__Manipulation_of_the_Spine__Thorax_and_Pelvis__An_Osteopathic_Perspective

HVLA thrust techniques - spine and thorax Figure B1.19.1 Figure B1.19.2 s. Palpation of contad point patient's head, within the cradle of )'OUf Locate the spinous process ofTI. Place the right arm (Fig. 81.19.1). thumb of your left band gently but firmly Gently introduce cervical rotation to me against the right side of this spinous process. Spretl.d the fingers of your left hand left ulllil a sense of tension is palpated at to entl.ble firm conttl.ct of your thumb. This the contact point (Fig. B1.19.2). If necessary, will ensure that you have good contact and you may add a compression force to Ihe will nOI slip off the spinous process when patient's shoulder girdle:, fcom your chest, to you apply a force against it. Maintain Ihis stabilize the upper torso before applying the thrust. contact point but do not press too hard, as it can be uncomfonable. 7. Adjustments to achieve appropriat@ pr@-thrusttension 6. Positioning for thrust Ensure the patient remains relaxed. Using your right arm, sidebend me patient's Maintaining all bolds. make any necessary head and neck to the right until a sense of changes in flexion. extension, sidebe:nding 152 tension is palpable at the contact point. lbis or rotation until you can sense a Slate of sidebending is achieved by gently lifting the appropriate tension and leverage at the

Cervical and cervicothoradc spine 1.19 Figure 81.19.3 contact point. ]ne patient should not be direction of the patient's left shoulder. 'Ine aware of any pain or discomfon. Make these thrust is accompanied by a simultaneous final adjusunents by balancing me pressure downward application of force with your and direction of forces between the left chest to the patient's right shoulder girdle, hand against the contact point and the right AI. the same time, introduce a slight increase hand and forearm against the patient's head in head and neck sidebending to the right and neck. with your right arm (Fig. BI.19.3). The thrust on the spinous process of1'2 and 8. Immediately pre-thrust slight increase in neck sidcl>ending to the right focus forces at the TI-3 segment and Relax and adjust your balance as necessary. cause cavilalion at that level. Do not apply Keep your head up and ensure that your excessive sidebending at the time of the conlacts are firm and that your body thrust as this can cause strain and position is well controlled. An effeoive discomfon. HVLA thrust technique is best achieved if the operator and patient are relaxed and not The thrust. although very rapid must holding themselves rigid. This is a common never be excessively forcible. 'l'he aim impediment to achieving effective should be to use the absolute minimwn cavitation. force necessary to acruE:\\'e joint cavitation. A common f.1UIt arises from the use of 9, Delivering the thrust excessive amplilude with insufficient velOCity of thnlsl, Apply a IIVLA thruSi to the spinous process of 1'2 down towards the couch in the 153 _ _ _ _ _ _ _ _ _ _ _ _ _ _L

HVLA thrust techniques - spine and thorax SUMMARY Cervicothoracic spine C7-T3 Sidebending gliding Patient side·lying • Contact point: Right side of 12 spinous process • Applicator: Thumb of left hand • Patient positioning: Patient lying on the left side. Flex the patient's knees and hips for stability • Operator stance: Facing the patient. Place your right arm under the patient's head, supporting the patient's occiput • Palpation of contact point Place the thumb of your left hand against the right side of the spinous process of 12 • Positioning for thrust Using your right arm, sidebend the patient's head and neck to the right (Fig. 81.19.1).lntroouce cervical rotation to the left until a sense of tension is palpated at the contact point (Fig. 81.19.2) • Adjustments to achieve appropriate pre-thrust tension • Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: The thrust is in the directton of the patient's left shoulder and down towards the couch. The thrust is accompanied by a downward application of force with your chest to the patient's right shoulder girdle. Simultaneously, apply a slight rapid increase of head and neck sidebending to the right with your right arm (Fig. 81.19.3). Do not apply excessive sidebending 154

Cervicothoracic spine C7-T3 Sidebending gliding Patient side-lying Ligamentous myofascial tension locking Assume sontatic dysfunaio71 (s·rf-A_R_T) is idelltified and }'Oll wish to use a sidebending gliding thrust, parallel to the apophysial join[ plane. CD produce caviUltion ill the 12-3 apophysial joint: KEY 1. Contact point ;i:. Stabilization Right side of the spinous process of1'2. • Applicator 2. Applkator - Plane of thrust (operator) Thumb of leCl hand. Q Direction or I:x>dy movement 3. Patient positioning (pattent) Palienllying on the left side. Plex !.he Note: The dimensions for the arrows paLienl's knees and hips for stability. are not a pictorial representation of the amplitude or force of the thrust. 4. Operator stance Stand facing the patient and gently plaet': 155 your right arm under the head. lightly spreading rOUT fingers around the patient's occiput. The head should now be CT3dled in your riglll arm with your upper ann against the patient's forehead and ),our forearm and hand supporting the head and neck.

HVLA thrust techniques - spine and thorax 5. Palpation of contad point Maintain this contaa poinl but do not press too hard, as it can be Lcx::ale the spinous process of1'2. Place the uncomfortable. thumb of )'OUf lefl hand genLly but firmly against the right side of this spinous 6. Positioning for thrust process.. Spread the fingers of your left hand to enable firm contact of your thumb and Using }'Our right arm, extend the patielll's position }'Our left forearm 0\\'eJ\" the posterior head and neck (Fig. 81.20.1). Now aspect of the patient's thorax and Iwnbar introduce sidebending to the right until a spine. lhis will ensure that you ha\\'e good contan and will not slip off the spinous sense of tension is palpable at the contaeL process when you apply a force against it. point \"Ill is sidebending is achieved by gently lifting the patient's head, within the mdle of your right arm (Fig. 61.20.2). If necessary, you may add a compression force to the patient's shoulder girdle. from your chest. to stabilize the upper torso before applying the thrust. 7. Adjustments to achieve appropriate pre-thrust tension Ensure the patient remains relaxed. Maimaining all holds, make any necessary changes in flexion.. extension, sidebending or rotation Wltil you can sense a stale of appropriate tension and leverage at the rontaa point. The patient should not be aware of any pain or discomfort. Make these final adjustments by balancing the pressure and direction of forces between the left hand against the contact point and lhe right hand and forearm against the palient's head and neck. Figure 81.20.1 156 Figure 81.20.2

Cervical and cervicothoracic spine 1.20 Figure 81.203 8. Immediately pre-thrust the dircaion of the patient's left shoulder. The thrust is accompanied by a Relax and adjust your balance as necessary. simultaneous downward application of Keep }'Our head up and ensure that your force with your chest to the patient's right contacts are finn and that your body shoulder girdle. At the same time. introduce position is well controlled. An effective an increase in head and neck sidebe:nding to HVLA lhrust technique is best achieved if the right with your right arm (Fig. 81.20.3). the operator and patient are relaxed and not llre thrust on the spinous process of1'2 and holding themselves rigid. This is a common increase in neck side:bending to the right impe:d.imem to achieving effective focus forces at the 1'2-3 segment and Cil.use cavitation. cavitation at that level. Do not apply exce:ssh~ sidebe:nding at the: time of the 9. Delivering the thrust thrust as this can Cil.use strain and discomfon. 'J1lis ,eclmique uses ligamerllow rtI)'ofmrial tension locking and nOf facet apposiricm locking. 11le thrust. although ''t'IY rapid. must 'J1lis apprOtlcll generaUy requires a greater never be excessively forcible. lhe aim erupluuis on IIle exLlggeramnJ of ptimary should be to use the absolute minimum let/erage /Iran is ti,e case lIIi,h facet apposition force necessary to adlie:ve joint cavit.ation. locki\"g tedmiques. A comlllon fault arises from the use of excessive amplitude with insufficient Apply a HVLA thrust to the spinous velocity of thrust. process of1'2 down towards the couch in 157

HVlA thrust techniques - spine and thorax SUMMARY Cervicothoracic spine C7-13 Sidebendlng gilding Patient sid~lying ligamentous myofascial tension locking • Contact point: Right side of T2 spinous process • Applicator: Thumb of left hand • Patient positioning: Patient lying on the left side. Flex the patient's knees and hips for stability • Operator stance: Facing the patient. Place your right arm under the pattent's head. supporting the patient's occiput • Palpation of contact point: Place the thumb of your left hand against the right side of the spinous process of T2 • Positioning for thrust Using your right arm, extend the patient's head and neck (Fig. 81.20.1). Introduce sidebending to the right until a sense of tension is palpable at the contact point (Fig. 81.20.2) • Adjustments to achieve appropriate pre-thrust tension • Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: The thrust is in the direction of the patient's left shoulder and down towards the couch. The thrust is accompanied by a downward application of force with your chest to the patient's right shoulder girdle. Simultaneously, apply a rapid increase of head and neck sidebending to the right with your right arm (Fig. 81.203). 00 not apply excessive sidebending 158

Cervicothoracic spine C7-T3 Extension gliding Patient sitting Ligamentous myofascial tension locking Assume somatic d)'s[zmclio7J (S-T-A-R-T) is identified and }'Oll lUisll to use ml extension gliding thrust, parallel to the apopllrsia1 joi1lt plane, to produce joint cavitation al12-3: KEY 1. Contact points .~'\" Stabilization (a) Spinous process or1'3 (b) Patient's forearms. • Applicator 2. Applicators - Plane of thrust (operator) (a) Operator's sternum, with a cushion or small rolled IOwel, tlpplied to the 1'3 Q Direction of body movement spinous process (rig. 81.21.1) (patient) (b) Operator's hands applied to the patient's forearms. Note: The dimensions for the arrows 3. Patient positioning are not a pidorial representation of Sitting wilh arms comfortably b)' side. the amplitude or force of the thrust 4. Operator stance Stand directly behind the patient wim your 159 feet apart and one leg behind the other. _ _ _ _ _ _ _ _ _ _1

HVLA thrust techniques - spine and thorax Figure 81.21.1 Figure 81.21.2 Bend your knees slightly to 100\\ler )'Our the tension can be localized to the 1'2-3 body. segment. Maintaining all holds and pressures, bring the patient back\"'lards until s. Positioning for thrust }'our body weight is evenly distributed Place the thrusting pan of your sternum, between both feet. with a cushion or small rolled towel. firmly 6. Adjustments to achieve appropriate against the spinaliS process of1'3. Place pre-thrust tension your hands between the patient's chest and upper arms to take hold of the patients' Ensure your p:nient remains relaxed. forearms (Pig. B1.21.2). Maintaining your Maintaining all holds, make any necessary grip on the forearms ask the patient to put changes in flexion, extension, sidebe.nding their hands behind their neck with fingers or rotation until you can sense a state of intertwined (Pig. BI.21.3). This results in appropriate tension and leverage at the your forearms contacting the patient's 1'2-3 segment. The patiem should not be axillae. Lean forwards with the thrusting aware of an)' pain or discomfort. Make these pan of your chest against the spinous final adjustments by slight movements process of1'3 and introduce a baoovards of the ankles, knees. hips and trunk A and compressive force to the patient's arms conunon mistake is to lose the chest and and axillae. These combined movements axillae compression during the final '60 introduce local extension to the thorndc adjustments. spine. By balancing these different leverages.

Cervical and cervicothoracic spine 1.21 -- Figure 81.21.3 Figure 81.21.4 7. Immediately pra-thnut thrust directJy forwards against the spinous process ofn via }'OUr sternum (Fig. Relax and adjust }'OUr balance as necessary. BI.21.4). Keep your head up and ensure that your contaas are firm and the patient's body The thrust. although \"ery rapid. must weight is well controlled. An effective HVLA never be excessively fordble. The aim thrust technique is best achieved if the should be to use the absolute minimum operator and patient are relaxed and not force necessary to achieve joint cavtlalion. holding themselves rigid. 'ibis is a common Common faults arise from the use of impediment to achiL>ving effective excessive amplitude. insufficient velocity of cavilation. thrust and lifting the patient off the rouch. When delh-ering the thnlst. particular care 8. Delivering the thrust must be taken to not allow' the patient's arms to mO\\'e away from the chest wall. The shoulder girdles and thorax of the patient are now a solid mass against which This technique has some modifications: a thrust may be applied. Apply a I IVLA • Respiration can be used to make the thrust to'\\vards you via your hands and forearms. Simuhaneously, apply a HVlA technique more effective. • A certain degree of momentum is often necessary for success in the technique. 161

HVLA thrust techniques - spine and thorax SUMMARY Cervicothoracic spine C7-T3 ExtensIon gilding Patient sitting ligamentous myofascial tension Jocking • Contact points: -Spinous process ofT3 -Patient's forearms • Applicators: -Operator's sternum applied to the T3 spinous process (Fig. 81.21.1) -Operator's hands applied to the patient's forearms • Patient positioning: Sitting with arms comfortably by side • Operator stance: Directly behind the patient with your feet apart. knees bent slightly and one leg behind the other • Positioning for thrust: Place your hands between the patient's chest and upper arm to take hold of the patients' forearms (Fig. 81.21.2). Maintaining your grip on the forearms ask the patient to put their hands behind their neck with fingers intertwined (Fig. 81.21.3). Lean forwards with the thrusting part of your chest against the spinous process ofT3 and introduce a backwards and compressrve force to the patient's arms and axillae. Maintaining all holds and pressures. bring the patient backwards until your body weight is evenly distributed between both feet • Adjustments to achieve appropriate pre-thrust tension • Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: The direction of thrust with your arms is towards you. Simultaneously, apply a thrust directly forwards against the spinous process of T3 with your sternum (Fig. 81.21.4) • Modifications to technique: -Respiration can be used to make the technique more effective -A certain degree of momentum is often necessary for success in the technique 162

Thoracic spine and SECTION rib cage PATIENT UPPER BODY Q. ...hich enables the operator 10 efTectivel}' POSITIONING FOR SITIING AND 'f Iocala. fO'CES '0 3 specific segment o(the_ / spine or ~b_cag! and d~iver ~ higtH1?:loo{)' SUPINE TECHNIQUES 100...-ampIItlKle (11VlA) (ory In a controlled There are a variety of upper body holds manner. Patient comfort must be a major available (rigs U2.0.I-U2.0.S). The...!!old: conside-:ation in selecting the m05t se:lectoo for any panirolar techniquelSihat appropnate hold. Figure 82.0.1 Figure 82.0.2 163

HVLA thrust techniques - spine and thorax • Figure 82.0.3 Figure 82.0.4 Figure 82.05 164

Thoracic spine and rib cage OPERATOR LOWER HAND controlled manner. Patienl comfort mUSI be POSITION FOR SUPINE a major consideration in selecting the most TECHNIQUES appropriate hand position. There are a varirty of hand positions that • Nrotnll hand position (Fig. B2.0.6) can be adopted. The hand position selected • Clenched hand position (Fig. B2.0.7) for any particular technique is thai which • Open fist (Fig.. B2.0.8) enables Ihe operator 10 effeahoely localize • Open fist with towel (Fig.. 82.0.9) forces to a specific segment of the spine or • dosed ftst (Fig. B2.0.tO) rib cage and deliver a HVU. force in a • dosed fist with to\\,'e! (Fig. 82.0. II) Figure 82.0.6 Figure 82.0.9 Figure 82.0.7 Figure 82.0.10 Figure 82.0.8 FIQure 82.0.11 16S

Thoracic spine T4-9 Extension gliding-.. Patient sitting Ligamentous myofascial tension locking Assume somatic dysfunction (5-T-A-R-T) is identified and )\"u wish la use an exlension gliding tJlTUSI.. parallel to t.he apophysial jojtTL plane, to produce joint cavitation at 15-6 (Figs B2.1.1, B2.1.2): Figure 82.1.1 Figure 82.1.2 KEY 1. Contact points .~, Stabilization (a) Spinous proct'Ss ofT6 • Applicator (b) Patienl's elbows. - Plane of thrust (operator) 2. Applicators ':> Direction of body movement (a) Operator's sternum, with a cushion or (patient) slllall rolled towel. applied 10 the T6 Note: The dimensions for the arrows spinous process (Fig. 82.1.3) are not a pictorial representation of (b) Opcratol/s flexed fingers. hands and the amplitude or force eX the thrust. wriSIS applied to the patient's elbows. 3. Patient positioning 167 Sitting with arms crossed O\\l(!r !.he chest and hands passed around the shoulders. 'Ine anns should be finnly clasped around the body as far as the patient can comfortabl}' \"\",ch.

HVLA thrust techniques - spine and thorax Figure 82.1.3 Figure 82.1.4 4. Operator stance }'Qw body weight is evenly distributed Stand directly behind the patient wilh your between both feet. feet apart and one leg behind the other. 6. Adjustments to achieve appropriate Bend your knees slightly to lower }'Qur pre-thrust tension body. Cnsure }'our patient remains relaxed. S. Positioning for thrust Maintaining all holds. make any necessary PIOlce Ihe Ihrusting pan of your sternum, dHmges in flexion, extension, sidebcnding with a rushion or small rolled towel. firmly or rotation until you can $Cnse a stale of againsl the spinolls proc€SS ofT6. Place appropriate tension ;md levernge OIl the your hands over the pmienl's elbows. Lean T5-6 segment. The patient should not be forwards wilh the thrusting part of your aware of an}' pain or discomfon. Make these dll.~t ag.1insl the spinous proc€SS of '1'6 final adjustments by SliglH movements (Fig. 112.1.4). Introduce a backwards of the ankles.. knees. hips and trunk. A (compressive) and upwards force 10 the common mistake is to lose lI,e chesl patient's folded arms. 11,ese combined compression during tlle final adjustments. movements introduce local extension to the 7. Immediately pre-thrust thornoc spine. B}' balancing these different leverages.. the lension can be localized to the Relax and adjust your balance as necessary. 168 TS-6 segment. Maintaining all holds and Keq> }'our head up and ensure that your pressures, bring the patirnt badwards until contacts are finn and the patient's body

- - - - - - - - - - - -Thoracic spine and rib cage \\\\lCigJll is well controlled. An effective IIVU. thrust technique is Ix':st adlievoo if the operntor and patient are relaxoo and nOI holding themselvcs rigid. This is a rommon impediment to achieving effective cavitation. Figure 82,1.5 8. Delivering the thrust This t«hllique uses ligamefllow m)'VflllCinl tension Inching and 1101 facel apposition lockillg. This approach gelleral1)' requires a gretller empluuis on the erilggertltion 0{ primary letfer-age tha\" is dIe case with faat apposition locking techJ1Up.teS. The shouJder girdles and lhorax of lhe patient all\" nO\\\\I a solid mass against which a thrust may be applied. Appl)' a JlVlA thrust to\\vards you and slightly upwards in a cE'phalad direction via )'OUr hands. Simultaneously. appl)' a I tVlA thrust directly forwards againsl the spinous procl'SS of'1'6 via )'OUr sternum (rig. H2.1.5). 'me. thrust, although very rapid. must nC\\-er bt> excessively forcible. The aim shouJd be to use the absolute minimum force necessary to achieve joint cavitation. A common faull arises from the use of excessive amplitude with insufficient velocity of thrust. 'Ihis technique has many modifications: • Different shoulder girdle holds can be used • Respiration can be used to make the tedmique more effective • A cert..,in degree of momentum is often necessary for success in the technique. 169

HVLA thrust techniques - spine and thorax SUMMARY Thoracic spine T4-9 Extension gilding Patient sitting ligamentous myofascial tension locking • Contact points: -Spinous process ofT6 -Patient's elbows • Applicators: -Operator's sternum applied to the T6 spinous process (Fig. B213) -Operator's flexed fingers, hands and wrists applied to the patient's elbows • Patient positioning: Sitting WITh arms crossed over chest • Operator stance: Directly behind the patient with your feet apart, knees bent slightly and one leg behind the other • Positioning for thrust: lean forwards with the thrusting part of your chest against the spinous process of T6 (Fig. B2.1.4).lntroduce a backwards (compressive) and upwards force to the patient's folded arms. Maintaining all holds and pressures, bring the patient backwards until your body weight is evenly distributed between both feet • Adjustments to achieve appropriate pre-thrust tension • Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: The direction of thrust with your arms is towards you and slightly upwards. Simultaneously, apply a thrust directly forwards against the spinous process of T6 with your sternum (Fig. 82.1.5) • Modifications to te<hnique: -Different shoulder girdle holds can be used -Respiration can be used to make the technique more effective -A certain degree of momentum is often necessary for success in the technique 170

Thoracic spine T4-9 Flexion gJ.idi~-~ Patient supine Ligamentous myofascial tension locking Assume sOIMtic dysfimetiOll (5-T-A-R-T) is identified and )\"u wish 10 use a flaimJ gliding thrust, parallel to the apop/l)'sial joint plane, lO produce joim cavitarion al T5-6~ KEY 1. Contact points •:t:. Stabilization (a) TransYelse processes of'1'6 (b) Palient's elbows. • Applicator 2. Applicators - Plane of thrust (operator) (a) Palm of the operator's right hand. held in a clenched position Q Direction of body movement (b) Operator's lower sternum or upper (patient) abdomen. Note: 1lle dimensions for the arrows 3. Patient positioning are not a pictorial representation of Supine with the arms crossed over the cht'St the amplitude or force of the thrust. and hands passed around the shoulden. \"l1l.e arms should be firmly clasped round the body as fae as the patient can 171 comforubly reach (Fig. 82.2.1).

HVLA thrust techniques - spine and thorax Figure B2.2.1 Figure 82.2.2 4. Operator stanceA~ If>'-~ patient back 10 the supine position. As the Stilnd on the riglu side of the patient, facing patient approadles the supine position, tmnsfer yOllr lefl hand and forearm to the head of the couch. support the patielll's head, neck and upper 5. Posftlonlng for thrust (horndc spine (Fig. 82.2.3). Allow' the pmiem to roll fully into the Reach over the patient with your left hand supine position. Flex the patient's head, 10 lake hold of the left shoulder and gently neck and upper thoracic spint' until tension pull it 100'J3rds you. With )'OUT right hand. is localized to the 1'5-6 segment. Lean over locate the transverse processes ofT6. NO\\v the patient and resl )'QUr lower sternum or placc the clenched palm of)'ow right hand upper abdomen on the patient's elbows. against the lram'\\'erse procE'SSt'S ofT6 (Fig. Initially, a slO'o'll but finn pressure is applied 1l2.2.2). with )'OUr 10'0\\'£:1\" sternum or upper abdomen 172 Keeping the right hand pressed againsr dO'o,,\"\\vards to\\vards the couch. Maintaining the lraos\\'erse processes of1'6. rolJ !.he this dO'ovoward leverage. introduce a force in

. . 22Thoracic spine and rib cage - -,-' Ftgure 82.23 line with the patient's upper arms. By 8. Delivering the thrust 173 baJancing these different leverages. tension can be locali7,.OO to the TS-6 segme.nL This tedmique uses ligamentous m}'Ofasdnl tensiOlI locking aud not facer apposition lockillg. 6. Adjustments to achieve appropriate This app;:ooe,rgelleraU,. retluires a greater pre-thrust tension emplwis on die exaggeration of primllry leverage dUIIl is tile CIISe widl facet ~itiOlI Ensure your patient remains relaxed. locking redmiques. Maintaining all holds, make any necessary changes in nexion, extension, sidebendillg The shoulder girdles and lhorax of the or rotation until you can sense a state of patient are now a solid mass against which appropriate tension and leverage at the a thrust may be applied. Apply a IIVLA TS-G segment. 11le palielll should not be thm\"it dO\\vnwards to\\vards the couch and in aware of any pain or discomfort. Make these a cephaJad direaion via your lower sternum final adjustments by slight movements of or upper abdomen. Simuhaneously, apply a ankles, knees, hips and Hunk. A common I-IVI.A thrust wilh your right hand against mistake is to lose the chest compression the tran\"iVerse processes in an upward and during the final adjustments. caudad direction (Fig. 82.2.4), 7. Immediately pre-thrust A common fault is to emphasize the thrust via the patient's shoulder girdles at Ilelax and adjust your balance as necessary. the expen.se of the thrust against the Ensure that your contacts are firm and the transverse processes. The hand contacting patient's head, ned< and upper thoracic the transverse proces.\"ies ofT6 must actively spine are well controlled. An effective HVLA panidpate in the generation of thrust forces. thrust technique is best achieo.u1 if the The thrust. although \\'el)' rapid, must never operator and patient are relaxed and not be excessivet), forcible. 11,e aim should be to holding themselves rigid. 'Ibis is a common use the absolute minimum force ne«ssary impediment to achieving effective to achieve joint cavitation. A common fault arises from the use of excessive amplitude ca\\~tation. with insufficient \\'elocity of thrusL

HVLA thrust techniques - spine and thorax Ftgure 82.2.4 This technique has man}' modifications: • Different shoulder girdle holds can be used • Different applicators can be used • Respiration can be used to make the technique more effecth-e 174

Thoracic spine and rib cage SUMMARY Thoracic spine 14-9 Flexion gliding Patient supine ligamentous myofascial tension locking • Contact points: -Transverse processes of T6 -Patient's elbows • Applicators: -Palm of the operator's right hand. held in a clenched position -Operator's lower sternum or upper abdomen • Patient positioning: Supine with arms crossed over chest (Fig. 82.2.1) • Operator stance: To the right side of the patient, facing the couch • Positioning for thrust: Take hold of the patient's left shoulder and pull it towards you. Place the clenched palm of your right hand against the transverse processes of T6 (Fig. 82.2.2). Roll the patient back to the supine position. As the patient approaches the supine position, transfer your left hand and forearm to support the patient's head, neck and upper thoracic spine (Fig. 82.23). Allowing the patient to roll fully into the supine position, flex the head. neck and upper thoracic spine until tension is localized to the T5-6 segment. Apply a firm pressure with your lower sternum or upper abdomen downward towards the couch. Maintaining this downward leverage, introduce a force towards the patient's head in line with the patient's upper arms • Adjustments to achieve appropriate pre·thrust tension • Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: The direction of thrust is downwards towards the couch and in a cephalad direction via your lower sternum or upper abdomen. Simultaneously. apply a thrust with your right hand against the transverse processes in an upward and caudad direction (Fig. 82.2.4). The hand contacting the transverse processes of T6 must actively participate in the generation of thrust forces • Modifications to technique: -Different shoulder girdle holds can be used -Different applicators can be used -Respiration can be used to make the technique more effective 175

Thoracic spine T4-9 Rotation gliding Patient supine Ligamentous myofascial tension locking Assume somatic dysfunction (S-T-A-R-T) is identified and )'Otl wish to use a rotation gliding thrust, parallel to the apophysial joint plane. to produce joint cavitation at T5-6: KEY 1. Contact points * Stabilization (a) Left transverse process ofTG (b) Poltient's elbows and left forearm. • Applicator 2. Applicators - Plane of thrust (operator) (a) Palm of the operator's right hand. held ..) Direction of body movement in a clenched position (patient) (b) Operator's lower sternum or upper Note: The dimensions for the arrows abdomen. are not a pidorial representation of the amplitude or force of the thrust. 3. Patient positioning Supine with the arms crossed over the chest and Lhe hands passed around the shoulden. The left arm is placed over the right arm (Fig. 82.3.1). The arms should be finnly clasped around the body as far as !.he patielll can comfortably reach.

HVLA thrust techniques - spine and thorax Figure 823.1 Figure 82.3.2 4. Operator stance Keeping contan wiLh the left transverse Stand on the right side of the patient. facing process ofTG. roll the patient back towards the couch. the supine position. Rest }our lower sternum or upper abdomen on the 5. Positioning for thrust patient's elboo,vs and left forearm (Fig. 82.3.4). Reach over the patient with your left hand Initially, a slow bUI firm pressure is to take hold of the left shoulder and gently applied with your lower sternum or upper pllllthe patient's shoulder towards you (Fig. abdomen downward toward.. the rouch. B2.3.2). With your right hand, locate the Mailllaining this downward le...erage. transverse processes of T6. Now place the introduce left rotation of Ihe patient's upper thenar eminence of your righl hand againsl thorax by directing forces 10\\vards the 178 the left transverse process ofT6 (Fig. palierll's left shoulder along the line of the 82.3.3). patient's left upper arm. By balancing these

Thoracic spine and rib cage Ftgure 8233 Figure 82.3.4 different leverages, tension can be localized of the ankles. knees, hips and trunk. A to the TS-G segment. common mistake is to lose the chest compression during the final adjuslments. 6. Adjustments to achieve appropriate 7. Immediately pre-thrust 179 pre-thrust tension Relax and adjust your balance as necessary. Ensure your palient remains relaxed. Keep your head up and ensure that your Maintaining all holds. make any necessary contacts are firm and the patient's body changes in flexion, extension, sidebending weight is \\vell controlled. An effective HVLA or rotation until you can sense a stale of thrust technique is best achieved if the appropriate tension and levernge at the operator and palient are relaxed and not TS-6 segment. The patient should nol be holding themselves rigid. This is a common aware of any pain or discomfort. Make impediment to achieving effective lhese final adjustments by slight movements cavitation.

HVLA thrust techniques - spine and thorax Figure 82.3.5 8, Delivering the thrust A common fault is to emphasize the thrust via the patient's shoulder girdles at. '11lis loclmique II.ses IigmnetllOUs m)fJfascinJ the expense of the thrust against the left fension locki\"8 (l1ld Plot fllCel apposition locking. uallSverse process. The hand contacting IhI' transverse process 0('1'6 must activeh 'this approodl gerll!mlly requires a greater participate in the generation of thrust f(1 a The thrust. aJthough \\'e.ry rapid. must fl(\"'\\'ef empllasis on dIe e:xJI8sermKm of primary be excessively forcible. The aim should hot- letlerage dUI1l is tI,e case widl fllCer appositiorl use the absolute minimum force necessat\\ lodrirlg rochl1iques. to achi~\"e joint cavitation. A common fa arises from the use of excessi\\\"e ampllluck The shoulder girdles and thorax of the with insufficient velocity of thrusL patient are nO\\\" a solid mass against which a thrust may be applied. Apply a IIVlA This technique has many modifications thrust dO\\'lOwards towards the couch and in the line of the patient's left upper arm \"ia • Different shoulder girdle holds can be your lower sternum or upper abdomen. used Simuhaneously, apply a I fVlA thrust \\...jth your right thenar eminence upwards against • Different applicators can be used the lefl transverse process ofTG (Fig. • Respiration can be used to make the 82.3.5). TIle force is produced by rapid pronation of your right forearm. technique more effective.. '80

Thoracic spine and rib cage 2.3 SUMMARY 181 , Thoracic spine T4-9 Rotation gliding I Patient supine ligamentous myofascial tension locking • Contact points: -left transverse process of T6 -Patient's elbows and left foreann Applicators: -Palm of the operator's right hand, held in a clenched position -Operator's lower sternum or Upper abdomen • Patient positioning: Supine with anns crossed over the chest (Fig. 82.3.1) • Operator stance: To the right side of the patient, facing the couch • Positioning for thrust: Take hold of the patient's left shoulder and pull it towards you (Fig. 82.3.2). P1ace the thenar eminence of your right hand against the left transverse process ofT6 (Fig. 82.3.3). Roll the patient back towards the supine position. Rest your lower sternum or upper abdomen on the patient's elbows and left forearm (Fig. 82.3.4). Apply a slow firm pressure with your lower sternum or upper abdomen downwards towards the couch. Maintaining this downward leverage, introduce left rotation of the patient's upper thorax by directing forces towards the patient's left shoulder along the line of the patient's left upper arm • Adjustments to achieve appropriate pre-thrust tension Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: The direction of thrust is downwards towards the couch and in the line of the patient's left upper arm via your lower sternum or upper abdomen. Simultaneously, apply a thrust with your right thenar eminence upwards against the left transverse process ofT6 (Fig. 82.3.5). The force is produced by rapid pronation of your right forearm. The hand contacting the transverse process ofT6 must actively participate in the generation of thrust forces • Modifications to technique: -Different shoulder girdle holds can be used -Different applicators can be used -Respiration can be used to make the technique more effective

Thoracic spine T4-9 Rotation gliding Patient prone Short lever technique Assume somali, dysjWlGliotl (S-T-A.R.Tj is identified and )'Ou wish to use a rotation gliding lhnlSt, parallel to the apopJT)'sial joim plane. to produce joint cavitation at. 1'5-6: KEY 1. Contact points ~~ Stabilization Transverse processes ofTS (right applicator) and TG (left applicator). • Applicator 2. Applicators - Plane of thrust (operator) Hypothenar eminence of left and right ¢ Direction ci body movement hands. (patient) 3. Patient positioning Note: The dimensions for the arrows Patient lying prone with the head and neck are not a pictorial representation of in a comfortable position and arms hanging the amplitude or force of the thrusL over the edge of the couch. 183

HVLA thrust techniques - spine and thorax Figure 82.4.1 Figure 82.4.2 4. Operator stance the hypothenar eminence of your left hand against the right transverse process of '1'6 Stand at the left side of the patient. feet (Fig. B2.4.2). Ensure that you ha\\>(': good spread slightly and facing the patient. Stand contact and will not slip across the skin or as erect as possible and avoid crouching as superficial musrulature when )'Ou appl)' this ,...ill limit the technique and restria downward and caudad or cephalad forces delivery of the thnlst. againsl the trallS\\'l?11>e processes. Maintain these contact points. S. Palpation of contact points 111ere are man)' different ways to perform 6. PositionIng for thrust this technique. This is one approach. Locate the tral1S\\'el1>e processes ofTS and T6. Place lhis is a shan lever technique and the the hypothenar eminence of ),our right hand \\>(':Iooly of the thrust is critical MO\\>(': your 184 against the left transverse process ofTS and centre of g.r.tvity O\\'er the patient by leaning establish a 6ml ronlaa (Fig. 82.4.1). Place your body weight forwards Onto )'Our anus

Figure 82.43 -Thoracic spine and rib cage and hypothenar eminences (rig. B2.4.3). 185 Shifting your centre of gravity forwards wjll direct a downward pressure on the transverse processes. You must apply an additional force dim::ted caudad with the left hand and cephalad wil.h the right hand. The finaJ dim::tion of thrust is influenct.>d by the degree of thoracic kyphosis and ally pre- existing scoliosis. 'rhis technique does not use facet apposition locking. The pre-Ihrust tension is achieved by positioning the '1\"5-6 segment towards the end range of available join! gliding. r.xtensive prnctice is necessary to de\\-eJop an appreciation or the required tension. 7. Adjustments to achieve appropriate pre-thrust tension [mure your patiem remains relaxed. Maintaining all holds and pressure upon thE\" transverse prOCf'SSt'S,. make any necessary changes by introducing very slighl components or extension. sidroending and rotation until you sense a st::lIE\" or appropriate tension and leverage at the 13-6 segmeOl. The patient should not be a\\\",\"\"e or any pain or discomron. 8. Immediately pre-thrust Relax and adjust your balance as necessary. Keep your head up and ensure that your comaas are firm. An effective HVLA thrust technique is best achieved if the operator and patient are relaxed and not holding themselves rigid. This is a common impediment to achieving effective cavitation. 9. Delivering the thrust Apply a IIVLA thrust directed in a downward and cephalad direction against the transverse process arTS while simultaneously appl)'ing a thrust downwards and in a caudad direction against the transve~ process orT6 (F;g. B2.4.4). The thrust. although very rapid. must nt'\\~ be excessively forcible_ The aim

HVLA thrust techniques - spine and thorax Figure 82.4.4 should be to use the absolute minimum force necessary to achieve joint cavilation. A common fault arises from the use of excessive amplitude with insuffidem velocity of thrust. 186

Thoracic spine and rib cage SUMMARY Thoracic spine 14-9 Rotation gliding Patient prone Short lever technique • Contact points: Transverse processes ofT5 (right applicator) and T6 (left applicator) • Applicators: Hypothenar eminence of left and right hands • Patient positioning: Prone with arms hanging over the edge of the couch • Operator stance: To the left side of the patient, facing the couch • Palpation of contact points: Place the hypothenar eminence of your right hand against the left transverse process of T5 and establish a firm contact (Fig. 82.4.1). Place the hypothenar eminence of your left hand against the right transverse process ofT6 (Fig. 82.4.2) • Positioning for thrust: This is a short lever technique and the velocity of the thrust is critical. Move your centre of gravity over the patient by leaning your body weight forwards onto your arms and hypothenar eminences (Fig. 82.4.3). Apply an additional force directed caudad with the left hand and cephalad with the right hand • Adjustments to achieve appropriate pre-thrust tension • Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: The direction of thrust is in a downward and cephalad direction against the transverse process of T5 while simultaneously applying a thrust downwards and in a caudad direction against the transverse process of T6 (Fig. 82.4.4) 187

----Ribs Rl-L Patient prone Gliding thrust Assume somalic drs/mIction (S·T-A-R-T) is identified and }'OU luisll lO produce cavitarion at the costolramverse joint of tile second rib on the rigllL (Figs 82.5.1, 82.5.2): Figure 82.5.1 Figure 82.5.2 KEY 1. Contact point Angle of the second rib on the right. .*. Stabilization 2. Applicator • Applicator Hypothenar eminence of the right hand. - Plane of thrust (operator) 3. Patient positioning c:> DIrection of body movement Patient prone with the point of the dlin (patient) resting on the couch and the arms hanging over the edge of the couch. Introduce a Note: The dimensions for the arrows small amount of sidebending to the left by are not a pictOl\"ial representation of gently lifting and moving the chin to the the amplitude or force of the thrust. patient's left (Fig. 82.5.3). Do not introduce too much sidebending. '89 4. Operator stance Head of the couch. feet spread slightly. Stand as erect as possible and a\\'Oid

HVlA thrust techniques - spine and thorax Figure 82.53 crouching ()'I.'{'f the patient as this will limit the technique and restrict delivery of the thrust. 5. Palpation of contact point Locate the angle of the second rib on the right. Place the hypothenar eminence of your right hand gently, bUI firmly, against the rib angle. Ensure that you have good contact and will not slip across the skin or superficial musculature when you apply a caudad and dO\\Vll\\vard force towards the couch against the angle of the second rib. Maintain this contact poinL 6. Positioning for thrust Keq>ing your position at the head of the couch, gently place your left hand againsl the right side of the patient's head and neck. While maintaining the left sidl..>bending, introduce rotation to the right. in the cervical and upper thoracic spine. by applying gentle pressure to the right side of the patient's head and ned:: with yow left hand (Fig. 82.5.4). Maintaining all holds 190 Figure 82.5.4

Thoracic spine and rib cage Figure 82.5.5 themselves rigid. This is a common 191 impediment to achieving t'ffectivt' and pressures, complete the rotation of the cavit.Ilion. patient's he3d and neck until a sense of tension is palpatro at your right hypothenar 9. Delivering the thrust eminence. Ket'p finn p~ure against the Apply a IIVL\\ thrust to the anglt' of tht' second rib on the right directed dowmvards contact point towtlrds the coud, and also in a caudad direction 100vards the patit'nt's right iliac 7. Adjustments to achieve appropriate crest. Simultaneously, tlpply a slight, rapid pre-thrust tension increase of head and ne<k rotation to tht' right with your left hand (Fig. 82.5.5). Vou Ensure the patient remains relaxro. must not ovt'remphasize the thrust with the Maintaining all holds, make any necessary left hand against lhe patiem's head and changes in extension, skkbending or neck. Vour left hand stabilizes the Icvt'rages rota Lion umil you can sense a Slate of and maintains tJ,c position of the hrnd and appropriate tension and leverage. TIle cervical spine against the lhrusl imposed patient should not be aware of any pain upon the contact point. The thrust is or discomfort. You make these final induced by a very rnpid contnlClion of the adjustments by altering the pressure and triceps, shoulder adductors and internal din.>(tion of forces between the left hand rotators. against the ptHiem's head and neck and your right hypothenar eminence against The thrust. although very rapid, mUSl the comact point. newr be excessively forcible. The aim should be 10 use the absolute minimum 8. Immediately pre-thrust force necessary to achieve joint cavitation. A common fault arises from the use of Relax and adjust your balance as necessary. exccssi\\'t' amplitude with insuffidenl Keep your head up and ensurt' that yow velocity of thrusL contacts are firm and your body position is well controlled. An effective IIVL\\. thrust techn.ique is best achieved if the operalOr and patient are relaxed and not holding

HVlA thrust techniques - spine and thorax SUMMARY Ribs R1-3 Patient prone Gliding thrust • Contad point: Angle of the right second rib • Applicator: Hypothenar eminence • Patient positioning: Patient prone with the chin resting on the couch and arms hanging over the edge of the couch. Introduce sidebending to the left (Fig. 82.5.3). 00 not introduce too much sidebending • Operator stance: Head of the couch. feet spread slightly • Palpation of contad point: Place your hYFXlthenar eminence against the angle of the second rib on the right. Ensure that you have good contact and will not slip across the skin or superficial musculature when you apply a caudad and downward force towards the couch against the angle of the second rib • Positioning for thrust: Place your left hand against the right side of the patient's head and neck. Rotate the cervical and upper thoracic spine to the right. by applying pressure to the right side of the patient's head and neck with your left hand until a sense of tension is palpated at the contact FXlint (Fig. 82.5.4) • Adjustments to achieve appropriate pre-thrust tension • Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: The thrust to the angle of the second rib on the right is directed downwards towards the couch and also in a caudad direction towards the patient's right iliac crest. Simultaneously, apply a slight. rapid increase of head and neck rotation to the right with your left hand (Fig. 82.5.5). You must not overemphasize the thrust with the left hand against the patient's head and neck 192

Ribs R4-10 Patient supine Gliding thrust Ligamentous myofascial tension locking Ass\"'''e solllalic dysfunClitm (S·'FA'/l-T) is identified .,UJ )'OU 1I1is/. 10 produce caviratioll lit tile coSlOlmmver5e joim of lhe sixth rib on the left (Fig. 82.6./): KEY Figure 82.6.1 ;:;:. Stabilization 1. Contact p~nts • Applicator (a) Sixth rib on the left, just lateral to the transverse process ofT6 - Plane of thrust (operator) (b) Patjent's elbows and left forearm. <;;) Directton of body movement 2. Applicators (patient) (a) Hypolhemu eminence of the openuor's Note: The dimensions for the arrows right hand are not a pictorial representation of (b) Operntor's lower sternum or upper the amplitude or force of the thrust. abdomen. 3. Patient positioning 193 Supine with the arms crossed over the dlt~SI and the hands passed around the shoulders. The left arm is placed O\\'I':f the right arm. The arms should be finnly clasped around the body as far as me paliel1l call comfortably reach.

HVlA thrust techniques - spine and thorax Figure 82.6.2 Figure 82.63 4. Operator stance position (Fig. B2.6.3). Continue until the Stand on the right side of the patient, facing patient's elbows are directly over your hypothenar eminence. This introduces the couch. additional rotation, which is a critical s. Positioning for thrust elemelll in Lhe technique. Hest your lower Sternum or upper Reach over the patient with your left hand abdomen on the patient's elbows and left to take hold of the left shoulder and gently foreann. Initially. a slow but finn pressure is pull it to...\"ards you. With your right hand, applied with your lower sternum or uppt>r locate the sixth rib on the left. Now abdomen downwards towards the couch. place the hypothenar eminence of your Maintaining this downward leverage, right hand against the rib just lateral imroduce left rotation of the patient's upper to the transverse process ofT6 (Fig. thorax by directing forces towards the 62.6.2). patient's left shoulder along the line of 194 Keeping contact with the rib, begin the patient's left upper ann. By balandng rolling the patient back to the supine these different leverages, tension can be

. -.. Thoracic spine and rib cage 2.6 ., Figure 82.6.4 loc.'lIi7.ed to lhe costotransverse joint of the 'nlis lIpprcxu;h generally requires a greater sixth rib. empluzm Ofl Ole exaggeration of prirnmy leverage tJlim is tile cnse with faal appositiml 6. Adjustments to achieve appropriate locking Lechlliqu€S.. pre-thrust tension \"Ille shoulder girdles and thora:< of the Ensure your paLient remains relaxed. patient are now a solid mass against which Maintaining all holds. make any necessary a thrust may be applied. Apply a IIVLA changes in flexion, extension, sidebending thrust dO\\vnward towards the couch and in and rotation until you can sense a SLale of the line of the patient's left upper arm via appropriate tension and leverage at the your lower sternum or upper abdomen. COStotransvtne joint of the sixth rib. The Simultaneously, apply a IIVlA lhrust with patient should nOt be aware of any pain or your right hypothenar eminence upo.V3.rd discomfort. Make these final adjustments by against the sixth rib (Fig. 82.6.4). The force slight movements of the ankles, knfi'S,. hips is produced by rnpid supination of your and trunk.. A common mistake is to lose the right foreann. chest compression during the final adjustmentS. A common fault is to emphasize the thrust via the patient's shoulder girdles at 7. Immediately pre-thrust the expense of the thrust against the sixth rib. The hand contacting the rib must I~elax and adjust your baltmce as necessary. :'!(lively participate in the generation of Keep your head up and ensure that your contacts are firm and the patient's body thruSl fOfCt$. weight is well controlled. An effective I [VL\\ The thrust, although very rnpid, must thrust technique is best adlieved if the operntor and patient are relaxed and not never be excessively forcible. \"l'lle aim holding themselvt'S rigid. This is a common should be to use the absolute minimum impediment to achieving effective force n«essary to :'!chieve joint cavitation. cavitation. A common fault arises from the U~ of excessivt> amplitude ,,,ith insufficient velocity of thrust. 8. Delivering the thrust 195 This technique I~ ligllment01lS mrofllSdal temiml locking and nor faat apposirion locking.

HVLA thrust techniques - spine and thorax SUMMARY Ribs R4-10 Patient supine Gliding thrust Ligamentous myofascial tension locking • Contact points: -Sixth rib on the left, lateral to the transverse process -Patient's elbows and left forearm • Applicators: -Hypothenar eminence of the operator's right hand -Operator's lower sternum or upper abdomen • Patient positioning: Supine with arms crossed over the chest • Operator stance: To the right side of the patient. facing the couch • Positioning for thrust Take hold of the patient's left shoulder and pull it towards you. Place the hypothenar eminence of your right hand against the rib just lateral to the left transverse process of T6 (Fig. 82.6.2). Roll the patient back to the supine position (Fig. 82.6.3). Continue until the patient's elbows are directly over your hypothenar eminence. This is a critical element in the technique. Rest your lower sternum or upper abdomen on the patient's elbows and left forearm. Apply a slow firm pressure with your lower sternum or upper abdomen downwards towards the couch. Maintaining this downward leverage. introduce left rotation of the patient's upper thorax by directing forces towards the patient's left shoulder along the line of the patient's left upper arm • Adjustments to achieve appropriate pre-thrust tension • Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: The direction of thrust is downwards towards the couch and in the line of the patient's left upper arm via your lower sternum or upper abdomen. Simultaneously. apply a thrust with your right hypothenar eminence upwards against the sixth rib (Fig. 82.6.4). The force is produced by rapid supination of your right forearm. The hand contacting the rib must actively participate in the generation of thrust forces 196 J

Ribs R4-10 Patient prone Gliding thrust Assume somatic dysfunction (S-'J:A-R-T) is identified and )-'Oll wish to produce cavitation aL ti,e costotransverse joint of tlie sixth rib on tile left.: KEY 1. Contact points \"',. Stabilization Angle of left sixth rib (right applicator). Right transverse process ofT6 (h:~ft • Applicator applicator). • Plane of thrust (operator) 2. Applicators ¢ Direction of body movement Hypothenar eminence of Idt and right (patient) hands. Note: The dimensions for the arrows 3. Patient positioning are not a pictorial representation of Patient tying prom~ with the head and neck the ampmude or force of the thrust. in a comfonable position and the arms hanging over the roW of the couch. 197 4. Operator stance Stand al the left side of the patient. feet spread slightly and fating the pallem. Stand

HVLA thrust techniques - spine and thorax Figure B2.7,1 Figure B2.7.2 as erect as possible and avoid crouching as 6. Positioning for thrust this will limit the technique and restrict This is a short lever technique and as a delivery of the thrust. consequence the velocity of the thrust is 5. Palpation of contact points critic.l!. Move your (entre of gTtlvity over the patient by I~ning )'Our body weight There are many different W3YS to perform fonvards onto your arms and hypothenar this technique. This is one approach. !..ocate eminences (Fig. 82.7.3). Shifting )'Our centre the transvm>e: proces.-.es ofT6. Place the of gravity forwards will direct a dcnvnward hypothenar eminence of your right hand pressure on both the tmnsverse pnxess of against the angle of the patient's left sixth '1'6 and the sixth rib. You must apply an rib and cstablish a firm contact (Fig. addition31 force directed cephalad with the 82.7.1). Place the hypothenar eminence of right hand against the angle of the sixth rib_ your left hand against the right tranS\\'Ene The finaJ direction of thrust is influenced by process ofT6 (Fig. 82.7_2). Ensure that you the degree of thorncic \"''YPhosis and 3ny pre- 198 have good contaQ and will not slip across existing scoliosis. This technique does not the skin or superficial musculature. use facet apposition locking. 1he pre-thrust

Thoracic spine and rib cage tension is achieved by positioning the 7. Adjustments to achieve appropriate CO'ltotf3.llS~rsejoint of the sixth rib to\\vards pre-thrust tension the end f3.n~ of av<Iilable joint gliding. Extensive practice is necessary to develop Ensure your patient remains relaxed. Maintaining all holds. make any neCfSSal)' an appreciation of the required tension. changes in extension, sidebending and rotation until )'Ou sense a state of appropriate tension and levera~ at the costotr.:lnsverse joint of the sixth rib. The patient should not be aware of any pain or discomfort. 8. Immediately pre-thrust Relax and adjust your balance as necessary. Keep your head up and ensure that your contaclS are firm. An effective HVLA lhrust technique is best achieved if the opern.lor and patient are relaxed and not holding themselves rigid. 'J11is is a common impediment [0 achieving effective cavitation. Figure 82.7.3 9. DeUvering the thrust Apply a IIVLA thrust directed in a downward and cephalad direction against the angle of the sixth rib. It is important to achieve fixation ofT6 by maintaining a finn dow'oward pressure against the tr.:lnsverse process ofT6 on the righL The thrust is generated by your right hand in contact with the sixth rib (Fig. 82.7.4). Figure 82.7.4 199

HVLA thrust techniques - spine and thorax The thrust. although very rapid. must A common fault arises from the use of never be excessiVl\"ly forcible. ·me aim excessh\", amplitude with insuffident should be to use the absolute minimum velocity of thrust. force necessary to achieve joint cavitation. SUMMARY Ribs R4-10 Patlent prone • Gliding thrust I • Contact points: Angle of left sixth rib (right applicator). Right transverse process ofT6 (left applicator) • Applicators: Hypothenar eminence of left and right hands • Patient positioning: Prone with arms hanging over the edge of the couch • Operator stance: To the left side of the patient, facing the couch • Palpation of contact points: Place the hypothenar eminence of your right hand against the angle of the patient's left sixth rib and establish a firm contact (Fig. 82.7.1). Place the hypothenar eminence of left hand against the right transverse process of T6 (Fig. 82.7.2) • Positioning for thrust: This is a short lever technique and the velocity of the thrust is critical. Move your centre of gravity over the patient by leaning your body weight forwards onto your arms and hypothenar eminences (Fig. 82.7.3). Appty an additional force directed cephalad with the right hand against the angle of the sixth rib • Adjustments to achieve appropriate pre-thrust tension • Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: The direction of thrust is in a downward and cephalad direction against the angle of the sixth rib. It is important to achieve fixation of T6 by maintaining a firm downward pressure against the transverse process of T6 on the right. The thrust is generated by your right hand in contact with the sixth rib (Fig. 82.7.4) 200 J

Ribs R4-10 Patient sitting Gliding thrust Assume somatic dj~fu\"ctioll (5-T-A-R-T) is idenrified alld )\"u wish to produce cavit.ation at. t.he costotransverse join! of the rig1lt sixth rib (Fig. B2.8.1): KEY Figure 82.8.1 * Stabilization 1. Contact point Angle of right sixth rib. • Applicator 2. Applicator • Plane of thrust (operator) Ilypothenar eminence of right hand. f.::> Direction of body movement 3. Patient positioning (patient) Sitting astride the treatment couch with the anns crossed over the chest and the hands Note: The dimensions for the arrows passed around Lhe shoulders. 1he arms are not a pidorial representation of should be finnly daslX>d around the body the amplitude or force of the thrust as far as the patient (an comfonably ream. 4. Operator stance 20' Stand behind and slighlly to the left of the patient with your feet spread. Pass )'OUf left arm across the front of the patient's chest to

HVLA thrust techniques - spine and thorax Figure 82.8.2 Figure 82.8.3 lightly grip over the patient's right shoulder rt.'gion (Fig. 82.8.2). 5. Positioning for thrust Trnnsltlte the patient's trunk to the right and tlwtly from you. This opens up the intercosttll sptlce between the sixth and seventh ribs U-ig. B2.8.3) and allo\\'.s beUer tlccess to the inferior aspect of the sixth rib. pltlce your right hypothenar eminence on the inferior surftlce of the angle of the sixth rib. The thorax is now rotated to the left (Fig. 82.8.4). Sidebending to the right is introduced to lock the spine down to T6. The operntor maintains tlS ered a posture as possible. Keep your right hypothenar eminence firmly applied to the sixth rib 202 with your right elbow held close to your Figure 82.8.4 body (F;g, 82.8.5).

Thoracic spine and rib cage Figure 82.85 Figure 82.8.6 6. Adjustments to achieve appropriate 8. Delivering the thrust pre-thrust tension A degree of momentum is necess.ary to Ensure your patient remains relaxed. achieve a successful cavitatjon. Rock the Maintaining all holds, make any necessary patient into and out of rotation while change; in flexion, extension, sidebending maintaining the other leverages. When you or rotation until you can sense a state of sense a state of appropriate tension and appropriate tension and leverage at the leverage at the sixth rib, apply a HVlJ\\ costotransverse joint of the sixth rib on the thrust ag::.inst the inferior aspect of the right. 'l1u: patient should not be aware of angle of the rib in a cephalad and anterior any pain or discomfOrL Make these final direction. Simultaneously, apply slight adjustments by slight movements of the exaggeration of left trunk rotation (Fig. shoulders, trunk. ankles, knees and hips B2.B.6). 7. Immediately pre-thrust 'l11e thrust, although \\'tlY rapid,. must nevt'f be excessively forcible. 111e aim Relax and adjust your balance as necessary. should be to use the absolute minimum An effooiw HVlA thrust technique is best force necessary to achieve joint cavitation. achieved if both the operator and patient A common fault arises from the use of are relaxed and not holding themselves excessive amplitude with insufficient rigid. This is a common impediment to velodty of thrust. achk\"Ving effective c3Vi~tion. 203

HVLA thrust techniques - spine and thorax SUMMARY Ribs R4-1 0 Patient sitting Gliding thrust • Contact point: Angle of right sixth rib • Applicator. Hypothenar eminence of right hand • Patient positioning: Sitting astride the couch with the arms crossed over the chest and the hands passed around the shoulders • Operator stance: 8ehind and slightly to the left of the patient with the feet spread. Pass your left arm across the front of the pattent's chest to lightly grip over the patient's right shoulder region (Fig. 82.8.2) • Positioning for thrust: Translate the patient's trunk to the right and away from you (Fig. 82.8.3). Place your right hypothenar eminence on the inferior surface of the angle of the sixth rib. The thorax is now rotated to the left (Fig. 82.8.4). Sidebending to the right is introduced to lock the spine down to T6. The operator maintains as erect a posture as possible. Keep your right hypothenar eminence firmly applied to the sixth rib with your right elbow held close to your body (Fig. B2.8.5) • Adjustments to achieve appropriate pre-thrust tension ! • Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: A degree of momentum is necessary to achieve a \" successful cavitation. The direction of thrust is in a cephalad and anterior direction against the inferior aspect of the angle of the rib. Simultaneously, apply slight exaggeration of left trunk rotation (Fig. 82.8.6) 204

•- Lumbar and SECTION thoracolumbar spine UPPER BODY HOLDS FOR LOWER BODY HOLDS FOR SIDE-LYING TECHNIQUES SIDE-LYING TECHNIQUES All techniques in this manUtll tire described There are a variety of lower body holds with the operator taking up the axillary hold ~i1able (Figs 83.0.5-83.0.9). The hold (Fig. B3.0.1). The hold selected for any seledoo for any particular technique is that particular technique is that which enables which enables the operator to effectively the operator to effeoively localize forces to 1000lize forces to a specific segment of the a specific segment of the spine and deliver spine and deliver a IfVLA force in a a high-velocity low-amplitude (IIVIA) force controlled manner. Patient comfort must be in a controlled manner. Patient comfort a major consideration in selecting the most must be a major consideration in selecting appropriate hold. the most appropriate hold. \"I'm~e alternative upper body holds 3rc available: • Pectoral hold (Fig. 83.0.2) • Elbow hold (Fig. B3.0.3) • Upper arm hold (Fig. 83.0.4)' Figure 83.0.1 205