuna spine are a funaion of the inte\"rertebral rotation to the same side:. lbis is consistent level and posture'. At the upper lumbar with Frycne's laws. However, in the levels, axial torque produced lateral extended position, lateral flexion was bending to the opposite side whereas at the associated \\\\lith conjuna rotation to the lower lumbar levels axial torque produced opposite side. which supports Stoddard'sll lateral bending to the same side. h was radiographic observations of coupled also noted 'that the spine does not exhibit motion in the extended position. These mechanical reciprocity' for example at L4-5 findings are not consistent with Fryetle's applied left axial torque produced coupled Laws, which predia sidebending and left lateral bending but applied left lateral rotation to lhe same side as lhe facets are bending produced coupled right axial not 'idling' when in the extended position. rotation. Vicenzino and 1\\vomey's' study reveals that the lS-$1 segmem is unique in that Panjabi et arsl ' finding that 3t 'Ll-3, conjunct rotation was ah\\l3)'S in the same coupled lateTal bending increased from direction as sideflexion, independent of about 0.5 0 in the fully extended posture to flexion or extension positioning. This 1.5 0 in neutral and to about 2 0 in flexed finding for the 15-51 segment was posture;', conflicts with Fryette's third Law, supported by Pearcy and Tibrewal u \\.mo whidl indicates that introduction of motion found that during axial rotation al I5-SI, to a vertebral joint in one plane lateral bending always ocOIrre:d in the same automatically reduces it.o; mobility in the direction as the axial r()(ation. other two planes. In lumbar flexion the coupled lateral bending increased by 0.5 0 Vicenzino and Twomey' dr.l\\v the from the neutral to the flexed position. conclusion that as both in l'itro and in vi.., studies hm.>e demonstrated conjunct A number of studies have indicated that rOlation, the non-contractile components coupled movement ocrors independently of of the Iwnbar spine may have primary muscular activit},.8.14,27 In 1977, Pope et al. 14 responsibility for the direction of conjunct rotation and that neuromuscular aaivit}, utilized a biplanar radiographic technique may only modify the coupling. The impact to evaluate spinal movements in intaa of muscular anivily on coupled motion cadaveric and living human subjects. 'nley in both the normal and dysfunctional confinned that 'vertebral motion occurs as intervertebral joint requires further study. a coupling motion, and that axial rotation uniformly is associated with lateral bend'. The presence of apophysial joint uopism FrymO}rer el al.n measured spinal mobility might influence spinal motion and using orthogonal radiogrnphy on 20 male confound prediaive models of vertebral cadavers and nine male living subjects. coupling. The incidence of facet uopism has They found that complex coupling doe; been reported as 20% at all lumbar lE\":\\ocls ocrur in the lumbar spine and but may increase to 30% at the 15-5I demonstrated remarkably similar spinal segment.l 'I'he incidence of facet tropism is behaviour between the two groups. 'I'hese also higher in patient populations attending studies indicate that coupling ocrurs manual medicine praaitioneT5. It has been independently of musOIlar aaivity.

-. HVLA thrust techniques - an osteopathic perspective estimated that as many as 90% of patients coupling behaviour from that of the normal presenting with low back pain and sciatica population.1'J have arlicular tropism with pain ocaming It is evident that many faaon;,. such as on the side of the more obliquety oriented facet tropism, vertebral I€:\\rd, ilUervenebral facet. J Cyran and Hulton28 subjeaed 23 disc height, back pain and spinal position, cadaveric lumbar imer\\'enebral joints to might influence the degree and direction of a combination of compressive and shear coupling. forces. \\'lhen asymmetric facels were While it appears that Fryeue's Laws are present, the vertebrae that have such facets open to Question and clinicians' concepts of rol'ated towards the side of the more lumbar mupling are inconsistent.Jll there are oblique facet. They concluded anirular still only two possibilities for the coupling tropism could lead to lumbar instability of sidebending and rotation, i.e. to the same manifesting itself as joint rotation toward or the opposite side. With this in mind. it the side of the more oblique facel. This was appears reasonable to dassify spinal not a study of coupled motion and no dear movement as TypE' I and Type 2 in relation comments can therefore be made ahom the to mupled sidebending and rotation. What influence of faro tropism on patterns of is nOI dearly established is the influence of coupling but it does suggest that tropism flexion and extension in relation to Type I can influence spinal mechaniex. and Type 2 mo\\'emenl 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~ CONCLUSION dimensional radiographic analysis of lumbar spinal movements. l1ley studied Conclusions that can be drawn from the patients \\vith back pain alone and patients litefature are limited for a number of with back pain plus nerve tension signs reasons. Cadaver studies exclude the demonstrated by restriaed straight leg raise. effects of muscular activity and normal Coupled movements were increased only in physiological loading; the studies were also Lhose patients without nerve lension signs often single segment analysis and generally indicating the possibility of asymmetrical of small sample size. Plain radiographic muscle aaion. II was concluded that studies have inherent measuring difficulties \"The disturoo.nce from the normal pattern of assodated with extrapolating three- coupled movements in the group with back dimensional movements from two- pain alone suggests that the ligaments or dimensional films. The use of biplanar muscles were involved unilaterally and thus radiographic assessment improved the acted asymmetrically when the patient accuracy of measurement and allowed moved'. The faCI Lhal coupled movements studies to be performed with muscular wefe increased in the back pain group activity and In more normal physiological suggests that muscular aajvity, while not conditions; again, however, the groups being essential for coupling. can influence studied were small. Notwithstanding these the magnitude of coupled movement. The observations, there are a number of adion of the contmctile elements in normal, conclusions that can be drawn: dysfunctional and pain states requires more ,. Coopled motion occurs in all regions of study before any definite statements can be the spine. made relating to their effea upon coupled 2. Coupled motion occurs independently of motion. Using peraltaneous tmnspedirular muscular activity but muscular activity screws and optoelearonic camera might influence the direction and measurement. Lund eI al. demonstrated that 14 magnitude of coupled movement chronic low back pain patients had differ£l1t

\" 3'-~~'. ~ . Kinematics and coupled motion of the spine ~ 3. Coupling of sidebending and rotation in innuencing factors. Ausl PhysiOlher 1993; 15 the lumbar spine is variable in degree and direction. , 39(4):299-306. Creenman Pf_ l'linciple:s of Manual Mooicine, 4. There are many variables that can 3rd oon. Philadelphia. Pi\\.: UppinCOIl Williams & Wilkins; 2003. orinfluence the degree and direction I. Cibbons P. Tehan P Mu.sde energy concepl$ coupled movement and include pain. and coupled mocion of lhe ~in~ Man -I'het\" vertebralle\\lel, posture and facet tropism. 5. There does not appear to be any simple 1998; 3(2):95-101 and consistent relationship between conjunct rotation and intervertebral II Brown L An illlroduction 10 the ueallnenl and motion segment Ievd in the lumbar examinalion of the spilM: by combined spine. ITlO\\'eIllCOIS. l'hysiother:apy 1988; 74(7):347-353. Thefe is evidence to support L.ovett's initial observaUons and Fryctte's laws in 12 Brown L Treatmenl and examination of the relation to sidebending and rotation spine by combined mO\\'Unents - 2. coupling in the cervical spine, i.e. Physk>thcrapy 1990; 76(2):666-674. sidebending and rotation ocror to the same 13 Stoddard A. Manual of Osleopathic l\"raclicr. I).\"side. However, the evidence in relation to London: Hutchinson MedKal l\"ublkations; 1969. lumbar spine coupling is inronsistent.-1.\\17.l9 While Fryette's laws may be useful for 14 I\"opt' \"''I. Wilder D. Mallen It Frymo)\"t'r J. EqlerimcotaJ measurenwnu of \\'ft1cbr.tl predicting coupting behaviour in the cervi- motion under load. Onhop Oin NOM Am cal spine caution should be exercised for the 1977; 8(1 ):155-161. thoracic and lumbar spine where modifica- tion orthe model may be necessary. 15 IUrcy M.. 1ibrewal S. Axial rotation and laleral bending in the I\"IOI\"mailumbar spine measured References by three-dimensional rndklgraphy. Spine 1984; 9(6):582-587. Fr)'eue H. PrindplO'i of ~teopathkTechnic. 16 l\"earry M, Portek I, Shtpherd I. -11M' effect of Newark. OH: Americall Academy of low back pain 011 lumbar spinal n)()\\ocmenlS rT\\t'a$ural by three-dimensional X-ray analysis. Osteopathy; 1954 (Re-prinl 1990). Spine 1985; 10(2):150-153. 2 Milchell 11... 'nle Mu:scle Energy Manual. F..a.sl 17 l>Jamonoon A. Gagnon M, Maurnis C. L.111.~ing, MI: MET Press; 1995, Applicalion of a S'ereoradiogrnphic method for 3 Bogtluk N, '1\\'>'Ollll'Y I:/: Qinical Analomy of the MUd)' ofinten-enebral moliOIl. Spine 1988; 13(9): 1027-1032. Ihe 1.111nbar SpiTle and Sacrunl, 3rd ron. Mcibolll1le: Churchill U\",ingslone; 1997, IS Mimur.t M. Moriya H, Watanabe T, Takahashi 4 lovell RW, 'Ihe mechanism of the normal K. Yama~ua \"''I. Tamaki '1: Three dimensional spine and ilS rclmiOIl 10 scoliosis. I:loslOn Mro SllIgJ 1905; 13:349-358, motion analysis of the cervical spine with 5 White A. Panjabi M. Oinical Biomechanics of special referenCE: to the axial rotalion. Spine the Spine. 'ibrolllo: I..ippincolt Company; 1990. 1989; 14(11):1135-1139. 6 Slokes I, Wilder 0, Iltymo)'er I, Pope M. Assc:ss.melll of palienls wilh low-back pain \" Panjabi M, Yamamoto I, Oxland T, Crisco J, by biplanar radiographic measuremelll of How'does. poslure affect coupling in lhe illlct\\'CJ1ebrai lTlOtion. Spine 1981; lumbar spinel Spine 1989; 14(9): 1002-1011, 6(3):233-240, 2. Nager! H, Kubein-Meesenburg D, Fanghancl I. 7 MacConaill M. The gromeuy and algebra of articular kinemalia. Bio Med Eng 1966; Elements of a general theoty of joints. Anal 5:205-211. Anz 1992; 174(l):6(,-75, 8 Vicel\\?jno G, Twomey L Sideflexion indLKCd 21 Bennett Sf_ Schenk It Simmon:o; E. Active range lumbar spine conjuncI rotation and ils of motion ulilized in the cervical spine 10 perfonn daity functional tasks. J Spinal Disord Tech 2002; 15(4):307-311. 22 Rr.welll~ Pearcy M. Un.s~YOrth A. Meawremem of the ranse and coupled lnQ\\oemenlS ob5er.w in the lumbar spine. Br 1Rheumatol 1993; 32(6):490-497. 23 Cook C. Coupling behavior of the Iwnbar spine: A lilerature review. J Man Manipulative Ther 2003; 11(3):137-145. ...

HVlA thrust techniques - an osteopathic perspective 24 Schultz A. warwick D, Befkson M. Nacherru;on subiects in vivo. J Biomechanics 1979; A. Mechanical properties of human lumbar 12:165-172. spine motion segments - Part 1. J Biomechanical Eng 1979; 101:46-52. 28 Cyron 8M. Hutton we Articular lropism and 25 McClashen J<. Miller A, Schultz A. Andersson stability ofthe Iwnbar spine. Spine 1980; C. Load displacemelll behaviour of the human 5(2):168-1n. lumbo-sacral joinL J Orthop Res 1987; 5:488-496. 29 l.und T, N}'degger T, Ing D. Schlenzk D, OxIand T. Three-dimensional motion pauems during 26 Weitz E. 101.' lateral bending sign. Spine 1981; acti,,. bending in )Xl.lienu with chronic 10l.... 6(4):388-397. back pain. Spine 2002; 27(17):1865-1874. 27 FrymO)'tt JW, Frymo)'er \\VW, Wilder DC, Pope 30 Cool.: C ShOl....altft C. A survey on the MH. lbe mechanical and kinematic analysis of importance of luntbaf coupling biomechanics t1w lumbar spine ill Ilonnalliving human in physiotherapy practice. Man lher 2004; 9(3):164-172. '6

Spinal positioning and locking SpinaJ locking is necessary for long-lever, CERVICAL SPINE 17 higlH'Clocily Jow-amplitude (HVI.A) ttthniques 10 locali7...e forces and achieve Creenman7 describes lhe normal coupled cavitation at a specific venebral segment.1- 7 motion of sidebending and rolation at the Short-lever HVlA techniques do not require occipitcratlalllal (CO-C1) segment as being locking of adjacem spinal segments. type I. The principle of facet apposition locking does not apply to HVI..A thrust tocking can be achieved by e:iLher facet to:::hniques directed 10 Ihe co-C 1 segment apposition or the utilization of Jigamelllous llC\\'>'eVef, facet apposition locking of the myofascial tension. or a combination of CO-CI segment can be utilized for IlVI.A both. '-17 The principle used in th€Se thrust techniques directed to other cervical approaches is 10 position the: spine in such levels (see Table A.4.1). a ,vay that levernge is localized to one joint without undue stmin being placed upon '(he Iype of coupled rnO\\·ement av.ailable adjacent segments. at the Cl -2 segment is complex, This segment has a predominalll role in total The osteopathic profession developed cervical rotation.,...l' lip to 77% of total a nomenclature to classify spinal motion cervical rotation occurs at the atlanto-axial ba.~ed upon the coupling of sidebending joint., with a mean rotation range of 40.5° and rotation movemems. This coupling to either side.'.11 The great range of rotation behaviour will vary depending upon spinal at the atlanto-axial joint can be attributed positioning: to facet plane, the loose nature of the ligamentous fibrowi capsule and the absence • 'IYpe J 1U00ICmerJI - sidebending and of ligamentum fiavum above: C2. 12 Only a small amount of rOlation occurs at the rolation occur in opposite diredions (see joinu above and below the atlanto-axial Fig. A.4. I\") joint. 1l- 1S • 'lyPe 2 movemen!. - sidebending and rounion occur in the same diro:::tion (see Below e2, normal coupling behaviour in Fig. A.4.2\"). the cervical spine is type 2, i.e. sidebending TIle prindple of facet apposition locking and rotation occur to the same side.;·16-11 is to apply leverages to the spine that cause 'rlle average range of cervical spine rotation the facet joinu of uninvolved segments from neutral position is 80° (Fig. A.43V' to be apposed and consequently locked. For patient comfort and safety lhe To achieve locking by facet apposition. the practitioner should limit the total range of spine is placed in a position opposite cervical spine rotation when applying thrust to thai of normal coupling behaviour. techniques. Below C2 lhis is achieved by The vertebral segment at which you wish to combining cervical spine rotation with produce cavitation should neveT be locked.

HVLA thrust techniques - an osteopathic perspective SidoOOnding IeII Sidebeoding lett Rotation left Figure A.4.1 Type 1 movement. Sidebending Figure A.4.2 Type 2 movement. Sidebending and rotation occur to opposite sides. and rotation occur to the same side. (Reproduced with permission from Gibbons (Reproduced with permission from Gibbons and Tehan.1) and Tehan.1) TableA.4.1 Coupled motion Facet apposition lodting Spinal level Type 1 Type> Complex - primary rotation Not applicable (O-Cl (occiplto-atlantal) Type 2 Type 1 (1-2 (atlanta-axial) C2-T4 opposite sidebending (Fig. A.4.4). 'Ib enables a thrust 10 be applied 10 one generate facet apposition locking for HVI.A venebrnl segment. The amount or degree of thrust techniques. the opET.l.tor must sidebending and rotation can be varied to inuoduce a type I movement, which is obtain facet locking. The intent should be 10 sidebending of the cervical spine in one have a primary and secondary 1C\\'efage. The direaion and rotation in the opposite prindpal or primary leverage can be either direction. e.g. sidebending right with sidebending or rotation (Fig. A.4.5). 18 rotation lefL lnis positioning locks the The principles of facet apposition locking segments abmre the joint to be cavitated and that apply to the cervical spine are also

Spinal positioning and locking Figure A.4.3 Full left cervical spine rotation. 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. Figure A.4.4 Introduction of right inconsistent. Although researrh does 19 sidebending limits the range of available left not validate any single model for spinal cervical spine rotation. positioning and locking in the Ihorade and lumbar spine the model in Table A.4.2 utilized for HVLA technique> to the is useful for leaching IIVLA techniques. cervicothoracic junaion (C7-T4). If cervkothoradc region techniqUe> require Evidence suppons tbe view that spinal locking via the cervical spine.. this is pn<iture and positioning alter coupling achieved by introducing type I movements behaviour.1O-v\"lbis has implications for to the cervical spine. joint locking in the thoracic and lumbar spine. In relation 10 patient positioning. THORACIC AND LUMBAR SPINE the locking procedure> will be different depending on whether the patient's spine Current research relating to coupled is placed in a flexed or a neutral/extended movements of sidebending and rotation in position. the thoracic and lumbar spine is 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.

HVlA thrust techniques - an osteopathic perspective Table A.4.2 Coupled motion Facet apposition locking Spinal level Type 1 or type 2 Type 2 or type 1 14-12 Type 1 or type 2 11-5 Type 2 or type 1 Type 2 Position of spine T4-L5 Type 1 - s1debending and rotation to the opposite Flexion side NeutraVextension Type 1 Type 2 - sidebending and rotation to the same side For patient romfon and safety, the In the example of neutral/extension practitioner should limit the total amowlt positioning (Fig. A.4.6), the practitioner of trunk rotation when using HVlA thrust uses spinal positioning and locking to limit techniques in the thoClcolumbar and the total range of trunk rotation. If the lumbar spine. In most instances. this can be praaitioner introduces trunk flexion from achieved using the facet apposition model below (Fig. A.4.7), or from above and and an understanding of neutral/extension below (Fig. A.4.8), an increased range and flexion positioning prior to the of trunk rotation is then required to application of a HVL\\ thrust technique achieve the necessary joint locking prior to These techniques can be applied in either the application of an JIVIA thrust a neutral/extension or in a flexed position. technique. 20

Spinal positioning and locking 4 Figure A.4.6 NeutraVextension positioning. Figure A.4.7 Note increased rotation necessary to achieve facet apposition locking with introduction of trunk flexion from below. Figure A.4.8 Note further increased rotation 21 necessary to achieve facet apposition locking with introduction of trunk flexion from both above and below.

HVLA thrust techniques - an osteopathic perspective Neutral/extension positioning shoulder girdle and creates a long C curve with the trunk side:bending to the patient's The patient's lumbar and thoeacic spine is right \\.. hen the patient lies on the left side. positioned in a neutr.al/extended posture (Fig. A.4.9). Using the model outlined. the Trunk rotation to the right is introduced normal coupling behaviour of sidebe:nding by gently pushing the patient's upper and rotation in the neutral/extension shoulder a\\YaY from the ope-r.ator. Rotation position is type 1 movement Facet and sidebending to Lhe same side achi(!\\~ apposition locking will be: achieved b)' facet apposition locking in the neutrnl or introducing a type: 2 movemenl, i.e. extended position, in this instance with sidebending and rotation to the same side. sidebending and rotation to the right (Fig. AA.l0). The spine in the neutral/extension position is slung between the pelvis and 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 spine. Trunk rotation to the right is introduced by gently pushing the patient's '111e patient's lumbar and thoracic spine is upper shoulder away from the operator positioned in a l1exed posture (Fig. A4.lt). (~1l!- M.12). '11(> normal coupling behaviour of sidebending and ralation in the flexed Mall)' factors. such as facet lTopism, position is type 2 mO\\.'CmenL Face! vertebral level. intervertebral disc height. apposition locking will be achieved by back pain and spinal position, can affect introducing a type I movement, i.e. coupling beha,'iour and there will be sidebending and rotation to opposite occasions when the model outlined needs sides. to be modified to suit an individual patient. In such circumstances. the operator \\\\ ill To achieve facet apposition locking of the need to adjust patient positioning to spine, in the flexed posture,. the trunk must facilitate effective localiz.ation of forces be rotated and sidebent to opposite sides To achieve this. the operator must develop (Fig. A4.12). TI1e operator imroduCt'$ trunk the paJpatory skills necessary to sense sidebending to the left by placing a rolled appropriate pre·thrust tension and leverage lowel under the patient's thoracolumbar 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 23 sldebendtng to opposite sides. i.e. sidebending left and rotation right.

HVlA thrust techniques - an osteopathic perspective References 12 Cuth M. A comparison of cervical rotation in 38C-matdlt.'d adoll'SCt'1lI competitive swimmers Nyberg R. Manipulation: definition. types, and hl'31thy mail'S. 1Orloop Sports Phys Ther application. In: Basmajian I, Nyberg R. eds. 1995; 21(1):21-27. Ration.al Manuallherapia Baltilll()ll', MO: Williams & Wilkins; 1993:21-47. 13 Penning I~ Normal mO\\'C!nents of the cnvical ~inc. 1 Roeut8ICnoi 1978; 2 Downing CII. Principles and l>rnctice of 130(2):317-326. <Ateopathy.l.ondon:Tamor Pienton; 1985. 14 White A. Panjabi M. Clinical Uiomechanics 3 Stoddard A. Manual of <hteopathic TechnklUt\". of the SpillC'. 2nd edn. Philadclphia. 1'1\\: 2nd edn. l.Dudon: Ihnchinson t.iedkal Uppiocott 1990. l>ubtication5; 1972. 15 l'oner6eld JA. DeRo5a e. Mechanical Neck 4 Ilanman L IlandOOok of Osteopathic Pain: 1'l'Bpt\"Cti\\\"t'lIi in functional AnalOmy. Technique, 3rd edn. l.ondon: Chapman & 1Ia11; Sydnty. WB saunders; 1995. 1997. I' Mimura M. Moriy.l II. Watanabe T, Takahashi 5 8«:31 Me. Thaching of basjc principles of K. Yarnagalill M. Tamaki T. Three dimensional 05tcopathk manipulati\\-e teehniqtxS. In: BeaI motion anatysis of the ceJVkal spine with Me. eds.. 1be l'rincipies of I'alpatory Oi3gnosis special reference 10 thE' axial rotation. Spine and Manipulatiw Technique. Newarlc 1989; 14(11):1135-1139. American Academy of O&tropa!hy; 1989:162-164. 17 Stoddard A. Manual of Osteopathic Ptaaice. London: Ilutehinson Medical Publications; • Kappler R£. Direct action techniques. In: Beal 1969. Me. eds. '!be Principles of Palpatory Diagnosis and Manipulati\\~l«hnique. Newark 18 Bmnett Sf~ Schenk It Simmons Eo Active ..-anse orAmerican AGKIemy Ostropathy; 1989: 16S--168. or motion utilized in the cervical spine to 7 Greenmail I'Eo. l'rinciples of M.anual Medicine perform daily functionallasb. JSpinal Disord 3rd edn. Philadelphia. PI\\: uppincott Williams & Wilkins; 2003. Tech 2002; 15(4):307-311. 8 Gibbons Po Tehan Po MU5de ene..gy concepts I. American Medical Associalion. Guides to the Evaluation of l'Umafll'nt Impainnent. 4th edn. and coupled motion of the spine. Man 11ln Chicago, II.: American M«Iical AssodaLion; 1998; 3(2):95-101. 1999. • crPe.nning I.. Wilmink fl'. Rotation of the cen'ical 20 VKeflZino G, TwOmey 1~ Sillel1exion induced spine: a study in normal subjeas. Spine lumbar spine conjunct rotation and its 1987; 12(8):732-138. influencing factors. Aust PhysiothE:f 1993; 39(4):299-306. 10 Mimura M. Moriya II. Watanabe 1: Takahashi K. Yamagata M. Tlunaki T. 'l1uec dimellSional 2\\ I ~te II. ['rinaples of Ostcopalhic Technic. Newark. 01 [: American Academy of motion analYSIS of the cervical spine with Osteopathy; 1954:15-21 (reprinted 1990). special rcll..-ence to aJual rotation Spine 1989; 14( II): 1135-1139 22 Panjabi M, ,'anwnoto I, Oxland\"r, Oisco J. 110\\'\" d0C5 posture affect coupling in the II lai II. Mor;ya II, Takahashi K. Yamagata M, lumbarspinef Spine 1989; 14(9);1002-1011. Tamald T 'nm~ dimensional motion analysis of upper cervical Spilll' during axial rolation. 23 Russell P, Pearey M, Unsworth A M'-'3.Surt-ment Spine 1993; 18(16):2388-2392. of the range and coupled mowmt>nlS oooerved in the lumbar spine. Br' RheumalOl 1993; 32(6):490-497. 24

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 18 Walking. kneeling at prayer, househc:Hd chores, sexual 8 leisure activities intercourse 10 Sustained rotation Clndlor Wallpapering. washing walls and cetlings, archery, extension 7 yoga 7 Short-lived rotation 2 and/or extension -Turning head white driving. backing out of driveway, looking up Sudden head movements Sneezing. fair ride. violent coughing. sudden head Misceflaneous. minor Imuma Minor fall, 'b<w1ging' head Adantc;axial instability, postpartUll\\ post-gastrectomy 6 Mtsc:eUaneous Total 58 Haldeman et aI.\" Difficulties arise in the estimation of risk Substantive reversible impairment for vertebrobasilar dissection afteT ned< manipulation, as patients may in faa seek • Disc herniation treatmem for symptoms of a progressing • Disc prolapse dissection. Smith e1 al. attempted to address • Nerve root compression this issue in a case controlled study of the • !'racture association bet\"\"ttn neck manipulation and cervical arterial dissection and reported that Transient neck manipulation is an independent risk faaor for vertebral artery dissection even • Local pain or discomfort after controlling for neck pain.JO , lowever, • lleadache Williams et al. indicate that estimates for • Tiredness/fatigue stroke following neck manipulation will • Radiating pain or discomfort always be difficult to quantify. Selection and • I}araesthesia realll bias in case control studies and age- • Dizziness relaled variables have the rx>tentiaJ to • Nausea confound the estimation of the risk of • Stiffness vertebrobasilar disseaion after neck • Ilot skin manipulation.Z1 • Fainting Classification of complications Less common transient reactions include Serious non-reversible impairment early or heavy menstruation, epigastric pain, tremor, palpitation and perspiration.n Transient side.-effects resulting from • Dealh manipulative treatmenl may be more • Cerebrovascular accident common than one might expect and may 26 • Spinal cord compression remain unreported by patients unless • Cauda equina syndrome infonnation is explicitly requested. Prospective studies repon common side-

Safety and high-velocity low-amplitude (HVLA) thrust techniques effects n~ulting from spinal manipulation -Inflammatory. e.g. severe rheumatoid occur betv,.'een 30% and 61% of arthritis patients.noon lnese: side..fff\"eclS usually begin within 4 h and are resolved within the next. - Traumatic. eg. fracture 24 h.1.5 • Neurological Causes of complications - Cervical myelopathy - Cord compression Incorrect patient selection - Cauda equina compression - Nerve root compression with • Lack of diagnosis • Lack of awareness of possible increasing neurological deficit complications • Vascular • Inadequate palpalOry assessment - Diagnosed vertebrobasilar insuffidency • Lack of patient consent - Aonic aneurysm - Bleeding diatheses. e.g. severe Poor technique haemophilia • f.:xcessive force • Lack of a diagnosis • Excessive amplitude • Lack of patient consent • Excessive leverage • Patient positioning cannOI be achieved • Inappropriate combination of leverage • Incorrect plane of thrust because of pain or resistance • Poor patient )Xlsitioning • Poor operator positioning Relative • lack of patient feedback Certain categories of patients have an CONTRAINDICATIONS 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: Whenevt?r a pranitioner applies a • Adverse reaaions to previous manual 27 therapeutic intervention. due consideration therapy muSI be given 10 the risk-benefit ratio. The benefit to the patient must outweigh • Disc herniation or prolapse any potential risk associated wilh the • Inflammatory arthritides intervention. Traditionally, contraindications have been classified as absolute and relative. • Pregnancy 'Ille distinction between absolute and • Spondyiolysis relative contraindications is influenced by • Spondylolisthesis faclors such as the skill, experience and • Osteoporosis training of the practitioner, the type of • Anticoagulant or long-term corticosteroid technique sellXted, the amOunt of leverage and force used, the age. b'eneral health and use physique of the patient. • Advanced degenerative joint disease and Absolute spondylosis • Bone: any pathology thai has led to • Venigo significant bone weakening: • Psychological dependence upon 1fVl.A - Tumour, eg. metastatic deposits -Infection. e.g. tuberculosis thrust technique - Metabolic. e.g. osteomalacia - Congenital, ego dysplasias • Ugamentous laxity -Iatrogenic, e.g. long-term corticOSteroid • Arterial calcification medication '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.

HVLA thrust techniques - an osteopathic perspective HVLA THRUST TECHNIQUES AND evidence that this approach for the DISC HERNIATION treatment of 10..... back pain is effective.)j 'n,e use of HVLA thrust techniqul'S for VERTEBROBASILAR patients with disc bulging or herniation is controversial but cited as a treatment option INSUFFICIENCY in a number of te>i:ts.7fo.-ze One study of 'Ille vertebrobasilar system comprises the 27 patients with MRI documented and twO \\mebral arteries and their union to symptomatic disc herniation of the cervical form the basilar artery (Fig. A.S.l). Th..is and lumbar spine reported that 80% of S)'Slem supplies approximately 20% of subjects achieved a good clinical outcome intracranial blood supply.36 Blood flow suggesting that chiropraaic care including spinal manipulation may be a safe and in the vertebral artery may be affeaed by effective lreatmem approach for patients intrinsic and extrinsic faaoTS. Intrinsic presenting with symptomatic cervical or faao~ such as atherosclerosis, narrow lumbar disc hemialion.;z, In a single-blind the vessel lumen. increase tmbulence and randomized clinical triaJ comparing reduce blood flow. Extrinsic faaoTS osteopathic manipulative lreauuent with compress or impinge upon the external wall chemonucleolysis for 40 patients with of the vertebral anery. 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. Figure A.5.l Relationship of the cervical spine A systematic reviC\\y of the safety of spinal to the vertebral artery. manipulation in the treatment of lumbar disc herniations reponed the risk of a 'Illere are three areas where the vertebral patient suffering a dinicaUy worsened disc artery is vulnerable to external compression: herniation or cauda €quina syndrome following spinal manipulation to be less I. At the level of the venebral foramm of than 1 in 3.7 million.14 C6 by the contraaion of the longus colli 'Ille use of manipulaLion techniques and/or (he anterior scalme muscles. under general anaesthesia for low back pain 2. Within the foramm transversarium 28 is associated with an increased risk of between C6 and C2. serious neurological damage.·n 'l'here is no 3. At the level of Cl and C2 (Fig. A.S.2).

Safety and high-velocity low-amplitude (HVLA) thrust techniques ,,,..,,,0,81 Diagnosis of VBI art\"\" For patients presenting ,-.rith head and neck pain, especially sudden and severe Altas (Cl) symptoms, it is impol1ant to determine if Axis (C2) there is associated dizziness and/or signs of brain stem ischaemia such as nausea and/or Figure A.S.2 Upper cervical rotation stretches vomiti ng. Dizziness is also a common the vertebral artery between the atlas and the presenting complaint ,-.rith multiple axis. 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 Box A.5.1 causes of dizziness 29 vertebrobasilar insufficiency Systemic: causes of dlzziness 'l1le ability to recogni7.e symptoms that may • Medication indicate vertebrobasilar insufficiency (VBI) • Hypotension is essential for safe practice. Symptoms of • Diabetes VBI OCQJr because of ischaemia in the • Thyroid disease structures supplied by the venebrobasilar • cardiac or pulmonary insufficiency system. ,11ere are a number of signs and symptoms that may be suggestive of VB!. Central causes of dizziness • Demyelinating diseases Signs of VBI • Tumours of brain or spinal cord • Seizures • Nystagmus • Vel1ebrobasilar insufficiency • Cait disturbaoces • Post-traumatic (concussion) vertigo • I lomas syndrome Peripheral causes of dizziness Symptoms of VBI • Benign positional vertigo • Meniere's disease • Ileadad1e/nec.k pain (especially if sudden • Cervical spine dysfunct\\on and severe) • labyrInthitis • Vestibulotoxk medication • Dizziness/vertigo • Nausea One diffi01lty in recognizing the • Vomiting symptoms of VBI is thai many of the • Diplopia common symptoms, e.g. headache pain and • TInnitus stiffness in the cE\"IVical spine. are similar to • Drop attacks those for mechanical non-specific neck • Dysarthria pain.·\" • Dysphagia • Facial paraesthesia Physical examination • Tingling in the upper limbs • Pallor and sweating Pre-manipulative testing movements for VBI • Blurred vision have been advocated as a means of risk • Light·hcadedness management with a view to minimizing • Fainting/blackouts patient hann.40 'l1lere are many physical

HVLA thrust techniques - an osteopathic perspective lests described for determining the presence harmful. It has been suggested that the tests or absence of VlII.(I.../> themselves may hold certain risks and could Tests for VBI have been based upon the have a morbid effect on the vertebral premise that cervical spine positioning may artery.ll Minor adverse effects associated reduce the lumen and blood flow in the with examination procedures involving venebral aneries.t1 .51 Studies on cadaverk rotation. induding those related to the use specimens have demonstrated reduced flow of an established vm testing protocol. have through contralateral venebral arteries in been documented.n combinoo extension and TOtation.S)'s( In vim Symons et al. auempted to quantify the studies also support the view that cervical internal forces on the vertebral anery during spine JX)Sitioning may roouce venebral neck manipulation and VBI testing on five artery blood. f1.ow.\".so..sus--~ A study of un-embalmed post.rigour cadavers. Strains nonnal volunteers conduded that blood sustained internally by the vertebral artery velocity altered signifiGlntly at 45 0 cervical during neck range of motion testing. VBI spine rotation and again at fuJI range screening and I M.A thrust techniques were cervical spine rotation and in the p[\"{'- similar and all were significantly less than manipulative JX)Sition\"~uz Other studies the forces required to disrupt the vertebral of vertebral anery blood flow have not arteJY mechanically. They condude that a identified significant change in flow related single typical' M..A thrust technique to the to cervical spine positioning.»~) neck is unlikely to cause mechanical Evidence linking vertebral aneJY disruption of the vertebral artery.\" narrO\\ving or occlusion with cervical spine An analysis of the published literature extension and rotation positioning has does not support the continuing use ofVBI comributed to the devE'lopment and use of screening tests or protocols in isolation as many pre-manipulativE' tests for VBI. It is none of the rotation. extension or postulated that a reduaion in blood flow combination test movements havE' been as a resull of cervical spine positioning \\vill shown to be valid or reliable prediaors of produce detect.lble symptoms or signs in a risk. palient with VIR Positive tests are assumoo Is it possible through physical 10 be a prediaor of patients at risk from examination or screening procedures to cerebrOV3SCUlar complications of identify patients at risk of vertebrobasilar manipulation. Ilowever. tests for VBI may injury from cervical spine manipulation? have low sensitivity and specificity for Q.lTTent evidence would suggest that the predicling cerebral ischaemia prior to neck answer is no.6,7(·15 A jury in an inquest inlo manipulation!>\" and the value of these tests the death of a female chiropraaic patient in determining VBI has been follO\\....ing a neck adjustment recommended questiolled. l6.tMl-70 thaI: 'based on evidence heard that Research over recent years has questioned practitioners ... be informed by their the continuing role of diagnostic VIU tests. respective regul:noly bodies that provocative Screening tesls should be both valid and testing (prior to performing high neck reliable predictors of risk. VIII testing manipulation) has not been demonstrated movements have neither of these qualities. 10 be of benefil and should not be \\'I1th available scientific evidence failing performed. Universities and Colleges to shO\\... predictive value. I1•6u7 Westa\\vay teaching high neck manipulation should et al. report a false-negative VB! test in also be teaching their students that these: an as)'mptomatic subject with a tests have nOI been demonstrated to be of radiographically unstable CI-2 segment and benefit and should not be pecfonned~7'6 a hypoplastic and atretic righl vertebral In the light of alTTent research findin~ 30 anery funher questioning the predictive what would ronstitute a suitable approach value of such screening procedures.1O to the pre·manipulatiw assessment of the Screening procedures should not be cervical spine?

Safety and high~velocity low·amplitude (HVlA) thrust techniques Pre-manipulative assessment <Ille reports of vertebrobasilar compUcations in the literature do not make If a significant number of symptoms, e.g. dear what type of manipulative techniques head pain, neck pain, di7.ziness,. nausea and were associated with vcrtebrobasilar \\Cmiting. are suggestive ofvm, it \\youid be complications. nor hO\\... well the techniques advisable to proceed with caution when \\\\'ere applied. The risks associated with testing full range IllO\\\"(':ment of the cervical I IVl.A thrust techniques can be minimized spine in patients who present with cervical by a thorough understanding of spinal and cervicothorack spinal syndromes. Such locking and positioning procedures as well patients should be referred for the as the attainment of a high level of psycho- appropriate medical investigation to confinn mOtor skill related to the use of minimal or rule out the presence of VBI. 'Ille use of leverage, high velocity, low amplitude and I rVIA thrust techniques in such patients controlled manipulative techniques. would be contraindicated until such time as the cause of the symptoms has been dearly lne safe application of HVL\\ thrust established. techniques is critically linked to comprehensive training and skill If a patient presents with a few .!>-ymptoms development in the appropriateness and that might be suggestive: of VB!, a normal de:liveTy ofl £VLA thrust te:chniques. physical examination \\'/Quld indude pain- free range of motion testing of the cervical I £VLA thrust techniques are believed spine (Figs AS.3-A5.8). Such range of to carry a higher risk of vertrorobasilar motion testing might include bOlh aClive compliol.tions than mobilization or non· and passive: movements, but would be impulse techniques. This view is challenged performed with care and to the point of provocation of symptoms only. by research demonstrating thai the strain sustained by the verte:bral artery during both the tnting of neck range of motion 31 Figure AS.3 Active rotation right. Figure AS.4 Active rotation left.

HVLA thrust technIques - an osteopathic perspective Figure A55 Active sidebending right Figure A5.6 Active sidebending left 32 Figure A5.8 Active extension. Figure A.S.7 Active flexion.

safety and high-velocity low-amplitude (HVLA) thrust techniques - -9 5 _ .'------ <'\\nd the <'\\pplication of <'\\ single I·IVIA thrust Congenital 33 technique was of a simil<'\\r m<'\\gnitude.7) Practitioners using non-impulse <'\\nd Incompetence of the odontoid process mobiliZ<l.tion techniques <'\\Iso need to be • Sep<,\\rate odontoid - 'os odontoideum' aw<'l.re that there is a risk of vertebrob<'\\silar • Free: apical segment - 'ossiculum complications with the <'\\pplication of non- thrust techniques. While published clinical terminale' guidelines for pre-manipulative assessment • Agenesis of odontoid base for the cervical spine focus upon • Agenesis of apical segmem minimizing risks <'\\ssoci<'\\ted with thrust • Agenesis of odontoid process techniques, it should be noted that these precautions should apply equally to cervical Incompetence of the transverse mobiliz<'\\tion techniques and cervical atlantalligament uaction.n • Idiopathic • Down's syndrome P<,\\st clinical practice h<'\\s placed an emphasis on pre-m<tnipulative screening Inflammatory tests to minimize the risk of vertebrobasilar complications <'\\s a result of HVLA thrust Incompetence of the odontoid process techniques. Current research would suggest • Osteomyelitis that the emphasis should be placed more on the combination of a thorough patient Incompetence of the transverse history, a comprehensive physical atiantailigament examination and the need for a high level • Bacterial infection of technical skill in the application of HVLA • Viral infection thrust techniques. • Granulomatous change • Rheumatoid anhritis UPPER CERVICAL INSTABILITY • Anh.)'losing spondylitis TIle bony anatomy of the atlanta-axial joint Neoplastic favours mobility rather than stability,111 with the atlanta-axial joint being more Incompetence of the odontoid process vttlnerable to subluxation than other • Primary tumour of bone segments of the celvical spine.79 'Ille • Metastatic tumour of bone transverse and alar ligaments have an integral role in maintaining stability in the Traumatic upper cervical spine. Instability of the upper cervical spine may compromise related Incompetence of the odontoid process vascular and neurological structures and • Acute bony injury in these circumstances would be <'\\ • Olfonic bony change contraindicatjon to the use of 1fVlA techniques. Incompetence of the transverse atlantalligament Instability must be differenti<'\\ted • Acute ligamentous damage associated from hypermobility.80<B1 Instability is a pathological situation that exists with \\'I1th fTacture and trauma clinical symptoms or complaints.80 Ca.uses • Chronic ligamentous change of upper cervical inst<'\\bility may be <'\\ result of incompetence of the odontoid process or Symptoms and signs of of the transverse atlantal ligament. 'l1,ese upper cervical instability causes can be classified as congenital, inflammatory, neoplastic and traumatic. Symptomatic instability of the upper cervical spine is rare. Instability occurs most frequently in patients with rheumatoid

HVLA thrust techniques - an osteopathic perspective arthritis and is also \\\\1£11 documented in 4. Nystagmus produced by active or passive Down's syndrome'l 8S and in patiems neck movements subsequent to relropharyngeal inflammatory processes.1l6 Ligamentous laxity following Currently the most reliable methcxl for an infectiOUS process in the head or nttl< detecting increased mO\\'l':ment in the upper occurs most frequently in children, but it is a cervical spine is by the use of imaging rare complication. Adult cases have also been techniques. 'Ine atlanto-denlal interval is the reponed.\" Between 7% and 30% of all indi- distance between the most anterior point of viduals with Down's syndrome show adanto- the dens of the axis and the back of the axial instability with most of the patients anterior arch of the atlas. \"I1Us is measured with radiographic evidence of on lateral radiographs of the cervical spine instability being asymptomatic../f1 Upper in flexion, neutral and extension positions. cervical ligamentous injuries and instability An adamo-dental interval >2.5-3 mm in can also result from tTauma- (Fig. A..5.9).lU adults and >4.5-5 mm in children indicatt'S atlanto-axial instability./f1 Cineradiography The ability to recognize symptoms and has also been shown to be a valuable signs that may indicate upper ce.rvka.1 adjunai\\'e technique in the diagnosis instability is essentiaJ for safe practice. These of cavical instabilhy.\" ComputerizOO symptoms are extremely variable and might tomography (CD may have some include:1I advantages over plain radiograph~ with magnetic resonance imaging (MRJ) also • Neck pain offering benefits becall.Se of the ability to • Limitation of neck movements provide dired sagittal projection./f1 • Torticollis • Neurological symptoms cr and MRI provide complementaJy • Ileadache • Dizziness information when combined with flexion • Buzzing in the ears and extension radiographs. 1100\\YVt':T, • Dysphagia caution should be used when using flexion • Neurological signs • Ilyper.rellexia and extension views in cases of acute • Cait disturbances • Spasticity cervical trauma.\" • Pareses 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 10 head movements 2. Fadallip paraesthesia, rq>roducro by Figure A.5.9 Cervical instability as a resutt active or passive n«.k mO\\'l':lTlt'11ts of rheumatoid arthritis. Note forward 34 3. Bilateral or quadrilateraJ limb displacement of C1 upon C2 and widening of paraesthesia either constant or the atlanto-dental interval (From Adams and reproduced by neck mO\\'l':ments Hamblen, 2(01).

Safety and high-velocity low-amplitude (HVLA) thrust techniques A number of physical tests have been Figure A.S.l0 ·Stabilization. <lescribed for the examination of inslability of the upper cervical region. I 7.'JO.'M-96 A comprehensive testing procedure should include movements and positions lhat stress both the tranS\\'erse atlantal and alar ligaments. Ilowe'ver, caution must be exercised when interpreting thest' tests if a practitioner relies solely upon the amown of palpable displacemenl and end feel. PH' When screening for upper cervical instability, consideration should also be given to symptom reproduaion or modification. Transverse atlantalligament Figure A.S.11 ·Stabilizatk>n.\" Plane of force 35 stress test (operator). The Sharp-Purser test was designed to 1. Onset of symptoms and signs with head demonstrate aillerior instability at the and ncc.k flexion atlanto-axial segment in patients with rheumaloid arthritis and ankylosing 2. Reduction of Symptoms <lnd signs with spondylilis.~·\" A modif1ed Sharp-Purser posterior translation of (he occiput and test analyses the onset of symptoms and atlas on the axis signs following head and neck flexion and the reduction of signs and symptoms 3. Palpable hypermobililY of accompanying posterior Lranslatioll of the anterior/postcrior translation occiput and atlas on the axis. Alar ligament stress tests Patient position There are many teslS thai purpon to stress Sitting with the he<ld <lnd neck relaxed in <l the alar ligaments and identify alar ligamem scmi-flexed position. instability. A comprehensive testing regime might include the following three tests. Operator position I. Patient silting with the ncc.k in a neulral Stflllding to the right of the p<lUent with position. Ensure that lhere is no your right <lOll cmdling the p<ltient's sidebending of the head and neck. 'rne forehead. Thc spinolls prOCels and vertebral operator stabilizes the spinous process <lrch of thc axjs is stabilized with your and \\~ebral arch of the axis with thumb thumb and index finger of your left hand and index finger. Passively rotate the (Fig. A.5.l0). occiput and atlas to the right 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:

HVLA thrust techniques - an osteopathic perspective Figure A.S.13 ·Stabilizatkln. Figure A.5.12 ·Stabilization. • .. Direction of 00dy movement. (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 Figure A.5.14 ·Stabilization. there is no rotation of the neck. 'l'he • .. Direction of body movement. 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 36 in all positions of nrum!, flexion and extension. Figure A.S.15 *Stabilizatton.

__.r'oSafety and high-velocity low-amplitude (HVLA) thrust techniques Figure A.S.16 ·Stabilization. 3. Patient supine with the head and neck Figure A.5.18 ......-~•• Direction of body beyond the end of the couch and in a movement. neutral position. Ensure the head is straight and there is no rot.ation of the Figure A.S.19 ned<. The operator stabilizes the spinous process and vertebral arch of the axis Transverse atlanta I and alar ligament stress with thumb and index finger while tests have been developed 011 the premise placing the other hand on the patient's that patients at risk from manipulation to vertex (Fig. A.S.I?). Both hands support the upper cervical spine may be identified the weight of the patient's head. Attempt using physical examination techniques. to passively sidebend the head to the left There is a need for continuing research to and then the right. There should be investigate the reliability and validity of minimal movement in either direction. upper celVical instability tests in identifying This lese must be repeated with the neck those patients at risk. 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.S.17 Infonned consent 37 Informm consent may be defined as: 'the voluntary and Te\\QCable agreement of a

HVLA thrust techniques - an osteopathic perspective Infonncd consent I competent individual to participate in a • Assessment of the patient's understanding therapeutic or research procedure, basro on • Asking the patient to expr£ss their an adequate understanding of its nature. preference. purpose and implications'.n Informed A suggested checklist prior to applying a consent comprises four elements, each of HVLA thrust technique is outlined in Box which should be present to a satisfactory A.5.2. degree if consent is to be valid (Fig. A.5.19).\" When a health practitioner provides Box A-'i.2 Infanned consent - practitioner information to a patient it should be free of checklist any controlling or coercive influences. The • Discuss the dlnlcal findings infonnation should also be presented in a • Discuss manipulation and why this relevant and meaningful manner that is both intellectually and emotionally treatment is recommended comprehensible to the patient.99 • Demonstrate manipulation treatment using videotaped material • Discuss alternative treatment approaches Information exchange • Discuss the benefits and risks of manipulation and treatment altematives The traditional meth<Xl of communication in the clinical encounter is verbal, but this • Discuss the uncertainties that arise from form of communication can be enhanced the conflicting evidence as to the benefits and risks of manipulation and the by wriuen information. To be effective. the treatment alternatives written information should be both legible • Assess the patient's understanding of the and readable. 100 Videotaped material has information provided also been shown to be effective in patient • Discuss the patient's preference for education p<lrticularly with regard to short- treatment ICfm knowledge. 101 Delany advocates that a • Ask the patient to sign a consent form combination of verbal. written and audiovisual information be provided to patienL~. 101 CONCLUSION lhc following have been identified as key elements for obtaining informed consent in It is often stated that manipulation of the clinical pradice;l1J spine is a therapeutic technique associated • Discussion of the clinical issue and the wtth a high level of risk. nature of the decision to be made The potential benefits100l,10!> for the patient • Discussion of the alternatives must be weighed against the risks • Discussion of the benefits and risks of associated with manipulation of the cervical alternatives spine. There are currently no high quality • Discussion of uncenainties associated data to enable accurate estimation of the 38 with the decision risk of stroke following cervical manipulation

i\" . ,~ Safety and high-velocity low-amplitude (HVLA) thrust techniques :..- - 5 : \\ or establish causation.lOll While there is a • Illlldeman S, Kohlbeck r, McCregor M. 3. temporal relationship it may not be a causal lInpredictability of cereblO\\lascular ischemia relationship. If there is a potential for serious associated with cavial splOe manipulation sequelae, the risk appears to be extremely therapy: a review of sixt), four cascs after cervical spine manipulation SplIle 2002, 10W.lm,10ll 27( I):49-55. The evidence review accompanying the 7 I Jaynes M. Stroke foUowlllg ttrVical national c1inkal guidelines on acute and manipulation in Penh Ollropr.lCOC J I\\IJSt recurrent low back pain indicates that the 1994; 24:42-46. risks of manipulation for low back pain are very low provided patients are assessed • Jaskoviak P. Complicalions aosing from and selected for treatment by trained manipulation of the ceMcal SPlIle. J practitioners.lOR.IIO In a review of the Manipulam'C Physiol'I'her 1980; 3:213-219. literature relating to the risk of neurovascular compromise complicating 9 Klougan N, 1.dxJeuf·Vrle C. Rasm~ lR. cervical spine manipulation Rivett Safety in chiropractk prnake. Pan I: the concluded that an analysis of the risks and ocrurfet'lQ of cerebrovucular accidents alto benefits supports the continued judidal use manipulation to the neck In Iknmark from of CE!Mcal spine manipulation by a prudent 1978---1988. J Manipu]atn.-e Physiol1her 1996; and appropriately trained practitioner.'W 19:371-3n. An extensive review of the literature indicates that the key to safety is dependent '0 Lee Kp, <:arlini We. McConnidc CF. AIbeB CW upon appropriate training, a thorough patient history and physical assessment Neurologic: complicalions following prior to the applkation of any manipulative chiropractic manipulalion: a SUf\\'q' of procedure, Appropriate training in the use California neurologiw. Nalrology 1995; of manipulative thrust techniques and 45:1213-1215. subsequent skill refinement through regular practice are key e~ments for safe practice II !'aliin ). Complications in manual medicine: and professional competence.'\" a review of the literature. J Man Mcd 1991; 6:89--92. References 12 Rn.-ett DA.. Milburn PA. 1\\ prospl.'Cth-e study of Carey 1'. II rl'pon on the occurren<:e of cerebral cervKaI spine manipulalioo. J M.an Mcd 1996; vascul:lr acridel1!s in chiropractic practice. J 4:166--170. Can Chiropractic As.wc 1993; 37: 104-106. 13 Rk~l D, Reid O. Risk of stroke for cervical 2 Ollbbs V, Laureni W. II risk as.'iE'S.'lment of 5Pine manipulalion in New zeaJand. N Z J PhysiolheJ 1998; 26:14-17. cervical manipulation vs NSIIIDs for the 14 Coulter ID. Ilurwiu £1.. Adams AH. et aJ. treatment of neck pain. J Manipulalive Physiot 1ne Approprialeness of Manipulation and Mobilil'.ation of the Cervical Spine. Santa '111l'r 1995; 18:530-536. Monica. CA.: RAND; 1996. 3 Do.'Or.1k J. Orctli n I low dangerous is 15 Reid 0, I ling W. AlP r'Onlm: l>rc-manipulathoe test ing of the cervical spine. Aust I PhysiOlher manipulation to the arvic.11 spine~ I Man Me<!. 1985; 2;1-4. 2001; 47:164. 4 D1.'Orak I, tou.~lal()( D, Baumganner II. Antinncs I. 11requency of complications of •• Powell Fe. I lanigan \\IJC. Oli\\'e/o \\\\\"C,. A manipulations of the spine. A survey among risk,lbenefit analysis of spinal manil)uladon the members of the Swiss medical .society of therapy for relief of lumbar or cervical pain. manual medicine. F.ur Spine J 1993; Neurosurgery 1993; 33:73-79. 2:136-139. 5 Cutmann C. Injuries to the \\~ebral anery 17 Oi lJabio RI'. Manil>Ulation of the Cervical caused by manual therapy. Man /l.icd 1983; Spine; Hiskli and lk.'I1efi/5. Ph)'ll·I'her 1999; 21:2-14. 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. woo19 K. Ichimaru K. ShimUTa II, Imakiire A. Cervical \\oeniSO after hair shampoo Ircallllent al a hairdressing salon: a casc report. Spine 2000; 25:632. 20 Smith W, Jotuwon S, Skalabrin F.. WC2\\\"\" M.. Azari P, A1beB G.. Cress 0 Spinal manipulaln\"f'

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