__Manipulation_of_the_Spine__Thorax_and_Pelvis__An_Osteopathic_Perspective

HVLA thrust techniques - spine and thorax Figure B3.0.2 Figure B3.03 Figure 83.0.4 206

Lumbar and thoracolumbar spine Figure B3.0.5 Figure B3.0.6 Figure B3.0.7 Figure B3.0.8 Figure B3.0.9 207

Thoracolumbar spine T1 O-L2 Neutral positioning Patient side-lying Rotation gliding thrust Assume sOl1JlJLic d)'sfunclion (S-'f-A-R-T) is identified and you wish to use a rotllli011 gliding (hmst to produce cavililtion at T12-Ll on the left (Figs 83.1.1,83.1.2): Figure 83.1.1 KEY Figure 83.1.2 ~\" Stabilization ,. Patient positioning • Applicator Lying on the right side wilh a pillow to support the head and neck. The Upp€T • Plane of thrust (operator) portion of the couch is raised 10-15\" to introduce left sidebending in the lower ¢ Direction of body movement thoracic and upper lumbar spine. (patient) Experienced practitioners may choose to achieve the left sidebending wilhout raising Note: The dimensions for the arrows me upper portion of the couch. are not a pictorial representation of Lmuer hotly. Straightm the paLiem's JO\\\\'ef the amplitude or force of the thrust. (right) leg and ensure that the leg and spine an~ in a straight line. in a neutral position. l;Jex the patient's upper hip and knee 209 slightly and place the upper leg just anterior to me lower leg.. The lower leg and spine 1 should form as near a straight line as ---

HVLA thrust techniques - spine and thorax possible, with no flexion at the lower hip or 3. Positioning for thrust knee. Upper body. Cently extmd the patient's Apply your right foreaml to the region upper shoulder and place the patient's left between gluteus medius and maJcimus. foreaon on the lower ribs. Using your right Your right foreann now controls lower hand to palpatE' theTI2-L1 interspinous body rotation. Your left foreann should be resting against the patient's upper pectoral space, introduce left rotation of the patient's and rib cage region and will control upper bod)' rotatioll. First. rotate the patient's upper body down to lhe T12-Ll segmenL pelvis and lumbar spine to\\\\'3rds you until This is achieved by genll)' holding the motjon is palpated at the T12-Ll segmenL patient's right elbow wim your left hand Rotate the patient's upper body a\\\\'3}' from and pulling it towards )'OU, but also in 3 you using )'Our left ann until a sense of cephalad direction towards the head end of tension is palpated at lhe T12-Ll segment. thE' couch. Be careful nOl 10 introduce any Be careful to a\\'oid undue pressure in the flexion to lhe spine during this movement. axilla. Finally, roilihe patient about 10-1S\" Left rotation is continued unlil your to\\vards you while mailuaining the build-up palpating hand al the TI 2-Ll segment of 1E:\\'erages at lhe T12-Ll segment. begins to sense motion. Take up the axillary hold: This arm controls the upper body 4. Adjustments to achieve appropriate rotation. pre-thrust tension 2. Operator stance EmUTe your patiel1l remains relaxed. Mail1laining all holds, make an)' necessary Stand dose to the couch with your feet changes in flex.ion, extension, sidebending spread and onE' leg behind the other (Fig. or rotation until you can sense a state of B~.1.3). Maintain an upright posture, facing appropriate tension and leverage at the slightly in lhe direction of the patient's T12-Ll segment. The palient should nOt be upper body. Keep your righl ann as dose aware of any pain or discomfort. Make these to your body as possible. final adjustments by slight movemeOlS of the shoulders, trunk, ankles. kne€S and hips. 5. Immediately pre-thrust Relax and adjust your balance as necessary. Keep your head up; looking down impedes the thrust. An effective IIVI.A thrust technique is best adlieved if both the operator and patient are relaxed and not holding themselves rigid. This is a common impediment to adlieving effective cavitation. 210 6. Delivering the thrust Figure 83.13 Your left arm against the patient's pectoral region does not apply a thrust but acts as a stabilizer only. Keep the thrusting (right) arm as dose to your body as possible. Appl)' a IlVlA thrust \"\"ilh your right fo~nn against the palient's buttock. The direction of force is down towards the

lumbar and thoracolumbar spine TtIIIUST IS OOWH \"\"'.....1'DWoUIDS T*. CClUCtt wmt SlJQHt I'tLVlC Figure 83.'.4 couch accompanied by a slight exaggeration should be to use the absolute minimum of pelvic rotation towards the operator force necessary to achieve joint cavitation. A common fault arises from the use of (Fi& B3.1.4). excessive amplitude wilh insufficient The thrust, although very rapid, must velocity of lhrust. never be cxc€SSively forcible. The aim 211

HVLA thrust techniques - spine and thorax SUMMARY Thoracolumbar spine T1 O-L2 Neutral positIoning Patient side-lying Rotation gliding thrust • Patient positioning: Right side-lying with the upper portion of the couch raised 10-150 to introduce left sidebending in the lower thoracic and upper lumbar spine: Lower body. Right leg and spine in a straight line. left hip and knee flexed slightly and placed just anterior to the lower leg Upper body. Introduce left rotation of the patient's upper body until your palpating hand at T12-l1 begins to sense motion. Do not introduce any flexion to the spine during this movement. Take up the axillary hold • Operator stance: Stand close to the couch, feet spread and one leg behind the other. Maintain an upright posture, facing slightly in the direction of the palienr, upper body (Fig. 83.1.3) • Positioning for thrust: Place your right forearm in the region between gluteus medius and maximus. Rotate the patient's petvis and lumbar spine towards you until motion is palpated at the T12-l1 segment. Rotate the patient's upper body away from you until a sense of tension is palpated at the T12-L1 segment. Roll the patient about 10-150 towards you • Adjustments to achieve appropriate pre-thrust tension • Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: The direction of thrust is down towards the couch accompanied by exaggeration of pelvic rotation towards the operator (Fig. 83.1.4). Your left arm against the patient's axillary region does not apply a thrust but acts as a stabilizer only 212

Thoracolumbar spine T1 O-L2 ~ositioning Patient side-lying Rotation gliding thrust Assume somatic d).function (S-T-A-R-T) is identified and )'011 lUish to use a rotat.ion gliding thrust Lo produce cavitation at T12-L I 011 tlle lefr: KEY 1. Patient positioning .:t: Stabilization Lying on the left side with a pillO\\\\I to support the head and neck. A small pillO\\v, • Applicator or rolled lo\\'\"el. should be placed under tbe • Plane of thrust (operator) patient's \\vaisl to introduce left sidebending ..., Direaion of body movement in the thorncolumbar spine. Experienced (patient) prnaitionel'5 may choose to ad\\ievE' the left sidebending without the use or a small Note: The dimensions for the arrows pillow or rolled towel. are not a pictorial representation of Lotver bod}\" Straighten the paLient's lower the amplitude or force of the thrust (left) leg at Lhe knee joint while keeping the lefl hip flexed. Flex the patient's upper hip and knee. Rest the upper flexed knee upon 213 lhe edge of the couch. anterior 10 the left lhigh, and place lhe patient's righl fOO( behind Ihe left calf. This posilion provides slability 10 the lower body.

HVLA thrust techniques - spine and thorax Upper bod}~ Gently extend Ihe patient's 4. Adjustments to achieve appropriate pre-thrust tension upper shoulder and place the patient's right foreallTl on the lower ribs. Using your left Ensure your patient remains relaxed. hand to palpate the T12-Ll interspinous Maintaining all holds, make any necessary space, introduce right rotation of the changes in flexion, extension, sidebending patient's upper body down to the Tl2-Ll or rotation until you can sense a state of ~~nL Rotation with flexion positioning appropriate tension and leverage at the IS achIeved by gently holding the patient's Tl2-U segment. The patient should not be ~efI elbow with )'Our right hand and pulling aware of any pain or discomfOrL Make these It towards you, but also in a caudad final adjustments by slight movements of direction towards the foot end of the couch. the shoulders, trunk. ankles. knees and hips. Left rotation is continued until )'Our 5. Immediately pre-thrust palpating hand at the T12-Ll segment Relax and adjust your balance as necessary. begins to sense motion. Take up the axillary KeqJ your head up; looking down impedes hold. This ann controls the upper body the thrust. An effective I-IVLA thrust rotation. technique is best achieved if both the operator and paU€Jlt are relaxed and not 2. Operator stance holding themselves rigid. This is a common impediment to achieving effective Stand dose to the couch with your feet cavitation. spread and olle leg behind the other. Maintain an upright posture, facing slightl)' 6. Delivering the thrust in the direction of the patient's upper body. Keep )'Our left arm as dose to )'Our body as Your right ann against the patient's pectoral possible. region does not apply a thrust but acts as a stabilizer only. Keep the thrusting (left) arm 3. Positioning for thrust as dose to your body as possible. Apply a HVLA thrusl with your left forearm against Apply the palmar asped of your left forearm ~he patient's sacrum and posterior superior to the sacrum and posterior superior iliac Iliac spine. The direction of force is dO\\\\ln spine. Your left forearm 00\\\\1 controls lower tmvards the couch accompanied by slight body rotation. Your right forearm should be exaggeration of pelvic rotation towards the resting against the patient's upper pectoral operator (Fig. 83.2.1). and rib cage region and will control upper body rotaUon. First, rotate the patient's TIlt' thrust, although very rapid, must pelvis and lumbar spine towards you until never be excessively forcible. The aim motion is palpated at theTl2-Ll segment. should be to use the absolute minimum Rotate the patient's upper body away from forcE' llt'Cessary to achieve joint cavitation. you using your right arm until a sense of A common fault arises from the use of tension is palpated at the T12-LI segment. excessive amplitude wilh insufficient Be careful to avoid undue pressure in the velocity of thrust. axilla. Finally, roll the patient about 10_15° to\\\\lards you while maintaining the build-up of leverages at the T12-Ll segment. 214

Lumbar and thoracolumbar spine -----.-T....... ..... Figure 83.2.1 215

I HVLA thrust techniques - spine and thorax I • 216 SUMMARY Thoracolumbar spine Tl0-L2 Flexion positioning Patient side-lying Rotation gliding thrust • Patient positioning: Left side-lying with a small pillow or rolled towel placed under the patient's waist to introduce left sidebending in the thoracolumbar spine: Lower body. left hip flexed with knee extended. Right hip and knee flexed with patient's right foot behind the left calf Upper body. Introduce right rotation of the patient's upper body until your palpating hand at T12-L1 begins to sense motion. Introduce flexion to the spine during this movement. Take up the axillary hold • Operator stance: Stand dose to the couch, feet spread and one leg behind the other. Maintain an upright posture. facing slightly in the direction of the patient's upper body • Positioning for thrust: Place the palmar aspect of your left forearm against the patient's sacrum and posterior superior iliac spine. Rotate the patient's pelvis and lumbar spine towards you until motion is palpated at the T12-L1 segment. Rotate the patient's upper body away from you until a sense of tension is palpated at the T12-L1 segment. Roll the patient about 10-15° towards you • Adjustments to achieve appropriate pre-thrust tension • Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: The direction of thrust is down towards the couch accompanied by exaggeration of pelvic rotation towards the operator (Fig. 83.2.1). Your right arm against the patient's axillary region does not apply a thrust but acts as a stabilizer only

Lumbar spine L1-5 Neutral positioning Patient side-lying Rotation gliding thrust Assume somatic dysfullction (5-TAR-T) is idelltified alld 1\"'\" wis\" to use II rottltion gliding thrust CO produce cavililliol1 at 13-4 011 tile righl (Figs 83.3.1, 83.3.2): Figure 83.3.1 Figure 83.3.2 KEY .:+: Stabilization ,. Patient positioning I217 • Applicator Lying on the left side with a pillow 10 support the head and neck .. Plane of thrust (operator) Lower bodJ~ Straighten the paliclll's lower leg and ensure that the leg and spine are in ¢ Direction of body movement a straight line. in a neutral position. Flex the (patient) patient's upper hip and knee slightly and place the upper leg just anterior to the lower Note: The dimensions for the arrows leg. The Imver leg and spine should form as are not a pictorial representation of near a straight line as possible. with no the am~itude or force of the thrust. flexion at the lower hip or knee. -~------~ Upper bod)'. Cently extend the pauent's upper shoulder and place the patient's right foreann on the lower ribs. Using your left hand to palpate the L3-4 inleJSpinous

HVLA thrust techniques - spine and thorax Figure 83.3.3 space. introduce right rotation of the patient's upper body down to the L3-4 segment. This is achie\\u1 by gently holding the patient'S left elbow with your right hand and pulJing it towards you, but also in a cephalad direction towards the head end of the couch (Fig. U3.3.3). Be: careful not to introduce any nexion to the spine during this movement. Right rotation is continued until your palpating hand at the 1..3-4 segment begins to sense motion. Take up the axillary hold. This arm controls the upper body rotation. 2. Operator stance Stand dose 10 the coud, with your feet spread \"nd one leg behind the ot.her (J:ig. 1\\3.3.4). Maintain an upright posture. facing slightly in the direction of t.he patient's upper body. Keep your left aml as dose to your body as possible. 3. Positioning for thrust Apply your left forearm to the region Figure 83.3.4 between gluteus medius and maximus. Your left forearm now controls lower body rotation. Your right forearm should be 218 resting against the patient's upper pCCloral and rib cage region and will control upper

lumbar and thoracolumbar spine body rotation. First, rotate the patient's the thrust. An effective HVlA thrust pelvis and lumbar spine towards you umil technique is best achieved if both the motion is palpated at thE' 1.3-4 segmenL operator and paLient are relaxed and not Rotate the paLient's upper body 41.\\'13)' from holding themselves rigid. This is a common you using your right arm until a sense of impediment to achieving effectiw tension is palpated at the 1.3-4 segment. Be cavitaLion. careful to avoid undue pressure in the axilla. Finally, roll the patient about 10_15 0 6. Delivering the thrust towards you while maintaining the build-up of leverages at the 13-4 segment. Your right ann against the patient's pectoral region does not apply a thrust but aas as a 4. Adjustments to achieve appropriate stabilizer only. Keep the thrusting (left) ann pre-thrust tension as dose to your body as possible. Apply a HVLA. thrust with your left foreann against Ensure your patient remains relaxed. the patient's bUllOCk. The direction of force Maintaining all holds. make any necessary is down to\\vards the couch accompanied changes in flexion, extension, sidebending by slight exaggeration of pelvic rotaLion or rotation until you can sense a state of towards the operator (Fig. B3.3.5). appropriate tension and 1C\\'E':rage at the 1.3-4 segment. The patient should not be The thrust. although vel)' rapid, must aware of any pain or discomfon. Make these never be excessively forcible. The aim final adjustments by slight movements of should be to use the absolute minimum the shoulders. trunk, ankles, knees and hips_ force necessary to achieve joint cavitation. A common fault arises from the use of 5. Immediately pre-thrust excessive amplitude with insufficient velocity or thrust. Relax and adjust your balance: as necessary. Keep your head up; looking down impedes Figure 833.5 219

HVlA thrust techniques - spine and thorax SUMMARY Lumbar spine L1-5 Neutral positIoning Patient side-lying Rotation gliding thrust • Patient positioning: left side-lying: Lower body. left leg and spine in a straight line. Right hip and knee flexed slightly and placed just anterior to the lower leg Upper body. Introcluce right rotation of the patient's upper body until your palpating hand at l3-4 begins to sense motion. Do not introduce any flexion to the spine during this movement (Fig. 833.3). Take up the axillary hold • Operator stance: Stand dose to the couch, feet spread and one leg behind the other. Maintain an upright posture, facing slightly in the direction of the palienf, upper body (Fig_ 83.3.4) • Positioning for thrust Place your left foreann in the region between gluteus medius and maxim us. Rotate the patient's pelvis and lumbar spine towards you until motion is palpated at the l3-4 segment Rotate the patient's upper body away from you until a sense of tension is palpated at the l3-4 segment. Roll the patient about 1~15° towards you • Adjustments to achieve appropriate pre-thrust tension • Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: The direction of thrust is down towards the couch accompanied by exaggeration of pelvic rotation towards the operator (Fig. 83.3.5). Your right arm against the patient's axillary region does not apply a thrust but acts as a stabilizer only 220

Lumbar spine L1-5 Flexion positioning Patient side-lying Rotation gliding thrust Assume somatic dysfunction (S-T-A-R-T) is identified and )00 wisll W use a rotation gliding thrust to produce cavitation at 13-4 on the right: KEY 1. Patient positioning *:- Stabilization Lying on the left side wilh a pillow to suppon the head and neck. A small pillow. • Applicator or rolled lowel, should be placed under the patient's waist to introduce left sidebending • Plane of thrust (operator) in the lumbar spine. Experienced practitioners may d100se 10 adlievc the left <> Direction of body movement sidebending without the use of a small pillow or rolJed lowel. (patient) Lower bod)'. Straighten the patient's lower (left) leg at the knee joim while keeping the Note: The dimensions for the arrows left hip flexed. Hex the patient's upper hip are not a pictorial representation of and knee. Resl the upper flexed kntt upon the amplitude or force of the thrust. the edge of the couch, anterior to the left thigh, and place the patient's right foot behind the left cal( This position provides 221 stability 10 the lower body. _ _ _ _ _ _ _ _1

HVlA thrust techniques - spine and thorax Figure 83.4.1 upper bod}~ Gently extend the patient's upper shoulder and place the patient's right forearm 011 the 100ver ribs. Using your left hand to paJpate the 1.3-4 interspinous space, introduce right rotation of the palient's upper body down lO the 13-4 segment. Rotation with flexion positioning is achieved by gently holding the patient's left elbow with your righl hand and pulling it towards you, but also in a caudad direction to\\-r.lrds the fOOL end of the couch (Fig. 83.4.1). Right rolation is continued until your palpating hand al the 1.3-4 segment begins to sense mOlion. Take up lhe axillary hold. This arm conlrols the upper body rolalion. 2. Operator stance Stand dose to lhe couch with your feet Figure 83.4.2 spread and one leg behind !.he olher (118- 1\\3.4.2). Maintain an upright posture. facing slighlly in the direction of the patient's upper body. Keep your left arm as dose lO your body as possible. 3. Positioning for thrust Apply your left forearm to the region between gluteus medius and maximus. 222 Your left forearm now controls 10wCT body rolation. Your right foreann should be

lumbar and thoracolumbar spine resting against the patient's upper pectoral the thrust. An effective HVLA thrust and rib cage region and will control upper technique is oot achieved ifboth the body rotation. First, rotate the patient's operator and patient are relaxed and not pelvis and lumbar spine to\\Yards you unlil holding themselves rigid. This is a common motion is palpated at the 13-4 segment. impediment to achieving effective Rotate the patient's upper body away from cavitation. you using your right arm until a sense of tension is paJpated at the L3-4 segment. 6. Delivering the thrust Be careful to avoid undue pressure in the axilla. Finally, roll the patient about 10_15 0 Your right arm against the patient's pectoral to\\vards you while maintaining the build-up region does not apply a thrust but aas as a of leverages at the L3-4 seg.menL stabilizer only. Keep the thrusting (left) arm as dose to your body as possible. Apply a 4. Adjustments to achieve appropriate J-1VLA thrust with your left forearm against pre-thrust tension the patient's buttock. The direction of force is dovm towards the couch accompanied Ensure your patient remains relaxed. by a slight exaggeration of pelvic rotation Maimaining all holds, make any necessary towards the operator (Fig. B3.4.3). changes in flexion, extension, sidebending or rotation until you can sense a state of The thrust. although very rapid must appropriate tension and leverage at the never be excessively forcible. The aim 13-4 segment. The patient should not be should be to use the absolute minimum a\\Yare of any pain or discomfort. Make these force necessary to achieve joint cavitation. final adjustments by slight movements of A common fault arises from the use. of excessive amplitude with insufficient the shoulders, I.IUnk. ankles. knees and hips. velocity of thrusL S.lmmediatefy pre-thrust Relax and adjust your balance as necessary. Keep your head up; looking down impedes Figure 83.43 223

HVLA thrust techniques - spine and thorax SUMMARY Lumbar spine L1-5 Flexion positioning Patient side-lying Rotation gliding thrust • Patient positioning: Left side-lying with a small pillow or rolled towel placed under the patient's waist to introduce left sidebending in the lumbar spine: Lower txxty. left hip flexed with knee extended. Right hip and knee flexed with the patient's right foot behind the left calf Upper body. Introduce right rotation of the patient's upper body until your palpating hand at L3-4 begins to sense motion. Introduce flexion to the spine during this movement (Ftg. 83.4.1). Take up the aXillary hold • Operator stance: Stand close to the couch, feet spread and one leg behind the other. Maintain an upright posture. facing slightly in the direction of the patienr, upper body (Fig. 83.4.2) Positioning for thrust: Place your left forearm in the region between gluteus medius and maximus. Rotate the patient's pelvis and lumbar spine towards you until motion is palpated at the L3-4 segment Rotate the patient's upper body away from you until a sense of tension is palpated at the L3-4 segment Roll the patient about 10-15\" towards you • Adjustments to achieve appropriate pre-thnast tension • Immediately pre-thnast Relax and adjust your balance • Delivering the thrust: The direction of thrust is down towards the couch accompanied by exaggeration of pelvic rotation towards the operator (Fig. 83.4.3). Your right arm against the patient's axillary region does not apply a thrust but acts as a stabilizer only 22.

Lumbar spine L1-5 Neutral positioning Patient sitting Rotation gliding th,ust Assullle ,olllolic dy<funaion (5-T-A-R-T) is idenlified ond you wish 10 use a rotation gliding thrust w produce caviun;on at 13-4 on the left: KEY 1. Patient positioning -$ Stabilization Sitting on the treatment couch with the arms folded. The patient should be • Applicator encouraged to maintain an erect posture. - Plane of thrust (operator) 2. Operator stance <> Direction of body movement Stand behind and slightly to the right of the patient with your feet spread. Pass your (patient) right ann across !.he front of the patienl's chest to lightly grip the patient's left thorax Note: The dimensions for the arrows (I'tg. B3.5.1). are not a pictorial representation of the amplitude or force of the thrust 3. Positioning for thrust Place your left hypothenar eminence to the 225 right side of the spinous process of L3 and

HVlA thrust techniques - spine and thorax Figure 83.5.1 Ftgure 83.5.2 introduce right sidebending to the: patient's 5. Immediately pre-thrust thoraac and upper lumbar spine (Fig. H3.5.2). The thoracic and upper lumbar Relax and adjust your balance as necessary. spine is now rotated to the right to lock the An effective HVLA thrust t«hnique is best spine down to but not including L3. The achiE:\\cl if both thc operator and paticlll operator maintains as erect a posture as are relaxed and not holding themselves possible. Keep your left hypothenar rigid. TIlis is a common impediment to eminence firmly applied to the spinous achieving effective cavitation. process of L3 with your left arm held close to your body. 6. Delivering the thrust 4. Adjustments to achieve appropriate A degree of momentum is n«cssary to pre-thrust tension achieve a successful cavitation. It is desirable for the momentum component of the thrust Ensure your paticnt remains relaxed. to be restricted to one plane of motion and Maintaining all holds, make any necessary this should be rotation. Rock the patient changes in flexion, extension, sidebending into and out of rotation while maintaining or rotation until you can sense a state of the sidebe.nding and flexion/extension appropriate tCl1Sion and leverage at the: positioning. When dose to full rotation. 1.3-4 segmcnt. The patient should not be you will sense a state of appropriate tension a\\va.re of any pain or discomfort- Make these and leverage at the 1.3-4 segment, at which 226 final adjustments by slight movements of poilll you apply a HVLA thrust against the the shoulders. trunk. ankles, knees and hips. spinous process of L3. Thc thrust is directed

lumbar and thoracolumbar spine to the spinous process of L3 aJld accompanied by a slight exaggeration of right rotation (Fig. B3.5.3). 1be thrust, although \\'el)' rapid. must never be excessi~ly forable. The aim should be to ust' the absolute minimum force necessal)' to achieve joint cavitation. A common fault arises from the use of excessive amplitude with insuffident velocity of thlU'it. Figure 835.3 227

HVLA thrust techniques - spine and thorax SUMMARY Lumbar spine L1-5 Neutral positioning Patient sitting Rotation gliding thrust • Patient positioning: Sitting erect • Operator stance: Behind and slightly to the right of the patient with your right arm across the front of the patient's chest (Fig. 835.1) • Positioning for thrust: Place your left hypothenar eminence to the right side of the spinous process of l3 and introduce right sidebending to the patient's thoracic and upper lumbar spine (Fig. 83.5.2). The thoracic and upper lumbar spine is now rotated to the right to kx:k the spine down to but not including l3 • Adjustments to achieve appropriate pre-thrust tension • Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: The thrust is directed to the spinous process of L3 and accompanied by exaggeration of right rotation (Fig. 83.5.3). A degree of momentum is necessary to achieve a successful cavitaUon. The momentum component of the thrust should be in the direction of rotation 228

Lumbosacral joint (LS-Sl) Neutral positioning Patient side-lying Thrust direction is dependent upon apophysial joint plane' Assume somatic d)'s/unction (S-T-A-R-T) is identified aPld you uris11 to D,J use a gliding thmst lO produce cavitntion at 15-51 on the right (Figs v-' \" i '8 3 . 6 . 1 , 8 3 . 6 . 2 ) : <, Figure 83.6.1 Figure 83.6.2 KEY 1. Patient positioning W' Stabilization Lying on th~ left side with a pillow to • Applicator support the head and neck. Lower body. Straighten the patient's lower - Plane of thrust (operator) (left) leg at the knee joint while placing the 1:) Direction of body movement 'The condition where joints are asymmetrically (patient) orientated is referred to as articular tropism. The Note: The dimensions for the arrows lumbosacral zygapophyslal joints would are not a pictorial representation of normally be orientated at approximately 45· the amplitude or force of the thrust with respect to the sagittal plane. There is considerable individual variation and you will encounter patients wilh lumbosacral apophysial joint planes that range between sagittal and coronal orientation. The variation in apOphysial joint plane means that considerable palpatory skill is required to localize forces accurately at the lumbosacral joint and to determine the most suitable direction d thrust

HVLA thrust techniques - spine and thorax Maintain an upright posture. fadng slightly in the direction of the patient's upper body. Keep your left arm as close to }'our body as possible. 3. Positioning for thrust Figure 83.6.3 Apply your left forearm 10 the region bt'twn~n gluteus medius and maximus. Your left forearm nO\\\\I controls 100\\lef body rotation. Your right foreann rests on the patient's right axillary area. This will control upper body rotation. First, appl}' pressure to the patient's pelvis until motion is palpated at the IS-SI segment. Relate the patient's upper body away from }\"1)u using }\"1)ur right ann until a sense of tension is palpated at the IS-SI segment. Finally, roll the patient aboul 10-15· towards you while maintaining the build~upof IC\\~ at the 15-5lsegmenL 4. Adjustments to achieve appropriate pre-thrust tension left hip in approximately 20° of flexion. Ensure your patient remains relaxed. Flex the patient's upper knee and place the Maintaining all holds. make any neCl'SSary patient's right foot behind the left lower leg changes in flexion, ext~nsion, sidebending (Fig. B3.6.3). This position provides stability or rotation until }UlI can sense a state of to Ihe lower body. appropriate tension aJld k\"\\~rage at the Upper !JOtI,.. Gently extend the patient's L5-S1 segment. The patient should not be uppe.r shoulder and place the patient's right aware of any pain or discomfort. Make these forearm on the lower ribs. Using your left final adjustments by slight movements of hand to palpate lhe 15-S I interspinous the should~rs. trunk. ankles. knees and hips. space, introduce right rotation of the patient's upper body down to the 15-S1 5. Immediately pre-thrust segment. This is achieved by gently holding the patient's left elbow with your right hand Relax and adjust your balance as necessary. and pulling it towards you, but also in a Keep your head up; looking down impedes cephalad direction towards the head end of the thrust. An effenive IIVlJ\\ thrust the couch. Be careful not to introduce any technique is best achieved if both the flexion to the spine during this movement. operator and patient are relaxed and not Right rotation is continued until your holding themselves rigid. This is a common palpating hand at the 15-S1 segment begins impediment to achieving effective to sense motion. 'rake up the axilIaI)' hold. cavitation. This arm controls the upper body rotation. 6. Delivering the thrust 2. Operator stance Your right arm against the pati~nt's axillary region does not apply a thrust but acts 230 Stand close to the couch with your fcd as a stabili7..er on I}' (Fig. 83.6.4). Keep the spread and one leg behind the other. thrusting (left) arm as dose to your bod}' as

lumbar and thoracolumbar spine Figure 83.6.5 Figure 83.6.4 possible. Apply a IIVLA thrust with )'OUr left forearm against the patienl's bUllOCk. lhe: direction of lhrust is variabl~ depending on the apoph)'Sial joint plane. Common!)' the dired.ion of thrusl approximates to a line along the long axis of the palient's right femur (Fig. 83.6.5). The thrust, allhougb \\~ry rapid, must never be exce:ssi\\~ly fordble. ·'he aim should be 10 use the absolute minimum force necessary to achieve joinl cavitation. A common fault arises from lhe use of excessive amplitude: with insufficient velocity of thrust. 231

HVLA thrust techniques - spine and thorax SUMMARY Lumbosacral Joint (L5-S1) Neutral posItIoning Patient side--Iying Thrust direction is dependent upon apophysial joint plane • Patient positioning: Left side-lying: Lower body. Left hip in approximately 200 of flexion with knee extended. Right hip and knee flexed (Fig. 83.6.3) Upper body. Introduce right rotation of the patient's upper body until your palpating hand at the l5-S1 segment begins to sense motion. Do not introduce any flexion to the spine during this movement. Take up the axillary hold • Operator stance: Stand close to the couch, feet spread and one leg behind the other. Maintain an upright posture, facing slightly in the direction of the patient's upper body • Positioning for thrust: Place your left forearm in the region between gluteus medius and maximus. Apply pressure to the patient's pelvis until motion is palpated at the l5-S1 segment. Rotate the patient's upper body away from you until a sense of tension is palpated at the L5-S1 segment. Roll the patient about 10-15° towards you • Adjustments to achieve appropriate pr~thrusttension • Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: Your right arm against the patient's axillary region does not apply a thrust but acts as a stabilizer only (Fig. 83.6.4). The direction of thrust is variable depending on the apophysial joint plane. Commonly the thrust is along the long axis of the patient's right femur (Fig. 83.6.5) , \" 232

~~\"\"\" (~..__ ((.t.f_-iILd lief v r r \"V'.. Lumbosacral'joint (LS-Sl) Flexion positioning Patient side-lying Thrust direction is dependent upon apophysial joint plane' Assume somatic dysfunction (S-T-A-R-T) is identified and you wish to use a gliding thrust to produce cavilati01l at l5-S1 on the right: \"' 1. Patient positioning *~ Stabilization Lying on the left side with a pillow 10 • Applicator support the head and neck. tower bod)\\ Straigtucn the patient's low'cr - Plane of thrust (operator) (left) Iq; at the knee join! while placing the c:> Direction of body movement left hip in approximately 20° of flexion. (patient) trhe condition where joints are asymmetricalty orientated is referred to as articular tropism. The Note: The dimensions for the arrows lumbosacral zygapophysial joints would are not a pictorial representation of normally be orientated at approximatety 45\" the amplitude or force of the thrust. wIth respect to the sagittal plane. There is considerable Individual variation and you will enCOU'ltef patients with lumbosacral apophysial 233 joint planes that range between sagittal and coronal orientation. The variation [n apophysial joint plane means that considerable palpatory skill is required to localize forces accurately al the lumbosacral joint and to determine the most suitable directtcm of thrust

HVLA thrust techniques - spine and thorax \"'ex the patient's upper knee and place: the patient's right foot behind the left lower leg (Pig. B3.7.1). 'Illis position provid€S stability to the lower body. Upper lJOd)'. Gently extend the patient's upper shoulder and place: the patient's right fore..1rm on the lower ribs. Using your left hand to palpate the LS-51 inteTSpinous space. introduce right rotation of the patient's upper body down to the l5-S1 segmenL Rotation with flexion JX>Sitioning is achieved by gently balding the patient's left eltxn\\l with )'OUr right hand and pulling it towards yOU, but also in a caudad direction towards the foot end of the couch. Right rotation is continued until your palpating hand at the 15-51 segment begins to sense motion. Take up the axillary hold. This ann controls the upper body rotation. 2. Operator stance 5tand close to the couch with )'Our feet spread and one leg behind the other. Maintain an upright JX>Sture, faong slightly Figure 83.7.1 in the direction of the patient's upper body. Keep your left arm as dose to your Ixxly as possible. 4. Adjustments to achieve appropriate pre-thrust tension 3. Positioning for thrust Ensure your patient remains relaxed. Apply your left fort'<1rm to the region Maintaining all bolds. make any necessary between gluteus medius and rnaximus. changes in flexion, extension, sidebending Your left forearm now controls lower body or rotation until you 0111 sense a state of rotalion. Your right fort..':I.rm rests on the appropriate tension and leverage at the patient's right tlxillary area. This will control 15-51 segment. The patient should not be upper body rotation. first, apply pressure to aware of any pain or discomfort. Make these the patient's pelvis until motion is palpated final adjustments by slight movements of <U the 1.5-51 segment. Introduce left the shoulders, trunk, ankles, knees and hips. sidebending to lumbar spine by applying 5. Immediately pre-thrust pressure with the left forearm to the patient's pc.lvis in a caudad direction (Fig. Relax and adjust )'Our balance as necessary. 33.7.2). Now rotate the patient's upper Keep )'Our head up; looking down impedes body away from you using )'Our right ann the thrust. An effective IIVl..A lhrust until a sense of tension is palpated at the technique is best achieved if both Lhe 1.5-51 segment. Finally, roll the patient operator and patient are relaxed and not about 10_15 0 towards you while holding themselves rigid. This is a common 234 maintaining the build-up of 1C\\'eT38€S at impediment to achieving effective the 15-51 segment. cavitation.

.Lumbar and thoracolumbar spine 3.7 Figure 83.7.2 6. Delivering the thrust Figure 83.7.3 Your right arm against the patient's axillary region does not apply a thrust but aos as a stabili7h only. Keep the thrusting (left) ann as dose to your body as possible and main!ain the left lumbar sidebending leverage. Apply a IIVU\\ thrust \\\"';'th )'our left forearm against the patient's buttock. The direction of thrust is variable depending on the apophysial join! plane. Commonly the direoion of thrust approximates to a line along the long axis of the patient's right femur (Pig. 83.7.3). The thrust, although very rapid. must nevt:r be excessively forcible. The aim should be to use the absolute minimwn of force necessary to achieve joint cavitation. A common fault arises from the use of excessive amplitude with insufficient velocity of thl1.1st. 235

HVLA thrust techniques - spine and thorax SUMMARY lumbosacral Joint (l5-S1) Flexion positioning Patient side-lying Thrust direction is dependent upon apophysial joint plane • Patient positioning: Left side-lying: Lower body. Left hip in approximately 20\" of flexion with knee extended. Right hip and knee flexed (Fig. 83.7.1) Upper body. Introduce right rotation of the patient's upper body until your palpating hand at the l5-S1 segment begins to sense motion. Introduce flexion to the spine during this movement. Take up the axillary hold • Operator stance: Stand close to the couch, feet spread and one leg behind the other. Maintain an upright posture, facing slightly in the direction of the patient's upper body • Positioning for thrust: Place your left forearm in the region between gluteus medius and maxim us. Apply pressure to the patient's pelvis until motion is palpated at the L5-S1 segment. Sidebend the lumbar spine to the left (Fig. 83.7.2) and then rotate the patient's upper body away from you until a sense of tension is palpated at the l5-S1 segment. Roll the patient about 10-150 towards you • Adjustments to achieve appropriate pre-thrust tension • Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: Your right arm against the patient's axillary region does not apply a thrust but acts as a stabilizer only. It is critical to maintain left lumbar sidebending when delivering the thrust. The direction of thrust is variable depending on the apophysial joint plane. Commonly the thrust is along the long axis of the patient's right femur (Fig. 83.7.3) 236

HVLA thrust PAKr techniques - pelvis Saaoillac joint: left innominate posterior. patient prone; ligamentous myofascial tension locking 239 2 Sacroillacjoint: right innominate posterior; patient side-lying 243 3 Sacroiliac joint: left innominate anterior; patient supine 247 4 Saaoiliac joint: sacral base anterior; patient side-lying 251 5 Sacrococcygeal joint: coccyx anterior; patient skte-lying 255 References 259 Introduction Mobility alters with age and can increase during pregnancy. The sacroiliac joint as a source of pain and dysfunction is a subject of controversy.'-6 A number of manual medicine t~ * refer Many authors implicate the sacroiliac joint as a possibfe cause of low back pain,6-16 but to the use of high-velc:x:ity low-amplitude there is disagreement as to the exact (HVlA) thrust technkjues to the joints of the prevalence of sacroiliac: joint pain within the peMs, but there is little evidence that low back pain population. While many cavitation is uniformly assoc.iated with these practitioners believe the sacroiliac joint is a procedures. When an audible release does source of pain and dysfunction and treat occur, its site of origin remains open to perceived sacroiliac lesions. there is no speculation. Studies undertaken to measure general agreement concerning the different the effects of manipulation upon the diagnostic tests and theIr validity in sacroiliac joints provide contradictory determining somatic dysfunctton of the findings. Roentgen stereophotogrammetric pehlis.I6-29 analysis was unable to detect altered position of the sacroiliac joint post- Various models of sacroiliac motion have manipulatK>n despite normalization of been proposed and there have been a different types of clinical tests.\"r However, number of studies relating to mobility in the an alteration in petvic tilt was identified sacroiliacjoint,lO-J7 but the precise nature of post-manipulation in one study of patients nonnal motion remains unclear.l..us There with low back pain48 and a further study is significant variation in sacroiliac joint demonstrated an immediate improvement in movement between individuals and within iliac crest symmetry immediately after individuals when mobility of one sacroiliac manipulation.4\\! joint is compared with the other side.14

HVlA thrust techniques - pelvis Sacroiliac region manipulation has been Part C describes in detail five HVlA thrust demonstrated to provide significant short· techniques for the pelvis. All techniques are term symptomatic and functional described using a variable-height improvement in a subgroup of patients manipulation couch. presenting wnh low back pain.§O A clinical prediction rule with five variables - symptom After making a diagnosis of somatic location. symptom duration. lumbar spine dysfunction and prior to proceeding with a thrust. it is recommended the following hypomobility, fear avoidance beliefs and checklist be used for each of the techniques range of hip internal rotation - was described in this section: developedso and subsequently validatedS1 to identify those patients most likety to respond • Have I excluded all contraindic.ations? favourably to sacroiliac region manipulation. • Have I ex~ained to the patient what I am Many practitioners believe that t-M..A thrust going to do? techniques applied to the sacroiliac joint can • Do I have informed consent? be associated with good dinical outcomes. As • Is the patient well positioned and a result many clinicians continue to use HVI..A thrust techniques to treat somatic dysfunction comfortabte? of the joints of the pelvis. • Am I in a comfortable and balanced Somatic dysfunction is identifted by the position? S-T-A~R·T of diagnosis: • Do I need to modify any pre-thrust physical • 5 relates to symptom reproduction or btomechanical factors? • T relates to tissue tenderness • Have I achieved appropriate pre-thrust • A relates to asymmetry • R relates to range of motion tissue tension? • T relates to tissue texture changes • Am I relaxed and confident to proceed? • Is the patienl relaxed and willing for me to proceed? 238

Sacroiliac joint Left innominate posterior Patient prone Ligamentous myofascial tension locking Assume somatic dj~function (S-T-A-R-T) is identified and )'ou wish to thrust the left imlOmiunt£ anteriorly: 1. Contact points 3. Patient positioning (a) Left posterior superior iliac spine (PSIS) (b) Anterior aspeCl of left lower thigh. Patient lying prone in a comfonable 2. Applicators position. (a) Ilypothenar eminence of right hand (b) Palmar aspect of left hand. 4. Operator stance KEY Stand at lhe right side of the patient.. feet spre3d slightly and facing the palienL Stand oJ!: Stabilization as erect as possible and avoid crouching as this will limit the technique and restrict • Applicator delivery of the thrusL - Plane of thrust (operator) 5. Palpation of contad points <> Direction of body movement Place the hypothenar eminence of ),our right hand against the inferior aspect of the left (patient) PSIS. Ensure that you have good contact and will not slip across the skin or superficiaJ Note: The dimensions (Of the arrows musculature. Place the palmar aspect of are not a pictOfial rept\"esentation of your left hand gently under the anterior the amplitude or force of the thrust. aspect of the left thigh just proximal to the knee. 239 6. Positioning for thrust Uft the patient's left leg into extension and slight adduction (fig. Cl.I). Avoid introducing extension into the lumbar spine. Apply a force directed downwards towards the (ouch and slightly cephalad to fix )'our right hand against the inferior aspect of the PSIS.

HVLA thrust techniques - pelvis direaion of pressure applied to the PSIS until applicator forces are balanced and you sense a state of appropriate tension and leverage at the left sacroiliac joint. 'llle patient should not be aware of any pain or discomfon. Make these final adjUSlments by slight movements of the shoulders. trunk.. ankles. knres and hips. 8. Immediately p~thrust Helax and adjust )'Our balance as necessary. Keep your head up and ensure that )'Our contacts are finn. An effeaive HVLA thrust technique is best achieved if the operator and patient are relaxed and not holding themselves rigid. 'Ibis is a common impediment 10 achieving effective cavilation. Figure C.l.l 9. Delivering the thrust Move )'Our centre of gravity O\\'tt the T'hu teclmilfue uses ligamentous m)'oflUCitll patient by leaning your body weight tetlSion locking and not fnat nppositibn locking. rorwards ontO }'Our right ann and 'f1Jis approach generally reqllim a grmler hypothenar eminence. Shifting your centre emphasis 01'1 the emggenuiotl of primary or gravity rorwards assists firm (Ontao point levrrage dlQn i.s die case Willi facer. apposilion pressure on the PSIS. locking lechniques.. 7. Adjustments to achieve appropriate Apply a I rvl.A thrust with }'Our right pre-thrust tension hand direoed against the PSIS in a curved Ensure your patient remains relaxed. plane towards the couch. Simultaneously, Mai ntaining all holds. make any necessary apply slight exagger.uion of hip extension changes in hip extension, adduction and with your left hand (Fig. C.I.2). It is rOtation. Simultaneously, adjust the imponanl that you do not overemphasize hip extension at the time of thrust. 'Ibe aim of this technique is to achieve anterior rotation of the left innominate and movement al Ihe left sacroiliac joint. 'Ihe direction of thrust will alter between patients as a result of the wide variation in sacroiliac anatomy and biomechanics. 'llle thrust, although veJ}' rapid, must never be excessi\\rety forcible. 'llle aim should be to use the absolute minimum force necessary, 240

Sacroiliac joint left innominate posterior Figure C.1.2 241

HVLA thrust techniques - pelvis SUMMARY Sacroiliac joint Left innomInate posterior Patient prone Thrust anteriorly Ligamentous myofascial tension locking • Contact points: -Left posterior superior iliac spine (PSIS) -Anterior aspect of left lower thigh • Applicators: -Hypothenar eminence of right hand -Palmar aspect of left hand • Patient positioning: Prone in a comfortable position • Operator stance: To right side of patient, facing the couch • Palpation of contact points: Place the hypothenar eminence of your right hand against the inferior aspect of the left PSIS. Place the palmar aspect of your left hand under the anterior aspect of the left thigh proximal to the knee • Positioning for thrust: Lift left leg into extension and slight adduction (Fig. Cl.1). Avoid introducing extension into the lumbar spine. Apply a force directed downwards towards the couch and slightly cephalad to fix your right hand against the inferior aspect of the PSIS • Adjustments to achieve appropriate pr~thrusttension: Make any necessary changes in hip extension, adduction and rotation. Simultaneously, adjust the direction of pressure applied to the PSIS • Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: The thrust against the PSIS is in a curved plane towards the couch and accompanied by slight exaggeration of hip extension (Fig. C.1.2) 242

Sacroiliac joint Right innominate posterior Patient side-lying Assume somatic dysfunction (5-T-A-R-T) is identified and yvu wish 10 thrust the light innominate anteriorly: 1. Patient positioning 90\". Flex the palielll's upper knee and place Lying on the Jeft side with a pillow to the heel of the fOOL just anterior to the support the head and neck. '[he upper knee of the lower leg. In.e lower leg and portion of the couch is raised 30_35 0 to spine should form as near a straight line as inuoduce right sidebending in the lower possible with no flexion at the lower hip thoracic and upper lumbar spine. or knee. Lotver bod)~ Straighten the patient's !O\\\\'er Upper body. Gently extend the patient's leg and ensure that the leg and spine are upper shoulder and place the patient's right in a straight line. in a neutral position. \"'ex foreann on the lower ribs. Using your left the patient's upper hip to approximately hand to paJpate the 1.5-S1 interspinous space, introduce riglll rotation of the KEY patient's trunk. dm...n to and including the lS-S I segment. This is achieved by gently ->f'\" Stabilization holding the patient's left elbow with your right hand and pulling it 10\\.,,-ards you, but • Applicator also in a cephalad direction towards the head end of the couch. Be careful not 10 • Plane of thrust (operator) inlroduce any nexioo to the spine during this movement Now modify the peCloral ¢ Direction of body movement hold by positioning the patient's upper (patient) afm behind the thorax. Note: The dimensions for the arrows 2. Operator stance are not a pictorial representation of the amplitude or force of the thrust Stand dose to the couch with your feet spread and one leg behind the other. Ensure that the patielll's upper knee is placed 243 between your legs. This will enable you to make the necessary adjustments to achieve the appropriate pre-thrust tension (Fig. C.2.l). Mailllain an upright posture. facing in the direaion of the patient's upper body.

HVlA thrust techniques - pelvis Figure C~l 3. Positioning for thrust S. Immediately pre-thrust Apply the h«1 of )'Our left hand to the Relax and adjust your balance as necessary. inferior asped of the posterior superior Keep your head up and ensure your contacts iliac spine (PSI ). Your right hand should are firm. An effective IIVLA thrust technique be resting agaima the patient's upper is best achieved if the operator and patient pectoral and rib cage region_ Cently rotate are relaxed and not holding lhemsel\\'U the patient's trunk away from you using rigid. This is a common impediment to your right hand until you achieve spinal achieving effective cavitation. locking. Avoid applying direct pres,'mre to 6. Delivering the thrust the glenohumeral joint. Finally, roll the patielll aboul 10_15° towards you \\\"hile Apply a IIVLA. thrust with the heel of )'Our maintaining the build-up of leverages. left hand directed against the PSIS in a 4, Adjustments to achieve appropriate curved plane towards you (rig. C.2.2). Your pre-thrust tension righl aml against the patient's pectoral region does not apply it thrust but acts as Ensure )'Our palient remains relaxed. a stabilizer only. '111e aim of this technique Maimaining all holds, make any necessary is to achieve alllelior rotation of the right changes in hip flexion and adduction. innominate and movement at the right Simuhaneously, adjust the direction of sacroiliac joint. '111e direction of thrust will pressure applied to the PSIS Wltil the forces alter between patients as a result of the \\\\'ide are balanced and you sense a state of variation in sacroiliac anatomy and appropriate tension and leverage at the right biomechanics. sacroiliac joint. The patient should not be 'l11e thrust, although very rapid. must aware of any pain or discomforL Make these never be excessively forcible. -111e aim 244 final adjuStmenlS by slight movements of should be to use the absolute minimum the shoulders,. trunk,. ankles. knees and hips. force necessary.

- .- . - Sacroiliac joint Right innominate posterior 2 Figure (.2.2 245

HVLA thrust techniques - pelvis SUMMARY Sacroiliac joint Right innominate posten or Patient side-lying Thrust anteriorly • Patient positioning: left side-lying with the upper portion of the couch raised 30-350 to introduce right sidebending in the lower thoracic and upper lumbar spine: Lower body. left leg and spine in a straight line. Right hip flexed to approximately 90\". Right knee flexed and heel of right foot placed just anterior to knee of lower leg Upper body. Introduce right rotation of the patient's upper body down to and including lS-Sl. Do not introduce any flexion to the spine during this movement. Modify the pectoral hold by positioning the patient's upper arm behind the thorax • Operator stance: Stand close to the couch, feet spread and one leg behind the other. Ensure that the patient's upper knee is placed between your legs (Fig. C2.1). Maintain an upright posture facing in the direction of the patient's upper body • Positioning for thrust: Apply the heel of your left hand to the inferior aspect of the PSIS. Rotate the patient's upper body away from you until spinallocldng is achieved. Roll the patient about 10-1So towards you • Adjustments to achieve appropriate pre-thrust tension: Make any necessary changes in hip flexion and adduction. Simultaneously, adjust direction of pressure applied to the PSIS • Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: The thrust against the PSIS is in a curved plane towards you (Fig. C2.2). Your right arm against the patient's pectoral region does not apply a thrust but aet5 as a stabilizer only 246

Sacroiliac joint Left innominate anterior Patient supine Assume somntic d).ftmction (S-T-A-R-TJ is identified mul )\"u wish to thrust the left innominate posteriorly: 1. Contact points their righL M.ove the feet. and shoulders in (a) Left anterior superior iliac spine (ASIS) the opposite direction to introduce left (b) Posterior aspect of left shoulder girdle. sidebending of the trunk. Place the patient's left fOOL and ankle on top of the riglu ankle. 2 Applicators Ask the patient to clasp their fingers behind (a) Palm of right hand (b) Palmar aspect of left hand and wria the neck (Fig. C.3.1)_ 3. Patient positioning 4. Operator stance Patient lying supine in a comfortable position. Move the patient's pelvis towards St.and at the right side orthe patient. feet spread slightly and facing the couch. Stand as erect as possible and a\\lOid crouching as this will limit the technique and restria delivery of the thrusL KEY 5. Palpation of contact points ->f, Stabilization Place the palm of your right hand over the • Applicator • Plane of thrust (operator) ASIS. Ensure that you have good contact and will not slip across the skin or superficial musculature. Place the palmar aspect of your left hand and wrist gently over the posterior aspect of the left shoulder girdle. <> Direction of body movement 6. Positioning for thrust (patient) Rotate the patient's trunk to the right and towards you. Il is criticaJ to maintain the Note: The dimensions for the arrows left trunk sidebending introduced during are not a pictorial representation of initial positioning. Apply a force directed the amplitude or force of the thruSL dmvnwards towards the couch and sHgtu!)' cephalad to fix your right hand against the inferior aspect of the ASIS (Fig. C.3.2). 247

HVLA thrust techniques - pelvis Hgurec.J.l Figure (.3.2 Move your centre of gravity over the adjusunenlS by slight movements of the patient by leaning your body weight shoulders. trunk. ankles. knees and hips. forwards onto your light ann and hand. Shifting your centre of gravity forwards 8. Immediately pre-thrust assists finn contao point pressure on the llelax and adjust your balance as necessary. ASIS. Keep your head up and ensure lhat your 7. Adjustments to achieve appropriate contacts arc firm. An effective I-IV[1\\ thrust pre-thrust tension technique is best achieved if the operator and patient are relaxed and not holding F.nsure your patient remains relaxed. themselves rigid. This is a common Maintaining all holds,. make any necessary impedimenl to achieving effective changes in trunk rotation. flexion and cavitation. sidebending. Simultanootl5ly. adjust the direction of pressure applied to the ASIS 9. Delivering the thrust until applicator forces are baJanced and ),ou sense a state of appropriate tension and Apply a HVLA thrust \\vith your right hand 248 leverage. The patient should not be aware directed against the ASIS in a curved plane of any pain or discomfort. lI.take these final towards the couch (Fig. C.3.3). Your left

Sacroiliac joint Left innominate anterior forearm, wrist and han<\\ over the palienc's shoulder girdle do not appl}' a thrust but act as stabilizers only. '111e aim of this technique is to achieve posterior rotation of the left innominate and movement at the left sacroiliac joint The direction of thrust will alter between pat.ienL~ as a result of the wide va.riat.ion in sacroiliac anatomy and biomechanics. The thrust. although very rapid must never be excessively forcible. The aim should be to use the absolute minimum force necessary. Figure 0.3 249

HVLA thrust techniques - pelvis SUMMARY Sacroiliac joint left innominate anterior Patient supine Thrust posteriorly • Contact points: -left anterior superior iliac spine (ASIS) -Posterior aspect of left shoulder girdle • Applicators: -Palm of right hand -Palmar aspect of left hand and wrist • Patient positioning: Supine. Move patient's pelvis towards the right. Move feet and shoulders in the opposite direction to introduce left sidebending of the trunk. Place the patient's left foot and anlde on top of the right anlde. Ask the patient to clasp fingers behind the neck (Fig. C3.1) • Operator stance: To the right side of the patient, facing the couch • Palpation of contact points: Place the palm of your right hand over the ASIS. Place the palmar aspect of your left hand and wrist over the posterior aspect of the left shoulder girdle • Positioning for thrust Rotate the patient's trunk to the right. Maintain left trunk sldebending. Apply a force directed downwards towards the couch and slightly cephalad to fix your right hand against the inferior aspect of the ASIS (Fig. 0.2) • Adjustments to achieve appropriate pre-thrust tension: Make any necessary changes in trunk rotation, flexion and sidebending. Simultaneously, adjust direction of pressure applied to the ASIS • Immediately pre-thrust: Relax and adjust your balance • DeliverIng the thrust: The thrust against the ASIS is in a curved plane towards the couch (Fig. C.3.3). Your left forearm, wrist and hand over the patient's shoulder girdle do not apply a thrust but act as stabilizers only 250

Sacroiliac joint Sacral base anterior Patient side-lying Assume somatic dysfunction (S-T-A-R-T) is U1entified and}uu luis', to thrust Ute apex of tlte sacrum anteriorly: ,. Patient positioning Upper- body. Gently extend the patient's l),jng on the right side with a pillow to upper shoulder and place the patient's left suppon the head and neck. forearm on the JOWl':r ribs. Using )'our right Lower body. Slrnighlen the patient's lower leg and ensure that the leg and spine are in hand to palpate the l5-S1 interspinous a straight line. in a neutral position. Hex the patient's upper hip and knee slightly and space introduce left rotation of the patient's place the upper leg just anterior to the lower trunk down to and induding the 1.5-$1 leg. The lower leg and spine should form as segment. 'I'his is achieved by gently holding near a straight line as possible with no the patient's right elbow with your left hand flexion at the low'er hip or knee. and pulling it IOw:uds )'ou, but also in a cephalad direction to\\\"\",rds the: head end of the couch. Be careful Ilot to ilurodua: any flexion to the spine during this movement. Take up the axillary hold. This ann controls and maintains trunk rotation. KEY 2. Operator stance .:f,- Stabilization Stand close to the couch with }'Our feet • Applicator spread and one leg behind the other. Maintain an upright posture, facing slightly in the direction of the p<ltient's upper body. • Plane of thrust (operator) 3. Positioning for thrust ¢ Direction of body movement Apply the palmar aspect of )'Our right (patient) forearm to the apex of the sacrum. Ensure !.hat cont<lct is below the second sacral Note: The dimensions fOf' the arrows segment. Your left forearm should be resting are not a pictorial representation of against the patient's upper pectoral and rib the ampJitude Of' force of the thrust. cage region and will control and maintain trunk rotation. Gently rOlate the patient's trunk away from )'Ou using )'Our left forearm 251 until you achieve spinal locking. Be careful .

HVLA thrust techniques - pelvis to \"void undue pressure in the axi!1\". firm. An effective IIVI.A thrust technique is Finally, roll the p\"tient about 10_150 best achieved if both the oper3tor and to\\v\"rds }'Ou while maintaining the build-up p,ujent are relaxed and not holding of levelilges. themseh'es rigid. This is a common impediment to achieving effective 4. Adjustments to achieve appropriate cwitation. pr~thrust tension 6. ~ivering the thrust Ensure your patiem remains relaxed. Maimaining all holds, make any necessary Apply a I-IVlA thrust with }'Our right changes in flexion, extension, sidebending forearm against the apex of the sacrum in or rOl<ltion until you are confident that a cu.rved plane to\\\\'3.rds }'OU (Fig. G.4.1). full spinal lod.:ing is achieved. The patient Your left arm against the patient's pectoral should not be aW2rf: of any pain or region does not apply a thrust but acts as a discomfon. Make these final adjustments stabilizer only. 'l1le aim of this technique is by slight movements of your shoulders. to achieve a counter-nutation mO\\'lTJlent of trunk. ankJes. kneE5 and hips. the sacrum. S. Immediately pr~thrust 1he thrust. although ''elY rapid. must nE\"\\~ be excessively forcible. 1he aim Relax and adjust )'Our balance as necessary. should be to use: the absolute minimum Keep }'Our head up and ensure contacts are force necessary. Figure CA.l 252

Sacroiliac joint Sacral base anterior SUMMARY Sacroiliac joint Sacral base anterior Patient side--Iying Thrust apex anteriorly • Patient positioning: Right side-lying: Lower body. Right leg and spine in a straight line. Left hip and knee flexed slightly and placed just anterior to the lower leg Upper body. Introduce left rotation of the patient's trunk down to and including the l5-$1 segment. Do not introduce any flexion to the spine dUring this movement. Take up the axillary hold Operator stance: Stand dose to the couch. feet spread and one leg behind the other. Maintain an upright posture. facing slightly in the direction of the patient's upper body • Positioning for thrust: Apply the palmar aspect of your right forearm to the apex of the sacrum. Ensure that contact is below the second sacral segment Your left forearm should be resting against the patient's upper pectoral and rib cage region. Rotate the patient's trunk away from you using your left forearm until you achieve spinal locking. Roll the patient about 10-15\" towards you • Adjustments to achieve appropriate pr~thrusttension • Immediately pre·thrust: Relax and adjust your balance • Delivering the thrust: The thrust against the apex of the sacrum is in a curved plane towards you (Fig. C.4.1). Your left arm against the patient's pectoral region does not apply a thrust but acts as a stabilizer only 253

Sacrococcygeal joint I ~r A r -Coccyx anterior Y .. --F\"\"\" - - - Patient 5id~lying Assume somatic dysfunction (5-T-A-R-T) is identified and ),ou wisll to thrust the coccyx posteriori)': 11le operator must exercise alT€ and thrust to the roccyx. Cocqdynia can be attention to ensure that the patient is fully severe and the choice of technique depends informed as to the nature of this procedure. as much upon pati~nt comfort as perceived 'f'his technique involves both assessment f'.fficacy of approach. Practitioners should and treaunenl via a rectal approach. It is becoml\" familiar \\\\'ith articulating thl\" assumed that the operator will examine the sacrococcygl\"al joint beforl\" attempting a anal and rectal region to detennine if there thrust to the coccyx. are any contrnindiGltions to performing this procedure. '['his technique can bE! used 1. Contact points either as a means of gently artirulating the sacrococcygeal joint or applying a I IVI.A (a) Ant~rior aspect of !.hI\" coccyx through thl\" posterior wall of the r~etum (b) Postl\"rior 3SpI\"Cl of thl\" coccyx. KEY 2. Applicators *, Stabilization (<l) lubricated index finger of operator's gloved right hand • Applicator (b) Thumb of operator's glO\\ d right hand. - Plane of thrust (operator) 3. Patient positioning Q Direction of txx:Iy movement Lying in the left lateml position with the (patient) maximal amount of flexion of the hips. knees and spine consistent with patient Note: The dimensions for the arrows com fOil. 'I'he p<ttlenl should be fully are not a pictorial representation of undressed so th<tt <tccess 10 the <tnal canal the amplitude or force of the thrust. is possible. The buttocks should be at the edgf of the couch. 255 7 4. Operator stance • S13.nd behind the patient. approximately at thl\" In'e!. of the patient's hip joints, fadng the couch and patient's back.

HVLA thrust techniques - pelvis A / Figure C.S.l Sacrococcygeal joint. A: The index finger is placed against the anal margIn. B: The finger Is Inserted as shown. C: After examination of the rectum, the coccyx is held between the index finger Internally and the thumb externally. 5. Palpation of contad points your right hand ext~mally to identify the posterior aspect of the coccyx between the The operator should be wearing a pair of buttocks. llle coccyx is nO\\.., gently held suitable g10\\'eS \"..ith lubricant smeared over between your index finger internally and the right index finger. 'llIe patient must be thumb externally (Fig. C.S.1C). Gentle informed that a finger within the rectum pressure is applied in a number of will cause a ~nsation similar to that of directions to determine undue tenderness or opening the bowels. Ask the patient to relax any reproduction of the patient's familiar and place the index finger of your right symptoms. The mobility and position of the hand against the anal margin (Fig. C.S.1A). coccyx relatiw to the sacrum is also noted. With steady pressure, insert your right index finger into the patient's anal canal in a 6. Fixation of contact points cephalic and slightly anterior direction (Fig. Keep your right index finger on the anterior C.5.1B). The finger will pass through the aspect of the coccyx while applying pressur~ anal sphincter and into the rectum. If the against the posterior aspect of the coccyx patient has difficulty relaxing.. ask him/her with your right thumb. The fIXation is gentle (0 bear down as if opening the bowels but linn with less pressure against the and gently slip your finger past the anal anterior surface of the coccyx. sphincter and into the rectum. Once through the anal sphincter, the direction of 7. Adjustments to achieve appropriate the rectum is cephalic and posteriorly along pre-thrust tension the curve of the coccyx and sacrum. At this stage an examination of the rectum should The operator should be in a position to be undertaken. for m.de patients this would move the coccyx through a range of motion include examination of the prostate gland. and in different planes. Ensure your patient 'Ine palpatjng right index finger identifies remains relaxed. Maintaining all holds, the sacrum and coccyx through the posterior make any necessary changes in flexion, wall of the rectum. Place the distal phalanx extension, sidebending and rotation of the of the right index finger against the anterior coccyx until you sense a state of appropriate 256 surface of the coccyx immediately below tension and leverage at the sacrococcygeal the sacrococcygeal joint. Use the thumb of joint.

Sacrococcygeal joint Coccyx anterior B.lmmediately pre--thrust 9. Delivering the thrust Relax and adjust )'Our balance as necessary. Appl)' a HVLA thrust Lowards you in a Ensure thai your contads are firm. An CUlWd plane (Fig.. G.S.2). effeclive IIVLA lhrust technique is best achieved if the ope:r:ator and patiem are \"'he thrust. although very rapid must relaxed and nOl holding themselves rigid. ne\\'ff be excessively forcible. The aim This is a common impediment to achieving should be: to use the absolute minimum effective cavitation. force necessary. Figure C.52 257 II