__Manipulation_of_the_Spine__Thorax_and_Pelvis__An_Osteopathic_Perspective

Cervical and cervicothoracic spine Figure B1.7.1 Figure B1.7.3 Figure 81.7.2 12. Delivering the thrust the thrust and can cause embarrnssing Apply a HVLA thrust to the right anirular proximity to the patient. An effective l-IVLA pillar of CA. The thrust is upwards and thrust technique is best achieved if both the towards the midline in the directjon of the operator and patient are relaxed and not patient's left eye.. paralJelto the apophysial holding themselves rigid. 'l11is is a common joint plane (Fig. 81.7.3). Trus thrust is impediment to achieving effeaive generated by rapid pronation of your right cavitation. forearm. Simultaneously, apply a slight rapid increase of rOlation of the head and Ensure the pmient's head and neck neck to the left\" but do not increase remain on the pillQ\\v as this facilitates the sidebending leverages. 'Ine increase of arrest of the technique and limits excessive rotation to the left is accomplished by slight amplitude of thrust. supination of the left wrist and forearm and is coordimnoo to match the thrust upon the contaa poinL This is a HVlJ\\ 'flick' type thrust. Coordination between the left and right hands and forearms is critical. The thrust. although very rapid, must never be excessively forcible. 'nle aim should be to use the absolute minimum force necessary to adlieve joint cavitation. A common fault arises from the use of excessive amplitude with insufficient velocity of thnlSt. • 99 _ _ _ _ _1

, HVLA thrust techniques - spine and thorax \" SUMMARY \" Cervical spine (2-7 Up-slope gilding , Cradle hold I Patient supine 100 • Contact point: Posterolateral aspect of the rtght (4 articular pillar • Applicator. Lateral border, proximal or middle phalanx I: • Patient positioning: Supine with the neck in a neutral relaxed position • Operator stance: Head of couch, feet spread slightly ; Palpation of contact point L. • Fixation of contact point • Cradle hold: The we;ght of the patient's head and neck is balanced between your left and right hands with cervical positioning controlled by the converging pressures • Vertex contact: None • Positioning for thrust: Stand upright at the head of the couch. The elbows are held close to or onfy slightly away from your sides. Introduce primary leverage of rotation to the left (Fig. B1.7.1) and a small degree of secondary leverage of sidebending right (Fig. B1.7.2). Maintain the contact point on the posterolateral aspect of the (4 articular pillar • Adjustments to achieve appropriate pre-thrust tension • Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: The thrust is directed towards the patient's left eye. Simultaneously, apply a slight, rapid increase of rotation of the head and neck to the left with no increase of sidebending to the right (Fig. B1.7.3)

Cervical spine C2-7 Up-slope gliding Cradle hold Patient supine Reversed primary and secondary leverage Tn certain circumstances, the operator might wish to perform an up- slope gliding t11nJSl but minimize the extelll of heml and neck rotation. Assume somatic dysfulletiUII (S-T-A-R-T) is identified mid YUII wish Iu use all upward mid furward glidillg thrust, parallel Iu the apaphysinl joitlt plane, (0 produce cavitation at C4-5 on the right: KEY 1. Contact point \"\" Stabilization Posterolateral a.~pect of the right articular pillar of CA. • Applicator 2. Applicator • Plane of thrust (operator) Lateral border, proximal or middle phalanx .~ Direction of body movement of operator's right index finger. (patient) 3. Patient positioning Note: The dimensions for the arrows are not it pktorial representation of Supine wilh the neck in a neut.rnl relaxed the amplitude or force of the thrusL position. If necessaJy, remove or adjust pillow heigtn. The technique should not nonnally be executed in any significant 101 degreE\" of flexion or extension. 4. Operator stance Head of couch. feet spread slightly. Adjust couch height SO that you can stand as erect

HVLA thrust techniques - spine and thorax as possible and avoid crouching over the 9. Positioning for thrust patient as this will limit the technique and restrict delivery of the thrust. 'l'he intent with this technique is to perform an up-slope gliding thrust but to limit the 5. Palpation of contact point amount of head and neck rotation. This modification requires a greater emphasis Place fingers of both hands gently under the upon the use of sidebending to achieve occiput. Uft the head to throw the articular joint locking. It is critical that the direction pillars into prominence. Rotate the head of thrust be parallel to the apophysial joint slightly to the left. taking its weight in plane in an up-slope direction. There should your left hand_ Remove: your right hand be no exaggeration of the sidebending from the occiput and palpate the right l\"\"\"\"'8e. articular pillar of C4 with the tip of your right index finger. Slowly but finnly slide -Ine ellxn.YS are held dose to or only your right forefinger downwards (to\\'Iards slightly away from your sides. This is an the couch) along the articular pillar until it essential feature of the crndle hold method. approximates the middle or proximal Stand easily upright at the head of the phalanx. several sliding pressures may be couch and do not step to the right as in the necessaIy to establish dose approximation chin hold method. to the conl;lct point. (a) Primary leverage of sidebcndillg. Maintaining all holds and contact points. 6. Fixation of contact point gently inlJOduce sidebending of the head and neck to the right until tension is Keep your right index finger firmly pressed palpated at the contact poim (Fig. BI.8.1). upon the contact point while you flex the To introduce the right sidebending. the other fingers and thumb of the right hand oper.ttor pivots slightly via the legs and SO as to dasp the back of the neck and thereby lock the applicator in position. You must now keep the applicator on the contact point until the technique is complete. Keeping the hands in position. return the head to the neutral position. 7. Cradle hold Keep your left hand under the head and spread the fingers out for maximum contact. Keep the patient's ear resting in the palm of the your left hand. Rex the left wrist, allowing you to crndle the patient's head in your palm, flexed wrist and anterior aspect of forearm. Keep your right index finger firmly on the contact point and press the right palm against the OCcipUl The weight of the patient's head and neck is now balanced between your left and right hands. with the cervical positioning controlled by the converging pressures of your two hands and <'Inns. When treating the lower cervical segments. the middle or distal phalanx may be used as the applicator. 102 8. Vertex contact None in this technique. Figure 81.8.1

Cervical and cervicothoracic spine trunk so that the trunk and upper body ankles, knees. hips and trunk. not by 103 rOlate to the left, enabling the hands and altering the position of the hands or arms. arms 10 remain in position. Do not lose firm COntact with your comacl point on the 11. Immediately pre-thrust anicular pillar of 01. A common mistake is to use insufficient primary leverage of head Relax and adjust ),our balance as necessary. and neck sidebending. Keep your head up; looking down impedes (b) Seamdary 'eJ>erage. Add a little rotation the thrust and can cau.o;e embarrassing to the left, down to and induding C4 (Fig. proximity to the patient. An effective HVl.A 81.8.2). This requires extensh-e practice thrust technique is best achieved if both the before one develops a refined 'tension opu3.tor and patient are relaxed and not sense'. Movement of your hands and holding themselves rigid. This is a common foreanns introduces the rotation. impediment to achieving effective 10. Adjustments to achieve appropriate cavitation. pre-thrust tension Ensure your patient remains relaxed. Ensure the patient's head and neck Maintaining all holds, make any necessary remain on the pillow as this facilitates the changes in flexion, extension, sidebending arrest of the technique and limits excessrve or rotation until you can sense a state of amplitude of thrusL appropriate tension and leverage. The patient should not be aware of any pain or 12. Delivering the thrust discomfon. You make these final adjustments by slight movements of your Apply a I lVlA thrust to the right an.icular pillar of 01. The thrust is upwards and • to\\vards the midline in the direction of the patient's left eye. parallel to the apophysial Figure 81.8.2 joim plane (Fig. B1.8.3). This thrust is generated by rapid pronation of }'Our right forearm. Simultaneously, apply a slight rapid increase of rotation of the head and neck to the lefL A key element in this technique is to avoid exaggeration of the primary levernge of sidebending when the thrust is applied. The increase of rotation to the left is accomplished by slight supination of left wriSl and foreann and coordinated to match the thnlst upon the contaCt point. 'l1,is is a IIVLA 'nick' type thrust. ('-..cordi nation between the left O'Ind right hands and forearms is critical. It must be appreciated that the use of sidebending as a primal)' levcrnge is predicated upon the operntor\"s desire to limit the amount of head and neck rotation. Generally, when sidebending is used as a primary leverage.. the aim will be to lhrust in a down-slope direction. Exaggeration of the sidebending leverage in this technique must be avoided. Sidebending enhances locking but does not assist with an up-slope gliding thrusL The thrust in lhis technique is accompanied by slight exaggeration of the

HVLA thrust techniques - spine and thorax Figure 81.8.3 secondary leverage of IOlation and is use the absolute minimum force necessary directed towards the patiern's opposite eye. to achieve joint cavitation. A common (aull llle thnast. although very rapid. must never arises from lhe use of excessive amplitude be excessively forcible. The aim should be to with insufficient velocity of thrust. '04

- - - - - - - - - - Cervical and cervicothoracic spine SUMMARY Cervical spine C2-7 Up-slope gliding Cradle hold Patient supine Reversed primary and secondary leverage • Contact point: Posterolateral aspect of the right C4 articular pillar • Applicator. Lateral border, proximal or middle phalanx • Patient positioning: Supine with the neck in a neutral relaxed position • Operator stance: Head of couch, feet spread slightly • Palpation of contact point • Fixation of contact point • Cradle hold: The weight of the patient's head and neck is now balanced between your left and right hands with cervical positioning controlled by the converging pressures • Vertex contact: None • Positioning for thrust: Stand upright at the head of the couch. The elbows are held close to or only slightly away from your sides. Introduce primary leverage of siclebending to the right (Fig. Bl.8.1) and a small degree of secondary leverage of rotation left (Fig. 81.8.2). Maintain the contact point on the posterolateral aspect of the (4 articular pillar • Adjustments to achieve appropriate pre-thrust tension • Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: The thrust is directed towards the patient's left eye. Simultaneously, apply a slight rapid increase of rotation of the head and neck to the left with no increase of sidebending to the right (Fig. 81.8.3). A key element in this technique is to avoid exaggeration of the primary leverage of sidebending when the thrust is applied. The use of sidebending as a primary leverage is predicated upon the operator's desire to limit the amount of head and neck rotation 105

Cervical spine C2-7 Up-slope gliding Patient sitting Operator standing in front Assume somatic d)'sfll'letion (S-'T-A-R-T) is identified and)'ou wish to use atl upward and forward thrust, parallel to the apophysial joint plane, to produce joint cavilllliml at C4-5 on the left KEY 1. Contact point .:t: Stabilization Poslerol~Iern.1 asped of the left articular pilhn of CA . • Applicator 2. Applicator • Plane of thrust (operator) Palmar aspect. proximal or middle phaltlllx q Direction of body movement of operator's right index or middle finger. (patient) 3. Patient positioning Note: The dimensions for the arrows SitLing with the neck in a ncutrnl relaxed are not a pictorial representation of position. '!1le neck should not be in any the amplitude Of force of the thrust. significalll ameum of flexion or extension. 4. Operator stance 107 Stand in front and to the right of the patient. feel spread slightly. Adjust couch he:ighl SO that you can stand as eroo as possible: and avoid crouching over the

HVLA thrust techniques - spine and thorax Figure 81.9.2 Figure 81.9.1 the applicator on lhe contact poinl until the technique is complete. The weight of the patient as Lhis will limit the technique and head and ned: is nO\\'I balanced between restrict delivery of the thrust (Fig. 131 .9.1). your left and right hands. with the cervical spine positioning cOnlrolled by the converging pressures of your two hands. S. Palpation of contact point 7. Positioning for thrust Place the fingers and palm of your leC! hand The elbows are held close to or only slightly ag:J.inst the patient's right occiput and neck. away from your sides. gently covering the patient's righl ear. Use (a) PrillUlry If!l'emge. Ensure: that the the index or middle finger of your right p<ltient's head is securely supported between hand 10 palpate the patient's left articular your two hands. Maintaining all holds and pillar of C4. Slowly but firmly slide your contact poims, rOtale the head and neck to applicator along the articular pillar of CA lhe right until tension is palpated at the until it approximates the proximal or contact point (I:ig. 131.9.3). Do not lose middle phalanx (Fig. B1.9.2). Several sliding contact between your applicator and the pressures may be necessary to establish dose articular pillar of 01. Do not force roLation; approximation to the contact point. take il up fully but carefully. A common 6. Fixation of contact point mistake is to use insufficient primary leverage of head and neck rotation. Keep your right index or middle fingf'f (b) ScrorliJary lel'f!rage. Add a \\-eIY small finnly pressed upon the contact point while degree of sidebending lO the left. down to you spread the other fingers and thumb of and including C4. Narc: slJongsidebending Lhe right hand to securely support the head, will lock the neck. Slight movements of the 108 mandible and neck. thereby locking the operator's forearms. shoulders and trunk applicator in posiLion. You must nO\\\\{ keep introduce the sidebending.

- - - - - - - - - Cervical and cervicothoracic spine 8. Adjustments to achieve appropriate pre-thrust tension Ensure your patient remains relaxed. It is important to keep your e1bO\\\\IS dose to your sides. Maint.aining all holds, make any necessary changes in flexion, extension. sidebending or rotation until you can sense ill state of appropriate tension and leverage. 11le patient should nOt be aware of any pain or discomfon. You make these final adjustments by slight mO\\'emenlS of yOUr l~ and tnmk. not by altering the position of the hands or arms. Figure 81.9.3 9. Immediately pre-throst Relax and adjust your balance as necessary. Keq> your head up; looking down impedes the thl'illit and can cause: embarrassing proximity t.o the patienL An effeah'e HVLA thrust technique is best achieved if both the ope.\"\"3.tor and patient are relaxed and not holding themselves rigid. This is a common impediment to achieving effective cavitation. FiguTl! 81.9.4 109

HVLA thrust techniques - spine and thorax 10. Delivering the thrust Coordination between the len and right hands and anus is critical. Apply a IIVIA thrust to the left articular pillar of C4. 1be thrust is upwards and The thrust. although \\'eI)' rapid. must to\\'lards the midline in the direction of the lle\\'e.r be excessively forcible.. The aim patient's right eye. parallel to the apophysial should be to use the absolute minimum joint plane (l-ig. BI.9.4). Simultaneously, force necessary to achieve joint cavitation. apply a 51ig11l. rapid increase of rOlation to A common fault arises from the use of the right, but do not increase sidebrnding excessive amplitude with insufficient Iewn.ges. This is a IIVl..A 'flick' type lhrust. \\'e1ocity of thrust. SUMMARY Cervical spine C2-7 Up-slope glidIng Patient sitting Operator standing in front .. Contact point: Posterolateral aspect of the left C4 articular pillar .. Applicator: Palmar aspect, proximal or middle phalanx • Patient positioning: Sitting with the neck in a neutral relaxed position • Operator stance: In front and to the right of the patient.. feet spread slightly (Fig. Bl.9.11 • Palpation of contact point • Fixation of contact point: Keep your right index or middle finger firmly pressed upon the contact point while you spread the other fingers and thumb of the right hand to securely support the head, mandible and neck (Fig. 81.9.2) • Positioning for thrust: Stand upright with the elbows held close to or only slightly away from your sides. Introduce primary leverage of rotation to the right (Fig. 81.9.3) and a small degree of secondary leverage of sidebending left. Maintain the contact point on the posterolateral aspect of the (4 articular pillar • Adjustments to achieve appropriate pre-thrust tension • Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: The thrust is directed towards the patient's right eye. Simultaneously, apply a slight, rapid increase of rotation of the head and neck to the right with no increase of sidebending to the left (Fig. 81.9.4). Coordination between both hands and arms is critical 110

.---- .. _', ~7_'-~'·--:: 1.10 Cervical spine C2-7 Up-slope gliding Patient sitting Operator standing to the side Assume somatic dysfflrldion (5-T-A-R-T) is identified and )'ml luisll to use an upward and lanvard gliding thrust, parallel to the apopll)'Sial joint plane, to produce cavitation at C4-5 011 the left: KEY 1. Contact point -:t:- Stabilization Posterolateral aspect of the left anicuJar pillar of C4. • Applicator 2. Applicator - Plane of thrust (operator) Palmar aspen. proximal or middle phalanx ¢ Direction of body movement of operators right indeJ[ or middle fmger. (patient) 3. Patient positioning Note: The dimensions for the arrows Sitting with c.he neck in a nculml relaxed are not a pictorial representation of position. 1'he neck shouJd not be in any significant amOUni of flexion or extension. the amplitude Of force of the thrust 4. Operator stance Stand to th~ right of th~ pati~nt. feet spread '\" slightly. Adjust couch h~ight so that you can stand as erect as possibl~ and avoid

HVLA thrust techniques - spine and thorax Figure81.10.1 Figure 81.10.2 crouching over the patjem as this will limit the applicator on the contact point until the the technique and restrict delivery of the technique is complete. 111e weight of the thrust (Fig. B1. 10.1). head and neck is now balanced Ixtween your left and right hands. with the cervical 5. Palpation of contact point spine positioning controlled by the Place the fingers and palm of your left hand converging pressures of your two over the right side of the patient's head and hands. neck. gently covering the right ear. Reach in front of the patient with your right hand 7. Positioning for thrust and palpate the left artiOJ.lar piJIar of C4 The elbows are held close to or only slightly with the tip of your right index or middle away from your sides. finger. Slowly but finnly slide your (a) Primary leverage. Ensure that the applicator along the articular pillar of patient's head is securely supported between C4 until it approximates the proximal or your two hands. Maintaining all holds and middle phalanx. Several sliding pressures conlaO points. rotate the hrnd and neck to may be nec£SSary to establish dose the right until tension is palpated at the approximation to the contact point. conlaO point (Fig. Bl.tO.2). Do not lose 6. Fixation of contact point contact between your applicator and the articular pillar of C4. Do not force rotation; Keep your right index or middle finger take it up fully but carefully. A common finnly pressed upon the contaa point while mistake is to lise insufficient primary you spread the other fingers and thumb of leverage of hrnd and neck rotation. the right hand to securely support the head, (b) Secondary leverage. Add a very small 112 mandible and neck. thereby locking the degree of sidebending 10 the left. down to applicator in position. You must now keep and including C4. NQte: Silong sidelxnding

Cervical and cervicothoracic spine r1.10 Tne patient should not be aware of any pain or discomfort. You make lhese final adjustments by slight movements of your legs and I.n.1nk. not by altering the position of lhe hands or arms. 9. Immediately pre-thrust RelaJe and adjust your balance as necessary. Keep your head up; looking down impedes the thrust and can cause embarrassing proximily to lhe palienL An effective HVLA thrust technique is best achieved if both the oper.alor and patienl are relaxed and not holding themselves rigid. This is a common impediment 10 achieving effective cavitation. Ag.81.103 10. Delivering the thrust will lock the neck. Slighl movements of the Apply a HVLA thrust to the lefl arurolar operator's forearms, shouldeJS and I.n.1nk pillar of C4. The thrust is upwards and introduce lhe sidebending. towaros the midline in the direaion of the palient's riglll eye. parallel to the apophysial 8. Adjustments to achieve appropriate joint plane (Fig. 81.10.3). Simultaneously, pre-thrust tension apply a slight. r.apid increase of rotation to Ensure your patient remains relaJeed. It is lhe righi, but do not increase sidebending important (0 keep your elbows close 10 your leverages. This is a HVI.A 'flick' type thrust sides. Maintaining aU holds, make any Coordination between the left and right necessary changes in flexion, extension, hands and anns is critical. sidebending or rotation unlil you can sense a state of appropriate lension and leverage. The thrust, although very rapid, must never be excessively forcible. 111e aim should be to use the absolute minimum force necessary 10 adlieve joint cavitation. A common faull arises from the use of excessive amplilude with insufficient velocity of thrust 113

- - - - - - - - - - - -HVlA thrust techniques - spine and thorax SUMMARY Cervical spine C2-7 Up-slope gilding Patient sitting Operator standing to the side • Contact point: Posterolateral aspect of the left (4 articular pillar • Applicator: Palmar aspect, proximal or middle phalanx • Patient positioning: Sitting with the neck in a neutral relaxed position • Operator stance: To the right of the patient. feet spread slightly (Fig. 61.10.1) • Palpation of contact point • Fixation of contact point • Positioning for thrust: Stand upright with the elbows held close to or only slightly away from your sides. Introduce primary leverage of rotation to the right (Fig. 81.10.2) and a small degree of secondary leverage of sidebending left. Maintain the contact point on the posterolateral aspect of the left (4 articular pillar • Adjustments to achieve appropriate pre-thrust tension • Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: The thrust is directed towards the patient's right eye. Simultaneously. apply a slight, rapid increase of rotation of the head and neck to the right with no increase of sidebending left (Fig. 81.10.3). Coordination between both hands and arms is critical 114

I~~ vt/;il171J.CDoewrnv-iscloaples~pliidnineg C 2-7 G-o Chin hold Patient supine Assume somatic dys/wiction (5-T-A-l?-T) is identified and you wish to use a dowT/ward a11d baclllvard gliding thrust, parallel 1.0 the apophysial joim plane, [0 produce cal/itation at C4-5 on rhe right: KEY 1. Contact point ->Ie Stabilization Lateral aspect of the right ~rticular pillar of C4. • Applicator 2. Applicator .. Plane ofthrust (operator) Lateral border, proximal or middle phalanx c:> Direction of body movement of operntor's right index finger. (patient) 3. Patient positioning Note: The dimensions for the arrows are not a pictorial representation of Supine with the neck in a ncuITal relaxed. the amplitude or force of the thrust. position. If necessary, remove pillow or adjust pillow height The neck should not be in any significant amount of flexion or l1S extension. 4. Operator stance I-lead of COUdl, feel spread slightly. Adjust couch height so Lhat you can stand as erect

HVLA thrust techniques - spine and thorax as possible and avoid crouelling over the until the fingers lightly clasp the chin. patient as this will limit the technique and Ensure thai your left foreann is over or !\"CStrict delivery of the thrust. slightly anlerior to the ear. Placing the forearm on or behind the ear puts the neck 5. Palpation of contact point into 100 much flexion. The head is now controlled by balancing forces between the Place fingers of both hands gently under the right palm and left foreann. Maintain the occiput. Rotate the head to thl' left. taking applicator in position. its weight in your left hand. Remove your right hand from the occiput and palpatl' 8. Vertex contact the right articuJar pi1lar of C4 with the tip of your index or middll' finger. Slowly MO\\'e }'our body fon\\'3rd slightly so that but firmly slide your right index finger your chest is in contact with the venex of dO\\..nwards (to\\vards the couch) along thl' the patient's head. The head is nO\\v securely articular pillar until it approximatl'S the cradled betwcen }OUr left forearm, the middle or proximal phalanx. Several sliding {Iexed left elbow, the right palm and your pressures may be necessary to establish c!a;e chest. Vertex contact is often usdUl in a approximation to Ihe contact point. heavy, stiff or diffICUlt case but can, on occasions, be omiued. 6. Fixation of contact point Keep your right index finger firmJy pressed 9. Positioning for thrust upon the contact point while you flex the Step slightly to the right, keeping the hands other fingers and thumb of the right hand finnly in position and taking care not lO so as to clasp the back of the neck and la;e pressure on the COntact point. This inlroduc('$ an element of cervical thereby lock the applicator in position. sidebending to lhe right. Straighten your You must now keep the applicator on the right wrist so that lhe radius and first contact point until the technique is met<lcarpal are in line. Align yOur body complete. Keeping the hands in position, and right arm for the thrust plane which is return the head to the neutral position. caudad in lhe direction of the patient's left shoulder and downwards to\\\\'3rds the 7. Chin hold couch. Keeping your right h:md in position, slide the left hand slO\\..ly and carefully forwards 116 Figure 81.11.1

b '.--~_ ... ' . t ,'-;:: 1 17 ' \";' ~' .. '-.Cervical and cervicothoracic spine (a) Primary leverage of sideIH!JJdirlg. patient should not be a\\vare of any pain Maintaining all holds and contan points, or discomfort. You make these final sidebend the patient's head and neck to the adjustments by slight movements of your right until tension is palpated at the contad ankles. knttS, hips and trunk, not by point (Fig. B1.11.1). lhe operator pivoting altering the position of the hands or arms. slightly, via the legs and trunk, introduces the right sidebending. so that the trunk and 11. Immediately pre-thrust upper body rotate to the left., enabling the hands and anns to remain in position. Do Relax and adjust your balance as necessary. not attempt to introduce sidebending by Keep your head up; looking dO\\vn impedes moving the hands or anns alone, as this will the thrust and can cause embarrassing lead to loss of contact and inaccurate proximity to the patient. An effecthre HYLA technique. Do not lose firm contact with thrust technique is best achiC\\--ed if both the your contad point on the articular piUar of operntor and patient are relaxed and not holding themselves rigid. This is a common C4. A common mistake is to use insuffident impediment to achieving effeal\\,re cavitation. primary Iew:rage of head and neck sidebending. 12. Delivering the thrust (b) S«ondary lerremge. Add a little rOlation to the left. dO\\vn to and including C4 (118- Apply a IIVLA thrust to the right anirular 81.11.2). lhis requires extensive pntetice pillar of C4. The directtcm of thrust is before one develops a refined 'tension caudad in the direction of the patient's sense: Movement of your hands and left shoulder and dO\\vmvards to\\vards the foreanns introduces the rotation. couch, parallel to the apophysial joint plane. Simultaneously. apply a slight. rapid 10. Adjustments to achieve appropriate increase of sidebending of the head and pre-thrust tension neck to the right but do nOt increase the rOlation leverage (Fig. 81.11.3). The increase Ensure your patient remains relaxed. of sidebending is induced by a slight Maintaining all holds, make any necessary rotation of the operator's trunk and upper changes in flexion, extension, sidebending body to the left. A \"cry rapid contraction or rotation until yOli can sense a state of of the flexors and addudOrs of the right appropriate tension and leverage. 'n,e 117 Figure 8 1 . 1 1 . 2 : J _ _ _ _ _1

HVLA thrust techniques - spine and thorax Figure 81.11.3 shouJder joint induce the thrust; if force necessary 10 achieve joint cavitation. necessary, lrunk and lower limb rnO\\'ement A common fault arises from the use of may be incorporated. excessh'e amplitude with insufficient velocity of thrust. The thrust, although \\'eI)' rapid, must 11e\\'er be excessh'ely forcible. The aim should be to use the absolute minimum 118

Cervical and cervicothoracic spine SUMMARY Cervical spine C2-7 Down-slopegliding Chin hold Patient supine • Contact point: Lateral aspect of the right (4 articular pillar • Applicator: Lateral border, proximal or middle phalanx • Patient positioning: Supine with the neck in a neutral relaxed position • Operator stance: Head of couch, feet spread slightly • Palpation of contact point • Fixation of contact point • Chin hold: Ensure your left forearm is over or slightly anterior to the ear • Vertex contact: Optional but often useful Positioning for thrust: Step slightly to the right. Introduce primary leverage of sidebending rtght (Fig. B1.11.1) and a small degree of secondary leverage of rotation left (Fig. 81.1 1.2). Align your body and right arm for the thrust plane, which is caudad in the direction of the patient's left shoulder and downwards towards the couch • Adjustments to achieve appropriate pre-thrust tension • Immediately pre-thrust Relax and adjust your balance • Delivering the thrust: The thrust is directed towards the patient's left shoulder and downwards towards the couch. Simultaneously, apply a slight, rapid increase of sidebending of the head and neck to the right with no increase of rotation to the left (Fig. B1.11.3) 119

Cervical spine C2-7 ---- Down-slope gliding 1.12 Cradle hold Patient supine Assume sammie d}'S[1mcLioPl (5-T-A·H-T) is identified and )'OU wish CO use a dOlll11ward and backward gliding tlrmsl, parallel co tile apophysial joint plnlle, to produce cavitiltion at C4-5 on tire right: KEY 1. Contact point .:+,. Stabilization The: lateral aspect of the right anirular pillar ofC4. • Applicator 2. Applicator .. Plane of thrust (operator) Lateral border. proximal or middle phalanx ,:) Direction of body movement of operator's right index finger. (patient) 3. Patient positioning Note: The dimensions for the arrows are not a pictorial representation d Supine with the neck in a neutral relaxed the amplitude or force of the thrust. position. If necessary. remove pillow or adju.st pillow· height. The neck should not be in any significant amount of flexion or 121 extension. I 4. Operator stance Head of couch. feet spread slightly. Adjust couch height so that you can stand as erect

HVLA thrust techniques - spine and thorax as possible and avoid crouching over the 9. Positioning for thrust patient as this will limit the technique and restrict deliwry of the thrust. The elbows are held dose to or only slightly away from )'Our sides. 'Ihis is an essential S. Palpation of contact point feature of the cradle hold method. Stand easily upright at the head of the COUdl and Place fingers of both hands gently under the do not step to the right as in the chin hold occiput. Rotate the head to the left. taking method. its weight in )'Our left hand Remove your (a) Pri\"IIU}' leverage of sidelxmdillg. right hand from the occiput and palpate the t\\laimaining all holds and contact points, right anicular pillar of C4 with the tip of gently imroduce sidebending of the head your index or middle finger. Slowly but and neck to the right until tension is finnly slide your light index finger palpated at the contact point (Fig. 61.12.1). downwards (towards the couch) along the To imroduce the righl sidebending. the anicular pillar until it approximates the operator pivots slightly via the legs and middle or proximal phalanx. Se\\.·eraI sliding pressures may be necessary to establish dose trunk so that the Hunk and uJ>PE':r body approximation to the contact point. rotate to the left. enabling the hands and 6. Fixation of contact point arms to remain in position. Do not lose Keep the light index finger finnly pressed on the contact point while you flex the other firm contact with )'Our contact point on the fingers and thumb of the right hand so as to articular pillar of CA. A common mistake is clasp the back of the neck and thereby lock to use imuffident primary levernge of head the applicator in position. You must now and neck sidebending. keep the applicator on the contact point (b) Seamdaf}' IClJeTage. Add a little rotation until the technique is complete. Keeping the to the left, down to and including CA (Fig. hands in posilion, return the head to the 81.12.2). This requires exte.nsi'\\T pracLice neutral position. before one develops a refined 'tension sense'. Movement of )'Our hands and forearms introduces the rotation. 7. Cradle hold Keep the left hand under the head and spread the fingers out for maximum contact; kE.'Cp the paticlU's ear resting in the paJm of the your left hand. Hex the left wrist, allowing you to cradle the paticlll's head in your palm, nexed wrist and anterior aspect of forearm. Keep your right index finger firmly on the contad poilU and press the right palm against the occiput The weight of the patient's head and neck is now balanced between your left and right hands. with the cervical positioning convolJed by the converging pressures of your two hands and arms. When veating the lower cervical segments,. the middle or distal phalanx may be used as the applicator. 8. Vertex contact Figure 81.12.1 122 None in this technique.

Cervical and cervlcothoracic spine 10. Adjustments to achieve appropriate or rotation umil you can sense a state of pre-thrust tension approprioue tension and levernge. The Ensure your patient remains relaxed. patient should not be aware of any pain or Maintaining all holds. make: any necessary discomfort. You make these final changes in flexion, extension. sidebending adjustments by slight movements of your ankles. knees, hips and trunk. not by • altering the position of the hands or arms. Figure 81.12.2 11. Immediately pre-thrust Relax and adjust your balance as necessary. Keep }'Our head up; looking dO\\'\\fIl impedes the thrust and can cause embarrassing proximiry to the patient. An effective IIVLA thrust technique is best achieved if both the operator and patient are relaxed and nOt holding themselves rigid. This is a common impediment to achieving effective cavitation. Ensure the patient's head and neck remain on the piUow as this facilitates the arrest of the technique and limits excessive amplitude of thrust Note that the final thrust is directed in a dO\\'\\fIl\\vard and backward direction parallel to the facet joint plane. the thrust is directed to\\varos the patient's left shoulder as iUustrated. 1lle primary leverage is sidebending to the right and the secondary (lesser leverage) is rotation to the left. Figure 81.12.3 123

HVLA thrust techniques - spine and thorax 12. Delivering the thrust Simuhaneou'ily, apply a very slight, rapid increase of sidebending of the head and Apply a HVLA thrust to the right art~rular neck to the right but do not increase the pillar of <:4. 'Ibe direction of thrust IS rotation leverage. caudad in the direction of the patient's left shoulder and downwards towards the 1be thrust. although very rapid must couch, parallel to the apophysial joint plane nC\\'et\" be excessively forcible. \"be aim (Fig. B1.12.3). 'Ibe operator rotaling the should be to use the absolute minimum trunk and upper Ixxly to the left. enabling force necessary to achieve joint cavitation. A the hands and anns to remain in position common fault arises from the USE': of on the cervical spine,. generates the thrust. excesshoe amplitude with insufficient \"clodly of thrust. 124 l

-. . 1.12 Cervical and cervicothoracic spine SUMMARY Cervical spine C2-7 Down-slope gilding Cradle hold Patient supine • Contact point: lateral aspect of the right C4 articular pillar • Applicator: lateral border, proximal or middle phalanx • Patient positioning: Supine with the neck in a neutral relaxed position • Operator stance: Head of couch, feet spread slightly • Palpation of contact point • Fixation of contact point • Cradle hold: The weight of the patient's head and neck is balanced between your left and right hands with cervical positioning controlled by the converging pressures • Vertex contact: None • Positioning for thrust: Stand upright at the head of the couch. The elbows are held close to or only slightly away from your s}des. Introduce primary leverage of sidebending to the right (Fig. 81.121) and a small degree of secondary leverage of rotation left (Fig. 81.12.2). Maintain the contact point on the lateral aspect of the right (4 articular pillar • Adjustments to achieve appropriate pre-thrust tension • Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: The thrust is directed towards the patient's left shoulder and downwards towards the couch. Simultaneously, apply a slight, rapid increase of sidebending of the head and neck to the right with no increase of rotation to the left (Fig. 81.12.3) 125

Cervical spine C2-7 Down-slope gliding Patient sitting Operator standing to the side Assllm. somaLic dysfullClioll (S-T-A-R-T) is ideruiji£d alld )'011 wisl. 10 use a downward lind oockwnrd gliding lhniSl.. parallel to tile apopllysinl joint. plane, to produce cavilillioll at C4-5 on the riglll: KEY ,. Contact point l\" Stabilization Lateral aspect of the right anicular pillar of • Applicator C4. • Plane of thrust (operator) 2. Applicator Palmar aspect, proximal or middle phalanx Q Direction of boc1y movement of operator's left index or middle finger. (patient) 3. Patient positioning Note: The dimensions for the arrows are not a pictorial representation of Sining with the neck in a neutral relaxed position. °llle neck should not be in any the amplitude Of force of the thrust. signifiGlflt amounl of flexion or extension. 4. Operator stance 127 Stand to the left of the patient. feet spread slightly. Adjust couch height so IDal )'Ou can stand as erect as possible and avoid

I-- H.V..:L;.A thrust techniques - spine and thorax FIgure 81.13.2 Figure 81.13.1 spread the other fingers and thumb o( the left hand to securely support the head crouching over the paLient as !.his will limit mandible and neck. thereby locking the the technique and restrict delivery of the applicator in position. You must now keep thrust (Fig. 81.13.1). the applicator on the contact poim until the technique is complete. 1he weight o( the 5. Palpation of contact point head and neck is now balanced between your right and left hands. with the cervical Place the fingers and palm of your right spine positioning controlled by the hand over the left side of the patient's head converging pressures o( your two hands. and neck, gentJy covering the left ear. Reach in front of the patient with your left hand 7. Positioning for thrust and palpate the right anicular pillar of CA The elbO\\vs are held dose 10 or only slightly with the tip of your lefl index or middle away (rom your sides. finger. SIO\\\\lly bUI timlly slide your (a) Primary leuerag£ Ensure that the applicator along the anicuJar pillar of patient's head is securely supported between C4 until it approximates the proximal or your two hando;. Maintaining all holds and middle phalanx. Several sliding pre;sures contan points sidebend the head and neck may be necessary 10 establish dose to the right unlil tension is palpated at the approximation to the COntact point. contact point (Fig. 81.13.2). Do not lose 6. Fixation of contact point contact between your applicator and the artiOllar pillar o( C4. Do not force '28 Keep your left index or middle finger firmly sidebending; take it up fully but carefully. pressed upon the contact point while you A common mistake is to use insufficient

Cervical and cervicothoracic spine sides. Maintaining all holds. make any necessary changes in flexion. extension, sidebending or rotation until )'Ou can sense a state of appropriate tension and I~rage. The patient should nol be aware of any pain or discomforL 9. Immediately pr~thrust Relax and adjusl your balance as ntn'SSary. Keep )'Our head up; looking down improes the thrust and can C3US4!: embarrassing proximity to the patient. An effecth'e IIVLA thrust technique is best achieved if both the operator and palient are relaxed and nOt holding themselves rigid. This is a common impediment to achieving effective cavitation. 10. Delivering the thrust Figure B1.13.3 Apply a HVLA thrust to the right anicular pillar of C4. The thrust is caudad and primary leverage of head and neck lowards the patient's left shoulder, parallel sidebending. 10 the apophysial joint plane (Fig. 1l1.13.3). (b) S«tmdllr)' letlCTt/Se. Add a ve:ry small Simultaneously. apply a slight. rapid degree of rotation to the left, dOMl 10 and increase of sidebending 10 the right but including C4. Slight movements of the do not increase rotation leverage. This is a operator's hands and arms imroduce the HVLA 'flick' type thrust. Coordination rotation. between the leC! and right hands and arms is critical. 8. Adjustments to achieve appropriate pre-thrust tension The thrust, although ve:ry rapid. must Ensure your palienl remains relaxed. II is never be excessively forcible. The aim imponam 10 keep your elbows dose to your should be to use the absolute minimum force necessary to achieve: joint cavitation. A common fault arises from lhe use of excessive: amplitude with insufficient velocity of thrust. 129

HVLA thrust techniques - spine and thorax SUMMARY Cervical spine C2-7 Down-slope glldmg Patient sitting Operator standing to the side • Contact point: lateral aspect of the right (4 articular pillar • Applicator. Palmar aspect. proximal or middle phalanx • Patient positioning: Sitting with the neck in a neutral relaxed position • Operator stance: To the left of the patient. feet spread slightly (Fig. 81.13.1) • Palpation of contact point • Fixation of contact point • Positioning for thrust: Stand upright with the elbows held close to or only Slightly away from your sides. Introduce primary leverage of sidebending to the right (Fig. 81.13.2) and a small degree of secondary leverage of rotation left. Maintain the contact point on the lateral aspert of the right (4 articular pillar • Adjustments to achieve appropriate pre-thrust tension • Immediately p~thrust:Relax and adjust your balance • Delivering the thrust: The thrust is caudad and towards the patient's left shoulder. Simultaneously, apply a slight. rapid increase of sidebending of the head and neck to the right with no increase of rotation to the left (Fig. B1.13.3). Coordination between both hands and arms is critical ,- 130

Cervicothoracic spine C7-13 Rotation gliding Patient prone Operator at side of couch As.sume somatic dysfunction (5-T-A-R-T) is identified and )00 wish to use a rolation gliding thrust, parallel to the apophysial joint, pume, to produce cavilation at the 12-3 apophysial joi,,, (Figs 81.14.1, 81.14.2) Figure 81.14.1 Figure 81.14.2 KEY 1. Contact point ~; Stabilization Right side of spinous process ofTI. • Applicator 2. Applicator - Plane of thrust (operator) lllUmb of right hand. ¢ Direction of body movement 3. Patient positioning (patient) Note: The dimensions for the arrows Patient lying prone with the head and neck turned to the left and arms hanging over the orare not a pictorial representation edge of the couch or against the patient's the amplitude or force of the thrust. sides (Fig. B1.14.3). Illlroduce a small amount of sidebending to the right by gently moving the patienl's head 10 lh~ right while in th~ rotated position. Do not introduce 100 much sidebending. 131

- - - - - - - -HVLA thrust techniques - spine and thorax Figure 81.14.3 Figure 81.14.4 4. Operator stance 6. Positioning for thrust Stand on the right side of the patient facing Keeping your position at the side of the towards the head of the couch. couch, gently place your left hand against the left side of the patient's head. This hand 5. Palpation of contact point will control the rOtation and sidebending Locate the spinous proc~ of1'3. Place the leverages. Increase rotation of the patient's thumb of your right hand gently but firmly head and neck to the left by applying gentle against the right side of this spinous pressure to the patient's head until a sense process. Spread the fingers of )'OUr right of tension is palpated at the contact point. hand to rest over the patient's right Move your right foreann so that it lines lrape7jus muscle with your fingertips resting up with your thumb against the spinous on the patient's right davicle (Fig. 81.14.4). process of'1'3 and forms an angle of Ensure that )UU have good contact and will approximately 90° at the elbow (Fig. not sLip off the spinous process ofT3 when 81.14.5). 132 you apply a force against it. Maintain this contact point.

Cervical and cervicothoracic spine 7. Adjustments to achieve appropriate rotation until you can sense a state of pre-thrust tension appropriate tension and leverage. ThE\" Ensure the patient remains relaxed. patient should not be aware of any pain or MaiOlaining all holds. make any necessary discomfort. Make these final adjustmE\"nts by c:hanges in extension. sidebending or altering thE\" pressurE\" and direction of forces between the left hand against thE\" patient's Figure B1.14.5 head and }'Qur right thumb at thE\" contaa point. B. Immediately pre-thrust Relax and adjust )'OUr balance as necessary. Keep your hE\"ad up and ensure that your contacts are firm and your body position is well c:ontrolled. An effective IIVLA thrust technique is best ac:hieved if thE\" operator and patiE\"nt are relaxed and not holding lhemselws rigid. This is a common impedimmt to achieving effeeth'e cavitation. 9. Detivering the thrust Apply a IIVlA thrust to the spinous process of13 in thE\" direaion of the patient's left shoulder joinl. Simultaneously. apply a slight. rapid inc:rE\"ase of hE\"ad and neck rotation to the left with }'OUr left hand (Fig. B1.14.6). The thruSl induces local rotation of the T3 venebra. focusing forces at the 1'2-3 segment. You muSl not overemphasize Figure 81.14.6 133

HVLA thrust techniques - spine and thorax the thrust with your left hand against the Th€\" thrust. although \\'ery rapid. must patient's head. Your left hand stabilizes Ihe never be excessively forcible. The aim leverages and maintains the position of the should be to use the absolute minimum head against the thrust imposed upon the contact point. The thrust is induced by a force necessary 10 achieve joint cavilalion. wry rnpid contraction of the shoulder A common fault arises from the use of adductors. excessivt' amplitude ,.,ith insufficient velocity of thrust. SUMMARY Cervicothoracic spine C7-T3 Rotation gilding Patient prone Operator at side of couch • Contact point: Right side ofT3 spinous process • Applicator: Thumb of right hand • Patient positioning: Prone with the head rotated to the left and arms hanging over the edge of the couch or against the patient's sides (Fig. 81.14.3). Introduce a small amount of sidebending to the right Do not introduce too much sidebending • Operator stance: Right side of the patient facing towards the head of the couch • Palpation of contact point: Place the thumb of your right hand against the right side of the spinous process ofD. Spread the fingers of your right hand to rest over the patient's trapezius muscle and clavicle (Fig. 81.14.4) • Positioning for thrust: Place your left hand against the left side of the patient's head. Increase rotation of the head and neck to the left until a sense of tension is palpated at the contact point. Move your right forearm so that it lines up with your thumb against the spinous process ofD and forms an angle of approxImately 90° at the elbow (Fig. 81.14.5) • Adjustments to achieve appropriate pre-thrust tension • Immediately pre-thrust Relax and adjust your balance • Delivering the thrust Thrust is directed towards the patient's left shoulder joint. Simultaneously, apply a slight rapid increase of head and neck rotation to the left with your left hand (Fig. 81.14.6). You must not overemphasize the thrust with your left hand against the patient's head 134

Cervicothoracic spine C7-T3 Rotation gliding Patient prone Operator at head of couch I Assume somatic dysfullaion [S-T-A-R-T) is identified and you wi511 Lo use a rotarion gliding thrust. parallel to the ap6physial joint. plane. Lo produce cavitacion at the 12-3 apoph)'sUll joint.: KEY 1. Contact point .;f\" Stabilization Transverse process of '1\"3 on the: left. • Applicator 2. Applicator .. Plane of thrust (operatOf) Ilypothenar eminence of left hand. ':> Direction of body movement 3. Patient positioning (patient) Patient prone with the point of the dlin Note: The dimensions fOf the arrows resting on the couch and the anns hanging are not a pictorial representation of over the edge of the couch or against the the amplitude or force of the thrust paliem's sides. Introduce a small amount of sidebending 10 the right by gently Hrling and moving the patient's chin 10 the right (Hg. B1.I5.1). Do nO( introduce tOO mudl sidebending. 13S

HVLA thrust techniques - spine and thorax Figure 81.15.1 4. Operator stance patient's right shoulder. While maintaining I lead of the couch, fet::t spread slightly. the right sidebending introduced earlier, Stand as erect as possible and avoid begin to rotate the cervical and upper crouching (wer the patient as this will limit thoracic spine to the left by applying gentle the technique and restrict delivery of the pushing pressure to the left side of the thrust. patient's head and neck with your right hand (Pig. B1.15.2). Maintaining all holds 5. Palpation of contact point and pressures, complete the rotation of the patient's head and neck until a sense of Locate the transverse process ofT3 on the tension is palpated at your left hypothenar left. Place the hypothenar eminence of your eminence. Keep firm pressure against the left hand gently but firmly against the contact point. transverse process of1'3 on the left. Ensure that you have good contact and will not slip 7. Adjustments to achieve appropriate across the skin or superficial musculature pre-thrust tension when you apply a caudad and dO'ovnward Ensure the patient remains relaxed. force towards the couch again.'it the Maimaining all holds. make any necessary transwrse process of1'3. Maintain this changes in extension, sidebending or contact point. rotation until )IOU can sense a state of 6. Positioning for thrust appropriate tension and leverage. The patient should not be aware of any pain Keeping your positjon at the head of the or discomfon. You make these final couch, gently place your right hand against adjustments by altering the pressure and 136 the left side of the patient's head and neck direction of forces between the right hand with your fingers pointing to\\vards the against the patiem's head and neck and

Cervical and cervicothoracic spine 7.15 your left hypOlhenar eminence against the COnlacts are firm and that your body contact point. position is well controlled. An eITectiw IIVl.J\\ thrust technique is best achieved if 8. Immediately pre-thrust the operator and patiem are relaxed and nOt holding themselves rigid. This is a Helax and adjust your balance as necnsary. common impedimcm 10 achieving Ke€p your head up and ensure that your effective cavitation. 9. Delivering the thrust Apply a IM..A lhrust to the left tranlo\",'et'Se process of1'3 down tQ\\Y<trds the couch and in lhe diTeaion of the patient's left axilla. Simultaneously, apply a slight. rapid increase of head and neck rotation to the left with your righl hand (Fig. 81.153). TIle thrust induces local rotation of the 13 vertebra. focusing forces at the T2-3 segment. You must not O\\'E:remphasize the thrust with your righl hand against the patienl's head and neck. Your right hand stabilizes the leverages and maintains the position of the head and cervical spine against the thrust imposed upon the contact point. The thrust is induced by a \\'l'.ry rapid contraction of the triceps, shoulder adduetors and intemal rotators. The thrust, although very rapid must never be excessively forcible. The aim should be to use the absolule minimum force n«essary to achieve joint cavitation. A common fault arises from the use of excessive amplitude wilh insufficient velocity of thrust. Figure 81.15.3 137

HVlA thrust techniques - spine and thorax SUMMARY Cervicothoracic spine C7-T3 Rotation glidmg Patient prone Operator at head of couch • Contact point: left T3 transverse process • Applicator: Hypothenar eminence of the left hand • Patient positioning: Patient prone with the chin resting on the couch and the arms hanging over the edge of the couch or against the patient's sides. Introduce sidebending to the right (Fig. B1.1 s.l). Do not introduce too much sidebending • Operator stance: Head of the couch, feet spread slightly • Palpation of contact point: Place your hypothenar er,ninence against the transverse process of T3 on the left • Positioning for thrust: Place your right hand against the left side of the patient's head and neck. Rotate the cervical and upper thoracic spine to the left by applying pushing pressure to the left side of the patient's head and neck with your right hand until a sense of tension ;s palpated at the contact point (Fig. 61.15.2) • Adjustments to achieve appropriate pre-thrust tension • Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: The thrust is in the direction of the patient's left axilla and down towards the couch. SimUltaneously, apply a slight rapid increase of head and neck rotation to the left with your right hand (Fig. B1.1s.3). You must not overemphasize the thrust with your right hand against the patient's head 138

Cervicothoracic spine C7-T3 Rotation gliding Patient prone Operator at head of couch - variation ~ Assume somaric dYSfu'u:tion (S-T-A-R-7J is identified and )\"u wish 10 use a rotation gliding thrust, parallel to the apophysial joint plane, to produce Ciliritati5!!J at tile 12-3 apopll)'sial jainl~ KEY 1. Contact point .:t~ Stabilization Transverse process of1'3 on the left. • Applicator 2. Applicator • Plane of thrust (operator) Ilypolhenar eminence of left hand. ':> Direction of body movement 3. Patient positioning (patient) Patient prone wilh the pOint of the chin Note: The dimensions for the alTows resting on the couch and the arms hanging are not a pictorial representation of over the edge of the couch or against the patient's sides. Introduce slight head and the amplitude or force of the thrust. neck flexion. No\"., introduce a small amount of sidebending 10 the right by gently lifting and moving the patient's hf'ad to the right (Fig. 81.16.1). 139

HVLA thrust techniques - spine and thorax Figure 81.16.1 4. Operator stance To the right of the head of me couch. feet spread slightly. Stand as erect as possible Figure 81.16.2 and avoid crouching over the patient as this will limit the technique and reslria delrvery of me Ihrust. sidebending introduced earljer, begin to 5. Palpation of contact point ralate the cervical and upper moracic spine to the left by applying gentle pulling LOGue Ihe transve~ process ofT3 on the pressure to the left side of the patient's head left. Place the hypothenar eminence of your and neck with your right hand (fig. left hand gently but firmly against the 81.16.2). Maintaining all holds and transverse process of1'3 on the left. Ensure pressures, complete the rotation of the that you have good contad and will not slip patient's head and neck until a sense of across the skin or superficial musculature tension is palpated at your left hypothenar when you apply a caudad and downward eminence. Keep finn pressure against the force towards the couch against me contad point. transverse process ofD. Maintain this contad point. 7. Adjustments to achieve appropriate pre--thrust tension 6. Positioning for thrust mUTe the patient remains relaxed. Keeping yOUT position at the head of the Maintaining all holds, make any necessary couch. gently place your right hand against changes in flexion, extE'.nsion, sidebending the left side of the patient's head and neck or rotation until you can sense a state of 140 with your fingers pointing towards the appropriate tension and It\"\\'erage.. 1he couch. While maim3ining the right patient should nol be a\\voue of any pain

Cervical and cervicothoracic spine ~;:.-7--.-76 or discomfon. You make these final adjustments by altering the pressure and direction of forces bet ....·een the right hand against the p_nient's head and neck and your left hypothenar eminence against the COntaa point. B.lmmediately pre-thrust Relax and adjust your balance as necessary. Keep your head up and ensure that your , / contacts are firm and that }~y - - - position is w€':l1 controlled. An effective IIVlA thrust technique is best achiewd if the operator and patient are relaxed and not holding themsel~ rigid. This is a common impediment to achieving effectivt> cavitation. 9. Delivering the thrust Figure 81.163 Apply a IM.A thrust to the left transverse point. 1be thrust is induced by a very rapid process of1\"3 down to\\Yards the couch and contraction of the triceps. shoulder in the direction of the patient's left axilla. adduoors and internal rotators. Simuhaneously, apply a slight. rapid increase of head and neck rotation to the TIt€': thrust, although very rapid. must left with your right hand (Fig. 6I.1G.3). never be excessivt>ly forcible. The aim The thmst induces local rotation of the T3 should be to use the absolute minimum wnebra. focusing forces at the 1'2-3 force necessary to adlieve joint cavitation. segment. You must not overemphasize the A common fault arises from the use of thrust with your right hand against the excessive amplitude with insufficient patient's head and neck. Your right hand velocity of thmSt. stabili7£s the leverages and maintains the position of the head and cervical spine against the thrust imposed upon the contact 141

HVLA thrust techniques - spine and thorax SUMMARY Cervicothoracic spine C7-T3 Rotation gliding Patient prone Operator at head of couch • Contact point: Left T3 transverse process • Applicator: Hypothenar eminence of the left hand • Patient positioning: Patient prone with the chin resting on the couch and the arms hanging over the edge of the couch or against the patient's sides. Introduce slight head and neck flexion. Introduce sidebending to the right (Fig. 81.16.1). Do not introduce too much sidebending • Operator stance: To the right of the head of the couch, feet spread slightly • Palpation of contact point: Place your hypothenar eminence against the transverse process of T3 on the left • Positioning for thrust Place your right hand against the left side of the patient's head and neck with your fingers pointing towards the couch, Rotate the cervical and upper thoracic spine to the left by applying pulling pressure to the left side of the patient's head and neck with your right hand until a sense of tension is palpated at the contact point (Fig. 81.16.2) • Adjustments to achieve appropriate pre-thrust tension • Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: The thrust is in the direction of the patient's left axilla and down towards the couch. Simultaneously, apply a slight rapid increase of head and neck rotation to the left with your right hand (Fig. 81.16.3), You must not overemphasize the thrust with your right hand against the patient's head 142

Cervicothoracic spine C7-T3 Sidebending gliding Patient sitting Assume somatic dysfunction (S-T-A-R-T) is identified and you wish to use a sidebending gliding tlirust, fX1rallel to tlie apopliysial joint. plane. W produce cavil11lion at the 12-3 apophysial joint: KEY 1. Contact point Left side of the spinous process 0['1'2. .:f(o Stabilization 2 Applicator • Applicator 'Ibumb of left hand. - Plane of thrust (operator) 3. Patient positioning Patient silting with bad: towards the ¢ Direction of body movement operalor. (patient) 4. Operator stance Note: The dimensions for the arrows Stand behind the palienL are not a pictorial representation of the amplitude or force of the thrust 5. Palpation of contact point Locate the spinous process of\"2. Place the thumb of your left hand gently but fumly 143 against the left side of this spinous process.

HVlA thrust techniques - spine and thorax FtgureBl.17.1 Ftgure 81.17.2 alongside the right side of the patient'S head and neck and gently rest the palm of your hand over the top of the patient's head (Fig. B1.17.2). Ensure that your forearm remains anterior to, and just over, the patient's ear. This hand will introduce and control the rotation and sidebending leverages. Use )'Our left hand to slightly rotate the patient's trunk to the left while using your right hand to introduce head and ned< rOl.ation to the right until a sense of tension is palpated at the conlact point (I:ig.. 81.17.3). Now gently inlrOdlXe cervical sidebending to the left by allowing the patient's body weight to fall slightly to the right. Keeping the patient's head centred over the sacrum, guide the neck into left sidebending with your right arm against the right side of the patient'S head. A vertex compression force call be added 10 assist in localizing forces to theTI-3 segment. Ensure that your applicator thumb forms a straight line with your left foreann. Spread the fingers of your left hand to rest 7. Adjustments to achieve appropriate pre- over the patielll's left trapezius muscle whh thrust tension your fingenips resting on the patient's left Ensure the patient remains relaxed. c1avide (Fig. B1.I7.1). I-:nsure that you have Maimaining all holds. make any necessary good contact and will not slip oIT the changes in flexion, extension, sidebending spinous process of'l\"2 when you apply a or rotation untjl )'Ou can sense a state of force against h. Maintain this contact poinL appropriate tension and leverage. \"11le 6. Positioning for thrust paliem should not be a\\\\'are of any pain or discomfort Make these final adjustments 144 Keeping your poshion behind the patient by b<dancing the pressure and direction of place your right hand and foreann forces between the left hand against the

Figure 81.17.3 Cervical and cervicothoracic spine contan point and the right hand and forea-nn against the patient's head and neck. 8. Immediately pre-thrust He.lax and adjust your balance as necessary. Keep ),our head up and ensurt' that )'Our contacts are firm and that the patient's body weight and position art' v.-ell controlled. An effective HYlA thrust technique is best achieved if the operator and patient are relaxed and not holding themselves rigid. \"Jllis is a common impediment to achieving effective cavitation. 9. Delivering the thrust Apply a HVlA thrust to the: left side: of the spinous process ofTI in the direction of the patient's right axilla. At the same time. slightly increase head and neck sidebending to the left with your right arm (Fig. 81.17.4). 'rbe thrust on the spinous process of12 and the slight increase in neck sidebending to the left focus forces at the - 145 Figure B1.17.4

HVLA thrust techniques - spine and thorax 1'2-3 segment and causes cavitation at that should be to use the absolute minimum level. 'l11e thrust is induced by a wry rapid force necessary to achieve joint cavilation, A contraction of the shoulder adductors. common fault arises from the use of The thrust, although very rapid, must excessiVE' amplitude with insufficient never be excessively forcible. The aim velocity of thrust. SUMMARY Cervicothoracic spine (7-13 Sidebendlng gliding Patient sitting Contact point: left side of the T2 spinous process • Applicator: Thumb of left hand • Patient positioning: Patient sitting with back towards the operator • Operator stance: Behind the patient • Palpation of contact point: Place your left thumb against the left side of the T2 spinous process. Spread the fingers of your left hand to rest oller the patient's trapezius muscle and clavicle (Fig. B1.17.1) • Positioning for thrust: Place your right hand and forearm alongside the right side of the patient's head and neck (Fig. Bl .17.2). Use your left hand to slightly rotate the patient's trunk to the left whilst using your right hand to introduce head and neck rotation to the right (Fig. B1.1 7.3). Introduce left sidebending to the cervical spine, localizing forces to the T2-3 segment Ensure that your applicator thumb forms a straight line with your left forearm • Adjustments to achieve appropriate pre-thrust tension • Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: The thrust is directed towards the patient's right axilla. Simultaneously. apply a slight, rapid increase of head and neck sidebending to the left (Fig. B1.17.4) 146

Cervicothoracic spine C7-T3 Sidebending gliding Patient sitting Ligamentous myofascial tension locking Assu\"\", sommie d)'sfuncriOl1 (5-T-A-R-T) is identifi£d and )'OU wis/. to use a sideberzding gliding thrust, parallel to the apophysinl joint plane, to produce cavitntion at the 12-3 apopl1ysial joint: V ...... i ..'~'. ~ -W. ~ .... ; : N. i KEY 1. Contact point Left side of me spinous process of1'2. .,;~ Stabilization 2. Applicator • Applicator 'l11umb of left hand. - Plane of thrust (operator) 3. Patient positioning Patient sitting with back tmvards the <> Direction of body movement operator. (patient) 4. Operator stance Stand behind the patient. Note: The dImensions for the arrows are not a pictorial representation of 5. Palpation of contact point the amplitude or force of the thrust. Locate the spinous process or1\"2. Place the lhumb of your left hand gently but finnly 147 _ _ _ _ _1

HVLA thrust techniques - spine and thorax Figure 81.18.1 Figure 81.18.2 6. Positioning for thrust Keeping your position behind the patient, place }'Our right hand and foreann alongside the right side of the patient's head and neck and gently rest the palm of )'Our hand O\\'er the top of the patient's head (Fig. BI.18.2). Ensure that )'Our forearm remains anterior to and just over, the patient's ear. lhis hand will introduce and control the rotation and sidebending leverages.. Use )'Our right hand to introduce a small amount of head and neck extension (Fig. Bl.18.3). Now introduce cervical sidebending to the left by allowing the patient'S body weight to full slightly to the right. Keeping the patient's head centred over the sacrum, guide the neck into left sidebending with your right ann against the right side of the patielll's head. A venex compression force can be added to assist in localizing forces to the 1'2-3 segment. Ensure that your applicator thumb forms a straight line with your left forearm. 7. Adjustments to achieve appropriate against the left side of this spinous process. pre-thrust tension Spread the fingers of your left hand to rest Ensure the patient remain.. relaxed. over the patient's left trnpezius musde with Maintaining all holds, make any necessary your fingertips resting on the patient's left changes in flexion. extension, sidebending davide (Fig. B1.18.1). Ensure that you have or rotation until you can sense a Slate of good contact and will not slip off the appropriate tension and le\\'erage. 'Ille spinous process of1'2 when you apply a patient should not be 3'\\13re of any pain 148 force against it. Maintain this contact or discomfort. Make these final adjusunents point. by balancing the pressure and direction of

Cervical and cervicothoracic spine 1.18 Figure 81.18,3 Figure 81.18.4 forces between lhe left hand against the emplll1Sis on lJ>e exJJggeralUm of prinwry \"9 contact point and the right hand and leverage tlmn i5 d>e case with faut apposition forearm a~inst the patient's head and IocIring rechniques. neck. Apply a IlVlA thrust to the left side of 8. Immediately pre.thrust the spinous process of1'2 in the direction of the patient's right axilla. At the same time. Helax and adjust your balance as necessary. increase head and neck sidebending to the Keep your head up and ensure that your left with your right arm (Fig. R1.18.4). 'the contacts are finn and that the patient's body thrust on the spinous process of1'2 and lhe weight and position are well controlled. An increase in neck sidebending to the left effective IiVLA thrust technique is best focus forces at the 1'2-3 segment and causes achieved if the operator and patient are cavitation at that level. 'I\"e thrust is induced rela.xed and nOI holding themselves rigid. by a very rapid contraction of the shoulder 'I\"is is a common impediment to achieving adductor'S. effective cavitation. 'Ihe thrust. although very rapid. must 9. Delivering the thrust n£'Ver be excessively fcrable. The aim should be to use the absolute minimum This feclmiqlle uses Iigamt!7ltous myofascinl force necessary to achieve joint cavitation. tension foching and nOf facet apposition Iocl.'ing. A common fault arises from the use of This approacll generally requires a gretJter excessive amplitude with insufficient velocity of thrust.

HVLA thrust techniques - spine and thorax SUMMARY Cervicothoracic spine C7-T3 Sidebendlng glIding Patient sitting Ligamentous myofascial tension locking Contact point: Left side of the T2 spinous process • Applicator. Thumb of left hand • Patient positioning: Patient sitting with back towards the operator • Operator stance: Behind the patient • Palpation of contact point: Place your left thumb against the left side of the T2 spinous process. Spread the fingers of your left hand to rest over the patient's trapezius muscle and davide (Fig. B1.18.1) • Positioning for thrust: Place your right hand and forearm alongside the right side of the patient's head and neck (Fig. B1.18.2). Use your right hand to introduce a small amount of head and neck extension (Fig. 81.18.3). Introduce left sidebending to the cervical spine localiZing forces to the T2-3 segment. Ensure that your applicator thumb forms a straight line with your left forearm • Adjustments to achieve appropriate pre-thrust tension • Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: The thrust is directed towards the patient's right axilla. Simultaneously, apply a rapid increase of head and neck sidebending to the left (Fig. 81.18.4) 150

Cervicothoracic spine C7-T3 Sidebending gliding Patient side-lying Assume somatic d).function (S-T-A-R-TJ is identified and)'OU wish to use a sidebending gliding tJl11lSt, parallel to the apophysial joint plane, w produce Cl1vitalion at the T2-3 apophysial joint: KEY 1. Contact point * Stabilization Right side of the spinous process orn. • Applicator 2. Applicator • P1ane of thrust (operator) 'Ihumb of left hand. ¢ Direction of body movement 3. Patient positioning (patient) Patient lying on the left side. Flex the Note: The dimensions for the arrows patient's knees and hips for stability. are not a pictorial representation of the amplitude or force of the thrust. 4. Operator stanc:e Stand facing the patient and gently place 151 your right arm under the head. lightly spreading your fingers around the patient's OCcipUL \"be head should now be cradled in your right arm with your upper arm against the patient's forehead and your foreann and hand supporting the head and neck.