__Manipulation_of_the_Spine__Thorax_and_Pelvis__An_Osteopathic_Perspective

Rationale for the use of high- velocity low-amplitude (HVLA) thrust techniques 'liglH,Ielocity 1000.,r-amplitude (HVlA) thrust OSTEOPATHIC TREATMENT techniques are \\\"ide1y used in patient MODELS caTe with increasing evidence of !.heir effectiveness. 1100\\'e\\'l?:T. the use of HVLA Scientific validation for the use of manual thrust techniques musllx considered within and manipulative approaches. including the context of a compre:~ive patient IIVlA techniques. is limited. Consequently. management plan. which may include praetitionf:lS must rely upon theoretical and the application of other osteopathic: clinical models to justify the: use: of I IVlA manipulative tech.niques and adjunctiVf' thrust techniques in clinical practice:. therapies. Osteopaths use five LIe:atment and clinical Various authors have described specific reasoning models\": indications for the use: of HVlA thrust 1. Biome:chanical 2. Neurological techniques (Box A.G.I). 80x A.6.1 SpeclfK Indications for HVtA a. autonomic nervous system techniques as listed by various authors b. pain c. neuroendocrine 3. Respiratory/circulatory 4. Bioene:rgy • Hypomobiliti~ 5. Psychobe:havioural. • Motion restrictionH • Joint fixalion6.7 Biomechanical (postural/strudural) • Acute joint lockingJ,II,9 This model is based upon the concept that • Motion loss with somatic dysfunction'0.\" mechanical and slmctural dysfunaion can r€Sult from single incidences of trauma • Somatic dysfunction'),,'· or from microlfauma occurring over time and as a result of poslUral imbalance or • Restore bony alignmenrU occupational and environmental stresses. • Meniscoid entrapment'.14.7.16 Cumulative microtrauma can lead to • Adhesionsl7 a breakdm...n of the body's nonnal • Displaced disc fragment lll compmsatory mechanisms with resultant • Pain modulation'.5.9.'9.X1 de-.Tlopment of dysfunaion and pain. • Reflex relaxation of muscles1.u,-n nu~ biomechanical model requires the • Reprogramming of the central nervous systemlJ • Release of endorphins:M practitioner to restore maximum function I4S to the neuromuscu)oskeJetal $)'Stem wilh enhanarnel1l of the body's ability to _ _ _ _ _1

HVLA thrust techniques - an osteopathic perspective compensate for external mechanical stresses flO'\", within the human body. '111e aim of and any primary or secondary postural treatment is to restore balance and harmony imbalance. Therapy is directed to'vards to these fields of energy. restoring as near nonnal motion and/or funaion to joints; ligaments; muscles and Psychobehavioural fascia. The aim is to regain optimal fWIction within the musculoskeletal system. This model recognizes that many internal and external factors influence a patient's Neurological response to pain and dysfunction. Social. economic and cultural factors all impaa ,11is model is based upon the concept that upon the way in which a patient deals neural mechanisms may be influenced by with pain, dysfunaion and disability. An the ll'>e of manual medicine approaches. understanding of the factors that can '11e neurological models provide a influence a patient's coping mechanisms is framework for treatmem that is based. upon pivotal to this model, as is a knowled~ of posLUlated mechanisms of imeraction the psychosocial interventions that may between the somatic and neurological assist the patient to deal with pain and systems. 'These mechanisms are complex disability. and beyond the scope of this manual. It is suggested that manual imefVflltion may ,11ese five models provide a conceptual influence: frame\\vork upon which decisions relating • the two divisions of the autonomic to patient management can be made. It nervous system must be understood that these are simply conceptual models with varying amounts • the integration of function between the of evidence to support their use central and peripheral nervous systems for modulation of pain 'l1tese osteopathic models provide a framework for choosing a treatment • the neuroendocrine-immune connection, approach and selecting osteopathic resulting in both local and systemic manipulative tedmiques. How£'Ver, the effects. treatment models do not dearly establish a Respiratory/circulatory rationale for the use of HVlA thrust techniques as distinct from other This model is based upon the concept that osteopathic manipulative tedUliques. normal fluid exchange is essential for the continued health of tissues at both the 'micro' and 'macro' level. Manual treatment CAVITATION ASSOCIATED WITH is directed towards improving blood and HVLA THRUST TECHNIQUES lymph flow and aiding intracellular fluid '111e aim of HVLA thrust techniques is to exchange by ellhancing musruloskeletal achieve joint cavitation Ihat is accompanied funnion. Treatment is directed to\\'imds by a 'popping' or 'cracking' sound. This restoring the capacity of the musculoskeletal audible release distinguishes HVI.A system to assist venous and lymphatic procedures from other osteopathic return. manipulative tedUliques. Bioenergy Research involving the metacarpo- phalangeal joint indicates that the audible This model is based upon the body's release is generated by a cavilation inherent energy fields that can be utilized mechanism resulting from a drop in the for diagnosis and treatmenL Internal and internal joint pressure.1s-n r\"OIIO'ving 46 external environmental factors may cavitation, there is an increase in the size of influence the vitality and quality of energy the joint space and gas is found within that

Rationale for the use of high-velocity low·amplitude (HVLA) thrust techniques space. l~-\" \"\"e gas bubble has been lechniques is to achieve ca,~tation 10wards 47 described as 80% carbon dioxide'6 or 1I1e end of zygapophysial joim range but having the density of nitrogen.14 'Ine gas nol at the anatomical end range. bubble remains within the joint for bt1,wero 15 and 30 min,l4.1S n.l'J whim is consistent Repeated 'cracking' or 'popping' of the joints of lIle hand associated ,~th with the time taken for the gas to be cavitation, has not been shown to be linked reabsorbed into the synovial f1uid. l6 An ,~th an increased incidence of degeneralive increased range of joim mOl ion mange.44,O immediately follO\\~ngcavitation has been d e m o n s t r a t e d . :19 EVIDENCE SUMMARY Widening of lumbar zygapophysial joints Best pl'3etice requires prnctitionel\"S 10 post manipulation has been demonstrated embrace the prindpJes of Evidence Based by magnetic resonance imaging (MRI) Medicine (EB1I.i). Evidence based medicine foIlO\\ving lumbar spine manipulation.lO It is incorporates the be51 results from clinical possible that cavitation occurring al spinal and epidemiological research with synovial joints has similar characteristics to individual clinical experience and expenise that exhibited al the metacarpophalangeal joint. A number of studies have reponed whilst taking accoum of patient thai thrust lechniques are associaled with a temporary increase in the range of spinal preferences.46,,·' Evidence for efficacy of interventions. motion.\"-loB Longer-leon effects of HVlA such as spinal manipulation can be thruSl lechniques have also been assessed aCfOrding to a hierarchy of reported\"'~ aJld it is ~tulated that these evidence that exists in the literature for lhat may be due to reflex mechanisms that either intervention. direclly cause muscle relaxation or inhibit pain.s HO\\vever, the sound of a 'crack' or Hierarchy of evidence 'pop' associated with a HVlA thrust technique does nOl necessarily indicate that • Randomi7.ed fOntrolled trials • Non-randomized controlled trials reflex or tissue changes have ocrurred. Some • Cohon or 10ngitudjJl31 studies authors have reported benefits from HVlA • Case-control studies thrust techniques without the accompanying • Cross-sectional descriptions amI surveys • Case series and case reports audible release.·' There continues to be • Expert opinion speculation as to the level and side of apophysial joint cavitalion when IIVLA I~ecommendationsarising from a review of thrust techniques are applied 10 lhe spine. the researdl reflect the strenglll of evidence Reggars and Pollard in a study of diver.:;ified and methodological quality, but not rotation manipulation of the cervical spine necessarily lIle clinical importUlce. found that cavitalion occurred more often on the ipsilaleral side to head rOLation.·' A Research evidence can be synthesized ill study of lumbar and sacroiliac manipulative a number of different \\\\I3YS. A systematic review can be undertaken which is the techniques found that there was no systematic synthesis of evidence across all conclusive specificity of technique to level trials for a given intervention. or side of cavitation.·) It is likely that the Syntheses level and side of cavitation will be dependent upon a range of mctors that • Systematic reviews including meta- might include spinal positioning and analyses locking. the specific technique applied, operator skill and patient compliance and • Decision and economic analyses whether the patiell1 is Symptomatic or • Guidelines asymplOmalic. 'Ine aim of IIVLA thrust

HVLA thrust techniques - an osteopathic perspective Meta-analysis is when a systematic review of RCfs published since 1995, relating to a uses special statistical meth<Xis for range of complementary therapies for non- combining the results of several studies, specific back pain, concluded that spinal Hecommendations based on research manipulation has real but modest benefiL<; evidence can be used to develop clinical for acute and chronic low back pain and practice guideli.nes and standards for t.hird- that the risks of lumbar manipulation are party payers and policy makers. low,SoI Willem et al. noted that all national Bronfort et al. report that since 1979, guidelines on the management of low back there have been in excess of 50 mostly pain included the use of spinal qualitative, non-systematic reviews manipulation. However, the data upon published relating to manipulation and which national recommendations are based mobiliZ<l.tion treatment for back and neck has been interpreted differently leading to pain.48 A number of systematic reviews and conflicting guidelines between COWllries meta-analyses have also been undertaken for the use of spi.nal manipulation in the that attempt to determine the efficacy of management of both acute and chronic spinal manipulation on low back pain,4'-57 back pain.56 A !>ystematic review of the back and neck pain,58,5' neck pain(>O-67 and efficacy of spinal manipulation for chronic chronic headache.63 headache concluded that spinal Bronfort et al. undertook an extensive manipulative therapy has an effect search of computerized and bibliographic comparable to commonly prescribed literature databases up to the end of 2002 prophylactic tension headache and migraine relating to the efficacy of spinal medications.63 Waddell, on reviewing the manipulation and mobiliZ<l.tion for low evidence in relation to acute Im'l back pain back and neck pain and concluded that the and disability, commented that there are lise of spinal manipulative therapy and/or numerous symptomatic treatment options mobilization is a viable option for the other than manipulation but there is little treatment of both low back pain and neck scientific evidence that they are effective and pain, 59 This systematic r€ViC'\\! identified the states that the evidence supports the use paucity of high quality trials distinguishing of manipulation as a treatment option for bel\\veen acute and chronic presentations symptomatic relief.64 and recommended that further research 'Ine United Kingdom Back Pain Exercise should examine the value of spinal and Manipulation (UK BEAM) randomised manipulation and mobiliZ<l.tion for well trial concluded thaL spinal manipulation defined sub-groups of patients and over a 12-week period produced statistically determine the cost-effectiveness of different significant benefits relative to best care in [Teatment approaches. A Cochrane review general practice at both 3 and 12 months.tiS of mani pulation and mobilization for Manual therapy approaches, including mechanical neck pain concluded that when HVLA thrust techniques, have been combined with exercise, mobilization negatively impaded by poorly designed and and/or manipulation is beneficial for implemented research studies. Studies have persistent mechanical neck disorders with been compromised because patients with or without headache, providing strong spinal pain are not a homogeneous group, evidence for using a multi-modal treatment which makes comparison of like with approach.GO A Cochrane database systematic like extremely difficult. Practitioners of review on spinal manipulative therapy for manipulative therapy are also not a low back pain concluded that there is no homogeneous group having differing levels evidence that spinal manipulation is of training and skill in the application of superior to other standard treatments for manipulative techniques. Future research 48 patients suffering acute or chronic low back will need LO use classification systems that pain.57 Cherkin et al. in a systematic review allow accurate identification of the sub-

Rationale for the use of high-velocity low-amplitude (HVLA) thrust techniques groups of spinal pain patients that might 'nley are subjroi\\'e and include negative benefit from manipulative therapy. coping Str'3tegies. fear avoidance behaviour, anxiety, depression and distress. If yellO\\\" CLINICAL DECISION MAKING nags are identified treatment should aim to reduce dependency on medication and IU our pre>ent state of kno\\,,Iledge. what Othe.r passive fonns of treatmenl, including model should guide our clinical decision manipulative therapy, and e.ncourage the making to incorporate IIVlA thrust deve.lopment of self-manageme.nt skills. techniques within a treatment regiTT'lE'? 'lne identification of yellow nag; requires All hea.lthcare practitioners utilize a a shih in the focus of care. clinical decision-making process prior to the application of a therapeutic intelWJ1tion, Identify the presence of a treatable e_g. 11VlA thrust technique (Box A6.2). lesion - somatic dysfunction Do. A.6.2 Clinical decision making A number of treatment models use elements ofT~A·R·Tas the basis for the selection of • Exclude contraindications (red flags) manipulative techniques including 11\\fLA. • Determine influence of yellow flags thrust techniques. U.ll.14,Z1.6Ml<lne aUlhors • Identify presence of a treatable lesion - advocate that the arrre.nt convention for the diagnosis of somatic dysfunction T-A-n-T somatic dysfunction should be expanded to include patient • Decide upon appropriate intervention feedback relating to pain provocation and the n::llroduaion of familiar symptoms. Exclude contraindications Somatic d}'sfunaion is identified by the (red flags) S-T-A-R-T of diagnosis and is made on the basis of a number of posilh-e findings Although the majority of patients who relating to symptom reproduction, tissue present with spinal pain wlll not have tenderness, asymmetry, range of motion and serious pathology, it is imperative thaI tissue texture changes (Box A6.3). practitioners maintain vigilance in excluding red flag conditions (see col1lraindicalions. Box A.6.3 Diagnosis of somatic dysfunction page 27). ·rne following may indicall:~ the presence of red flags: • Patient younger than 20 or older than 50 • S relates to symptom reproduction with first onset of spinal pain • T relates to tissue tendemess • A relates to asymmetry • Pain following trauma • R relates to range of motion • Constant and worsening pain • T relates to tissue texture changes • Past or present history of malignancy • Long-term corticosteroid use Decide upon appropriate • Ceneral malaise intervention • Night sweats/pyrexia • Weight loss • Neurological symptoms and signs ·,ne identification of red nags requires Broadly speaking. manipulati...e techniques 49 further investigation and specialist referral. will be selected based upon one or more of the following: Detennine influence of yellow flags • Evidence Yellow flags are ps}uosodal risk faaors • Convention associated with d'lTonic pain or disability. • Training and exPffience

•- HVLA thrust techniques - an osteopathic perspective 50 Within manual medicine, there is an techniques requires the Ktentification and ongoing debate about the specific effects exdusKln of red Rags, recognition of the of individual manipulative teclmiques. impact of yellow flags upon patient including HVlA thrust techniques. While presentation and prognosis and the there is ~rch evidence demonstrating the KtentiflCation of a treatable lesion. There is effects of HVLA thrust techniques in conflicting evidence for the use of tM.A increasing range of motion,JI-M altering pain thrust techniques in clinical practice, with no pe.rception)4·68 and altering autonomic ~fJex dear direction as to which manipulative activity,65I this research does not infonn approach would be effective. As a practitioners of when to apply any given consequence, decisions relating to direction manipulative technique including HVLA. of thrust, which combination of thrust techniques. manipulative techniques and the sequencing of technique in a multi-modal In clinical praclice, lhe trealment of approach will continue to be made upon spinal pain and dysfunction commonly the basis of convention and the individual combines several interventions, e.g. practitioner's training and experience. maJlipulation, mobili7..3lion and exerdse with evidence supporting a multi-modal References approach.lIl-n '111ere is currently no evidence to guide the dinician with regard to lhe c:Kenna Murtagh J. Back Pain and Spinal following aspects of manipulative treatment interventions: Manipulation, 200 Ed1\\. Oxford: Bunerworth· Heirwmann; 1989. I. Direction of thrust 2 Bruc:knes- P, Khan K. OinKaJ Spons Medidne. 2. lhe combination of manipuJative t'ew York. NY: M.cCnw-l-lill; 1994. 3 l.t:wit K. Manipulathoe 'f1'M!npy in techniques that will be most effective Rehabililation of the I.ocomotor S)'$tem. 2nd 3. \"l'he most effective sequencing of ron. Oxford: Buuerworth-Heinnnann; 1991. technique within a multi-modal approach <1 t.laigne R Diagnosis and Treatment of I\"'Mn of Venebral Origin. Baltimore. MD: Williams \" In the absence of research evidence. the Wilkins; 1996. decision regarding these aspects of treaunent GIn only be made upon the basis 5 Brodeur R The audible release iWOdated with of convention and practitioner uaining and experience. joinl manipulation. J Manipulall\\Y l'hysiol Ther 1995; 18(3):155-164. CONCLUSION 6 F..der M, Tilscher H. Chiropr.tClk Thempy. Practitioners rely upon theoretical and Diagnosis and Treatmelll. Gaithersburg. MD: clinical models to justify the use of HVlA Aspen; 1990. thrust techniques in dinical practice. Best practice also requires incorporating the 7 Sammut F.. Searle-Barnes I~ Osteopathic results from clinical and epidemiological Diagnosis. O..ehenham: Stanley 'nlOffit':!l; 1998. research with the individual clinical experience and expertise of the practitioner 8 Gainsbul)' I. High-\\oelocity thru!il and while taking account of patient preferences. pathophysiology of segmental dysfunction. In; Osteopaths have used HVl..A thrust Glasgow E,. Twomey I~ Sallie E,. \"1t')'flhans A. techniques for the treatment of somatic. ldc:zak R. eds. Asp«:ls of Mauipulati\\Y Therapy. dysfunction for many years. Clinical decision 2nd edu. Melbourne; Churchill Livingstone; making retating to the use of these 1985:0\\. 13. 9 Zusman t..i.. What does manipulation dol The net'd for basic research. In: Boyting J. P:tla.sWl;il M. eds. GrinY'S Modem Manual Therapy, 2nd edn. New York Chwchill Uving.stone; 1994;01.47. 10 Kuchen ,v, Kuchera M. Osteopathic Princip&es in l'r.Ktke. Kirksville. M(); KCOM; 1992.

Rationale for the use of high-velocity low-amplitude (HVlA) thrust techniques II Kappler R. lones I. 'nnust (higll-\\~locityl 27 Meal G, Scott R. \"ualysis of the join! crack by 51 low-amplitude) techniques. In; \"'<lrd R. ed. simultaneous recording of sound and tension. I Foundations for Osteopathic Medicine:. ManipulativE' Physiol 'nlel\" 1986; 9: 189-195, Philadelphia: Uppincott \\'lilliams & Wilkins; 28 Wal50n r. Mollan R. Cinerddiography of a 2003:Ch. 56. cracking joint. Ilr J Radiol 1990: 63:145-147. I2 BourdiIJon J, Day F.. Bookhout M. Spinal I,29 Mierau 0, Cassidy J, I\\o\\ven V, Dupuis I~ Manipulation. 5th edn. Oxford: Butu.'f\\\\.'orth- Noftall t.lanipulation and mobilization of Heinemann; 1992. lhe third metacarpophala~ljoinr. a quantitarn,oe radklgraphic and range of motion 13 Kiwheriy I~ r'Ormulating a prescription for study. Man Moo 1988; 3:135-140. -'heosteopathic manipulatiw treaUne:nt. In: BEaI M. 30 Darner G, Gregerson 0, Knudsen I, Hubbard B, Usw L. GmlU I. The effects of side-jX)Stwe ed. Principles of Palpatol)' Diagt1<Xiis and positioning and spinal adjusting on the': lumbar Manipulati\\'e 'f£chnique. Newark American Z joints.. Spine 2002; 27(22):2459-2466. Acad£ffi)' of Osteopathy; 1992:146--152, 31 Howe DH, Newcombe RG, Wade Mr. 14 Greenman PE. Principles of Manual Medicine. Manipulation of the cervical spine: a pilOl 3rd edn. Philadelphia. PA: lippincott Williams study. I R Coil Ge:n PTact 1983; & \\'lilkins; 2003. 33(254):574-579. IS Nyberg R. Basmajian J. Rationale for the: use: of J2 Nan.sel D, Cremata E, Carlson I, Sl'lazak M. Effect of unilateral spinal adjusunenlS on spinal manipulation. In: Basmajian \" Nyberg goniometricaJlyassessed tttVical Iateral-f1aion e:nd-r\". asymmetries in otherwi~ R. eds.. Rational Manual ·Ille:rnpies. Baltimore, asymptomalic sub;eas.. J Manipulali\\'E' P~iol MD: \\'/iJliams & \\'/iUdns; 1993:01, 17, Ther 1989; 12(6);419-427. 16 Bogduk N, Twomey L Cinical Anatomy of the Lumbar Spine 2nd txl.n. Melbourne: Churchill 33 Nansel 0, l'eneff A. Carlson I, Szlazak M. TIme Uvingslone; 1991. course ronsider.uions for the effects of unilateral lower cervical adjustments wilh 17 Sloddard A. Manual of Osteopathic Practice. !\\'SpecliO the amelioralion of cervkal lateral- London: Hutchinson; 1969, flexion passi~ end-range asymmeuy. I Manipulatiw Physiol Ther 1990; 18 Cyriax I, 'fextbook of Orthopaedic Medicine. 13(6):297-304. 6th OOn. I.ondon; Baillibe Tindall; 1975:\\U1. I. 3. Cassidy JD, Quon JA. l.afrance (J, Yong-Ying K 19 'Ierrett A. Vernon H. Manipulatlorl and pain The erfl'Cl of manipulation on pain and range tolerance. A cOfluolled slUdy on the effect of of mOlion in the cervical spine: a pilot study. J spinal manipulation on paraspinal CUlaIleOUS Manipulaliw I'hysiol'l1ler 1992; pain tolerance levels. Am I Ptlys Med 1984; 15(8):495-500, 63:217-225. 35 Nansel D, Peneff A. Quitoriano D, Effecti\\'eness 20 Hoehler r, Tobis j, Buerger A. Spinal of upper \\'er'5US lower cervical adjustments with !\\'Spec! to the ameliOrdlion of passive manipulation for 10\\\"\" back pain. 1Am Moo rolalional \\~rsu.s latel<ll-f1cxion end-rnnge Assoc 1981; 245:1835-1838. asymmetries in otherwise asymptomatic subjects. J Manipul;ltive Physiol'nler 1992; 21 Kucher\" W, Kuchera M. Osleopathic Principles 15(2):99-105. in Prdetice, OH: Grey<.len Press; 1994:292. 36 Nilsson N, Chrislenson JlW, Hilnrigson J. 22 Neumann I r. Introduction to Manual Lasting changes in passive range of motion Medicine. Berlin: Springer; 1989, after spinal mllnipuli!tion: a rnndomised, blind 23 Fisk J. A cOlllroliOO tn;l! of manipulation in a controlled trial. J Manipulath\"l'. I'hysiol Ther selected sroup of (XllienlS wilh low back pain 1996; 19(3):165-168, favouring one side. N Z Med J 1979; 37 Surkitt D, Gibbons p, Mcl.o1ughlin I'. High velocity low amplilUde milnipulatioll ofthE' 90:288-291. allanto-axial joint: Effect on atlanto-axial and cervical spine rotation asyml1lelJ}' in 2' Vernon H, Dharrni I, Howk')' T, Annett R. Spinal manipuilltion and betil-endorphin: a Mooilsymplomatic subjects. , Osteopath 2000; controlled study of the effect of iI spinal manipulation on plasma beta-endorphin lE\"A'ls 3(1):13-19. in normal males. J Manipulali\\'e Physiol Ther 1986; 9:1l5-123. 38 aeme:n1S 8. Cibbons r. Mclaughlin I'. lhe 25 ROSIon J, Haines R. er\"cking in the amel.ioration of atlanlo-axial asynlmelry using metarnrpophalangeal joint. J Anat 1947; 81:165-173. 26 UllS\\vonh A. Dawson D, Wright V, Cracking joints: a bioengineering study of ca\\~tation in the metacarpophalangeal joinl. Ann Rhewn Dis 1972; 30:348-358.

HVLA thrust techniques - an osteopathic perspective high \\It':locity )0\\'\" amplilude manipulation: Is help people with chronic 10\\'\" back pain1 Ausc , Ihe direction of thrusl importanl1 J Osteopalh PhysiotlM.'r 2002; 48(4):277-284. Moo 2001; 4(1):8-14. 53 1\\>rIgeIII, t.taher C. Ref.shauge K Sy.sIenUttic 39 Slodolny J, Chmielewski H. Manualthef\"clpy review of conM'rvati~inlef\\'entions for in the treatment ofpatiems with cervical Mlbacute low bad: pain, Oin Rehabil 2002; migf\",tine. Man Med 1989; 4:49-51. 16(8):811-820. 40 Nordemar It 'l1lomer C. TrealJl'M.'nt of acu!t: 54 Olerkin D, Sherman K. Deyo It. Shekelle I~ A «:rvical pain: a comparalhl~ group sludy. Pain review of Ihe evidena for the effecti\\'ftles5, 1981; 10:93-101. 5ilfely. and 0051 of ilCUpunctun'.. massage Iherapy. and spinal manipulalioo for back 41 I-lynn'l; r.,.itt J, Wainl'M.'1' It Whitman J. The pain. Ann Intern Med 2003; 138(11):898-906, audible pop is noc nettSSary !Of .successful 55 I,\"rreira M. Prmira I~ Lalimer J. Herben It spinal high-\\'docity thrust manipulation in Maher C. Efficacy of spinal manipulati\\'e individuals with 10\\'\" back pain, Arch l'hys t.1ed t1M.'rclP)' (or low back pain ofless Ihan lhree Rehabil2003; 84:1057-1060. monlhs' duration. I Manipulath.'e l'hysiol 42 RqgaB J, Pollard H_ Analysis of Z)\"giIpophyseal ,. Ther 2003; 26(9):593-601. Willern J, AumdeUt \\~ Morton S. Yu I!., )oim cracking during chiropractic Suuorp M. St~lIe P. Spinal manipulau\\'e therapy for low back pain. A meta-anal}'5is of manipulation. J Manipulali\\~ Physiol'£ber dTeoi\\'t'OeU relath't: to Olher therapies.. Ann Intern Med 2003; 138( II ):871-881. 1995; 18(2):65-71- 57 AssendeUt W, Mortoo S. Yu F~ Sunorp M. 43 Beffa R. Malhr:ws R. Does lhe adjustmenl Shekelk P. Spinal manipubli\\'e lherapy for low Gl\\'itate the tatgt'ted ;oina An imatigalion back pain, Cochrane Database Sy.sI Rev 2004; into the iocaIion o( C'.Mtaooo sounds. J 1:<:0000447, Manipublh'e 1\"hysioI'£ber 2004; 27(2):e2. 44 Sweuy It Swezey S. The consequences of habitual knllCkle cr.Kking.. West J Moo 1975; 122:377-379. 45 Castellal'lOli J, AWrod D. Effect of habitual 5. Mior S. Manipulalion and mobili7.ation in the knuckle crncking 00 hand (unction. Ann lreatment of chronic pain. Oin 1 Pain 2001; 17(4);570-876, Rheum Dis 1990; 49:308-309. 4G Sacketl D. Richardson W; Rosenbetg W, Haynes 59 Bron(on Co Haas t-I, Evans R. Bouler L F..fficacy R. Evidena Based Medkine. How to l\"rania & 'leach r.BM. New York Olurchill Ij\\\";'ngstone-; ofspinal manipulalion and mobilization for 1997. low back pain and neck pain: a S)'SIemalic review and !)t'$1 evidence sylllhesis. Spine 2004: 47 Pedersen'J: C'Juud C. Gottsche P, Maum P, 4(3):335-356. Wille-Jorgensen P. W1uII is evidena--based medicine? lIgeskr l..aeg 2001; 163(27): 60 Gross A, HO\\Iing I, Haines'l: Goldsmith C. Kay 3769-3772. T, AXer I~ Bronfon G. A Cochmne review of manipulalion and mobili\"'.iuion for mechanical 4. Bronfon G. Hass M, Evans It Bouler L Effieaty neck disorders. Spine 2004; 29( 14):1541-1548. o( spinal manipulation and mobilization for low back lind nttk pain: A SYSlemlltic review 61 GI\"06S A. K.'l)' T. I londras M, el ill. M.mual and best evidence synthesis. Spine 2004; therapy (or mechaniC'cll neck disorders: a 4(3):335-356. li)'Sl.ematic review Manual 'n-.erapy. 2002; 7(3):131-149. 49 Koes B, Assendelft W, Ileijden G van det G2 Hurwitz E. Aker I~ Adams A. Meeker W. BoUler L. Spinal manipulation (or low back Shekelle P. Manipulalion and mobilization o( pilin. An updated ~)'Stematic review of Ihe cervical spine. A S)'lilematic review of the randomi¥.ed dinicaltrials. Spine 1996; Iitercllure. Spine 1996; 21 (15): 1746-1759. 21(24):2860-2871. 63 Bronfon C, Assendelfl \\'i, F.v,tns It l-faas M, 50 van Thlder M Koes B, Bouter L. Consef\\'ati\\'e Bollier 1_ Effic-clC)' of spinal manipulalion for Ireatment of aCUle and chronic nonspecific 10\\'\" chrooic headache: a syslemalic review. J back pain. A S)'SIematic revif'W o( randomized Manipulali\\'e I'hysKll \"Cher 2001; 24(7):457-66. controlled lrials of the mO!it common 64 Waddell G. lbe Back I~in Re\\'Qlulion, 2nd 000. inteJ\\'enlions. Spine 1997; 22( 18):2128-21 56. Edinburgh. UK: OlurchiIJ U'l1ngslone; 2004. 51 Bronfort C. Spinal manipulation: cunttll Slale 65 UK BfA\\t Trial 'learn. United Kingdom Back of research and its indications. Neurol Oin Jl'ain Exercise and Manipulation (UK BEA.M) 1999; 17(1):91-111. randomised lriaJ: l-.ffecth'Ult'SS of physical 52 52 r't'JTei.ra M, f-enei.ra I~ Lalimer ), Herbert It treatments (or back pain in primal)' care. Brit Maher C. Does spinal manipulali\\'e t1-.erap)' Med J 2004; 329(7479):1377.

Rationale for the use of high-velocity low-amplitude (HVLA) thrust techniques 66 DiGiovanna El. Schiowitz S. An Osteopathic 70 lull G. Trott I~ POller H, et at A randomized Approach to Di<lgnosis and Treatment, 2nd colllrolled lIial of exercise and manipulaliw ron. Philadelphia, PA: lippincott Williams & therapy for cervicogenic headache. Spine 1002; Wilkins; 1997. 17( 17}:1835-1843. 67 Mitchell F. The Muscle Energy Manual. EaSt 71 Gross A, Kay 1; Kennroy C. et al. ainiGl.I Lansing. MI: Ml:.T; 1995. practice guideline on the use of manipulation 68 Vernon H, Aker r. Burns S. Viljakaanen S, Shon or mobilization in Ihe treatment of adults with mechanKaI neck disorders. Man lher 2002; L Pressure pain threshold evaluation of the 7(4}:193-2OS. effect of spinal manipulation in the treatment of chronic neck pain: A pilot study. J 72 Grunnesjo M, Bogekldl S, Svardsudd K. Manipuhlli\\oe Ptlysiol'l1ler 1990; 13( 1):285-289. Blomberg S. A randomized controlled dinK:.al trial ofstay-aetiw care \\'oeI'SUS manual thetapy 69 Gibbons I', Gosling C. Holme; M. 11le shon in addition 10 slay-aeth-e care: f-unctional term effects of cervical manipulation on edge variables and pain, I Manipulalhoe Physiol Ther 2004; 27(7):431-441. light pupil cycle time: a pilot stud)'. I l>-tanipulatnoe I\"tlysiolTher 2000; 23(7}:46S-469, S3

Validation of clinical practice by research Responsibility for the scientific credence not an indulgence or academics. but Iss thai can be afforded osloopathic medicine constitutes the basis of best prncLicf' and rests largely within its own disc:ipline. quaJityassurance \"Ille osteopathic profession is obligated to question the value of teaching Various osteopathic authors ha,,~ unsubstantiated doctrines, except \\~thin acknO\\\\'ledged the need for research and the their historical perspecth'e. Students and the importance of rominwng to search for ne\\v profession should be encouragro 10 engage knowledge.J-S ,11e need for research should in active research. Research is nerned be indisputable. but where shouJd the both 10 establish the clinical efficacy of osteopathic profession's resources be osteopathic therapeutic inteT'\\~tion and concentrated? Bogduk and Mercer\" express a to elaborate the biological basis and view thai it is more valuable to demOl1su<ue physiological mechanisms that lU1derlie the the efficacy of a therapy before one explorE'S osteopathic principles of practice. Patient its mechartism. They suggest there may be satisfaction is also an important measure limited value in utiJi7jng scarce r£'SOUrc~ of the quality of care. I If there is to be a researching the underlying mechanisms of a commitment to researclt. where should the therapy that may eventually be shown to be osteopathic profession focus ils research ineffective. funds and activities? It would also be reasonable for a WHY UNDERTAKE RESEARCH? profession to hold the VleW thaI there is a place for bOth therapeutic trials alld Civen the tinallcial constraints placed upon continuing research 10 explore the biological health expenditure and Ihe increasing basis and physiological mechanisms that pressure upon thjrd-pany payers to underpin osteopathic Lreatmelll. However, it rationali7£ and limit costs,. one can expect should be recognized that even if we had a that health professionals will be required to clear understanding of the biological and demonstrate efficacy of treaunenL It will no physiological mechanisms underlying all longer be acceptable to claim that therapy is osteopathic therapeutic interventions. this in beneficial solely because individual patients itself would not prove that their use would report improvement after treatment. The produce a positive clinical outcome. Only challenge is to demonstrate that symptom properly conducted clinical trials can improvement is a direct outcome of specific I~timize a therapy by demonstrating intervention rather than nalural Il'CO\\'ff}' positive outcomes from therapeutic and that this inlervemion is moll' effecti\\T inu~rvention. Many government bodies. and cost-effective. than marketplace professional associations and third-pany competitors. Bogdulr argues that research is payers promote evidence based guidelines for the management of musculoskeletal pain.''' However. such guidelines are

HVLA thrust technique.s - an osteopathic perspective promoted without evidence of their advantages and limitations, with varying effectiveness.' applicability. differing ranges of validity and ethical conSLraints and will generate WHERE SHOULD RESEARCH differing sets of data Which approach would be most useful for outcome sttKiH's BE FOCUSED? in osteopathic medicine? The nature of the Research effort should be directed towards research question should guide the selection designing and implementing effective therapeutic mals that could demonstrate of research design. the efficacy or othenvise of therapeutic interventions.6 Validation of osteopathic One of the major problems associated practice b}' outcome studies could be a way forward. Management of patients utilizing wilh clinical trials related to spinal pain lies outcome measures has the benefit of establishing baselines. documenting in the area of diagnosis. I~ The aetiology progress and assisting in quality assurance. II of most low back pain is unknown,I7 with Osteopathic practice is diverse. Individual practitioners. depending upon their style of the pathological or structural diagnosis practice and interests, treat a wide variety of different complaints. Osteopaths see and uncertain in 80-90% of patients presenting treat a significant number of patients presenting with spinal pain.n.l ' Outcome with disabling back pain. la-XI Assessment studies on patients presenting with spinal pain and disability are an obvious area for procedures used may not be able to osteopathk research. Despite this faa. there is a paucity of osteopathic outcome studies. diagnose the pathology involved or may Various authors\"'),'· highlight the point be incorrectly interpreted.:n Problems that there are significant difficulties associated with clinical research in the associated with poor inter-observer osteopathic area StoddardI' emphasizes that clinical research in osteopath)' is reliability for clinical findings further hampered by the complexity and diversity of the presenting problems and the confound the picture. difficulties associated with patient allocation to syndrome groups that vary constantly Palpatory findings are integral to the over lime. Ilowevcr, similar problems associated with clinical research exist for establishment of an osteopathic diagnosis. other disciplines practising manual therapies. Despite the difficulties, other r\"OT palpatory diagnosis to be useful for disciplines are panicipating in an increasing number of research projects. classification purposes,. good inter..-aaminer reliability needs to be demonstrated It is well documented that there is poor inter- observer reliability for palpatory findin~ W.Ithout p·am pl\"O\\'OCa.tlon.1J-U .r-or ,._- '10;::.0::: reasons. current osteopathic diagnostic labels cannot be used effeah.oely in clinical trials of spiJlal pain 3Jld disability and an alternative means of classification needs to be identified. The Quebec Task r-orce16 reeogni7..oo the lack of uniformity in diagnostic temlinology used for spinal disorders and proposed a classification that does not depend upon pathological entities. but reflects the clinical presentations encountered in practice. A modified form of this classification am be utilized for conducting research. This classification system can be used by all PATIENT CLASSIFICATION clinicians. regardless of discipline.. to categorize patients with spinal pain in A possible spearum of research designs the clinical setting and links patient would include com-entional and symptomatology with dunnion of unconventional group designs. symptoms and working status (Table A.7.1). 56 ethnomethodological designs and single The Quebec Task Force classification consists case studies. IS Each research method has of 11 categories with classification based

Validation of clinical practice by research Table A.7.1 Classification of activity-related spinal disorders Classification Symptoms Duration of Working 1 Pain without radiation symptoms status at from onset time of 2 Pain + radiation to extremity, proximally } evaluation 3 Pain + radiation to extremity, distally 4 Pain + radiation to upper/lower limb + a «7 days) neurological signs b (7 days-7 weeks)) W (working) 5 Presumptive compression of a spinal nerve c(>7 weeks) I (idle) root on a simple roentgenogram (Le. spinal instability or fracture) W (working) 6 Compression of a spinal root confirmed by: I (idle) - specific imaging techniques (Le. CAT, myelography or MRI) - other diagnostic techniques (e.g. electromyography, venography) 7 Spinal stenosis 8 Post-surgical status, 1-6 months after intervention 9 Post-surgical status, > 6 months after intervention 9.1 Asymptomatic 9.2 Symptomatic 10 Chronic pain syndrome 11 Other diagnoses Source: Quebec Task Force.16 upon historical markers and clinical and osteopathic or mechanical diagnosis. '111is 57 paraclinical examinations. Some categories does not obviate the need for the are further subdivided by stage. i.e acute. practitioner to Wldertake a full and subacute and chronic. and whether the thorough assessment of each patient, but patiem is able to work. does allow classification of patients into groups for the purpose of research. lhis A number of authors have suggested form of classification removes the obstacles different methods of patient to research associated with a lack of classification.36•37 DeRosa and PonerfieJd37 standardization and validation of diagnostic modified the Quebec Task rWC£ tenninology in spinal disorders. classification for spinal pain, making it more appropriate for physical therapy The Quebec Task Forrel8 published a diagnosis rrable A.7.2). similar classification for whiplash-associated disorders. This classification of whiplash Dtegorizing patients using the Quebec 'provides Gl.tegories that are jointly Task Force or a similar system of exhaustive and mutually exclusive, clinically classification enables outcome studies 10 meaningful, stand the test of common sense be performed on groups of patients with and are \"user friendly\" LO investigators, spinal pain without the need for a specific

HVLA thrust techniques - an osteopathic perspective Tabll! A.7.2 Modified physical therapy diagnosis classification Category Definition 1 Bad. pain without radiation 2 Back pain w;th referral to extremity, pfOximally 3 Back pain with refenal to extremity, distally 4 5 Extremity pain greater than back pain 6 Back pain w;th radiation and neurological signs 7 «6Post-surgical status months or >6 months) Source: DeRosa and Porterfteld.v Chronic pain syndrome clinicians, and patients'. A classification upon work and leisure and p.!>ychosocial system exists that \\\\IOuld also allow outcome ftlctors. While patient records tire easily studies on 'whiplash' patients to be accessible to the practitioner, there are undertaken. 'lowever, if the measurable problems associated wilh this fonn of data outcome from a therapeutic intervemion is collection for the purpose of outcomes likel}' to be small, i.e. small effect size, then assessmenL Recording in palient records studies using these classification systems lacks slandardization and is often need to be undertaken on populations of incomplete and what is recorded may sufficient size to demonstrate a statistically nOt reOect what has acrually occurred.» significant change. Practitioners also record physical examinalion findinp;;,. but the large MEASURING OUTCOMES variability in normal values and poor inter- examiner agreement limit the use of such Consideration needs to be given as to what tests in research. instruments might be used to measure A variety of easily used tools has been patient outcomes arising from osteopathic developed that allO\\... praetilionen; 10 assess intervention. 'Ine process of selecting specific outcomes resuJting from lherapeutic appropriate measuring instruments can be interventions. Leibenson and YeomanslO broken down into three stages. have identified eight categories of available 1. The researcher muSt identify what he or outcome approaches Crable A.7.3). As lhe range of questionnaires and pain she wishes to measure, e.g. spinal pain raling scales is diverse. researchers must be and disability. confident that they have selected the most 2. What is to be measured mUSt be defined appropriate measurement tools for their dinical trials. A different approach and in quantifiable terms, e.g. the intensity of rating instrument would be selected for pain suffered by the patient. the impact assessment of chronic spinal pain, with the the pain and disability have upon the possibility of a strong affective component. patient's activities of daily living. etc. as compared with arute spinal pain. 3. Selection of appropriate data collection Clinicians undertaking research must be and recording instruments that will give cogni7.an1 of both the advantages and reliable and valid results. Broadly speaking. outcome measures disadvantages of individual outcome 58 attempt to quantify pain, physical assessment insnurnenls. Once the mosl impairment. limitation of activity, impact appropriate measurement tools have been

Validation of clinical practice by research Table A.7.3 Outcome approaches category based on assessment goals OUtC.OmH assessment instrument 1. Pain level 1 Numerical pain scale (NPS) 2 Visual analogue scale (VAS) 3 Mc.GilVMelzac::k Pain Questionnaire 2. Regionlcondition-specific disability 4 Oswestry low Bad< Pain Disability Questionnaire questionnaires 5 Roland-Morris low Back Pain Disability Questionnaire 6 Dallas Pain Questionnaire LBP 7 low Back Pain 'TyPE' S Neck Disability Index (NOI) Neck 9 Headache Disability Index (HOI) Headache 3. General health 10 Dartmouth COOP charts 11 Health Status Questionnaire 2.0 12 Short Form (SF)-36 4. Psychometrics 13 Health Status Questionnaire (HSQ) 20 14 5F-16 15 waddell's Non-organic LBP signs 16 Modif.ed lung Questionnaire 17 Modified Somatk Perception Questionnaire 18 Beck's Depression SCale 19 Fear Awidanc.e ~iefs Questionnaire 20 SCL~ 5. Patient satisfaction 21 Patient Satisfaction Questionnaire 22 Visit 5pedfK Questionnaire 23 Chiropractic Satisfaction Questionnaire 6. Job dissatisfaction 24 APGAR 7. General disability 25 Vermont Disability Questionnaire 26 Vermont Disability Questionnaire: brief form 27 Functional Assessment Screening Questionnaire 28 Fear Avoidance 8efiek Questionnaire 8. Job demands 29 Job Demands Questionnaire Source: Adapted from Leibenson and Yeomans.10 selected, they should be used throughout o\\'er time. '111e Oswestry Low Back Pain 59 the period of the study. Different scales and Disability Questionnaire·~-M and Ihe questionnaires are nOt interchangeable. Roland-Morris low Back Pain Disability Questionnaireu h3\\'e been shown in In relation to spinal pain and disability, randomized controlled trials to have validity there is evidence that appropriately designed and reliability in measuring results for questionnaires have at least equal scientific patients with back pain. A modified validity to practitioner measurements.40.~ Oswestry low Back Pain Disability Specific questionnaires can measure a Questionnaire demonstrated superior patient's presenting level of pain and measurement properties and higher levels disability and be used to reflect changes in of test-retest reliability and responsiveness that pain and disability after treatment and

·1------....;....-......;-.;......;,-------HVLA thrust techniques - an osteopathic perspective 1 100 mm )wI No pain 1-1- - - - - - - - - - - - - - - 1 1 Excnriating pain Figure A.7.1 Visual analogue scale. No pain 0 1 2 3 4 5 6 7 8 9 '0 Excruciating pain Figure A.7.2 Numerical rating scale. when compared with the Quebec Back Pain the 100 mm scale. This can be repeated at Disability Scale.46 ~ liken modified second and subsequent visits. 11le researcher venion of the Roland-Morris Disability measures the pain level for all visits by Questionnaire has shown greater sensitivity measuring from the left end of the 100 mm to change over time than the original line. As the line is 100 mm long. all version.47 Vernon and Mior'\" demonstrnted measurements can be expressed as a a high degree of test-retest reliability and percentage. Iloweve.r, even with this simple internal consistency for the Neck Disability scale. experience has demonstrated that Index. 'Ihis index was modified from the patients need oral reinforcement and Oswestry Low Back Pain Disability supervision in addition to wrillen Questionnaire. A whiplash specific disabijjty instructions in cm;e they use a circle or a questionnaire has also been developed cross to indicate level of pain rather than a that has shown internal consistency and perpendicular line. Such responses would validity.d render the rating imprecise and invalid. Of the large number of scales available Modifications to refine the use of the visual to measure functional disability and analogue scale to indude pain level at impairment in back. pain patients, the most present. a..-erage pain grade and worst pain widely accepted are the Roland Oswestl)'. grade. have been Suggested.53 If applied in a Million and Waddell scales.50 These scales c1iniGlI setting. it is recommended that the have been demonstrated to reliably detect scale be used every 2 weeks.54 changes in the level of disability and 'llle numerical rating scale is similar to impairment O\\Ier time and are reproducible the visual analogue scale. but offers the and acceptable to patients. Some patient more defined pain categories to questionnaires include items that may nOt mark. 'llIe patient is asked 10 rate the be directly relevant to a particular patient. severity of pain by marking one box on the \"lie patient-specific functional questiolUlaire scale in Figure A,7.2, allows the measurement of patient- With the verbal rating scale. the generated and -specific activities that are of patient must select an adjective. from a concern to them.S!.\"i2 standardized list, that best describes the 'ille subjective sensation of pam can be pain. 'lllere are many verbal rating scales self-rated by patients using a number of with the level of pain severity being different measures.. 'l1le mOSt commonl)' represented in the questionnaire varying used include the visual analogue scale. from as few as 4, to 14 (Fig. A.7.3). numerical rating scale and the verbal rating 'lllere is evidence that tissue tenderness is scale. With the visual analogue scale (Fig. also measurable. 'Ilie American College of 60 A.7.1). the patient records the level of pain Rheumatology recommends a five-grade by making a single perpendicular line along classification of tenderness (Box A.7.1 ).ss

7 IValidation of clinical practice by research _ _ _ __-------.J Not noticeable chronic pain. The Depression, Anxiety and Just I\"IOticeable Positive Outlook Scale (DAPOS) has been developed in an attempt to measure these Very v.eak Weak fpaacm.to.r~s in patients that present with chronic Mild CONCLUSION Moderate Strong There is a need for the osteopathic profession to undertake dinical research. Very strong Establishing the effectiveness of osteopathic Intense treatment was rated highly in a study of responses from a group of osteopathic Very intense professiooals.S!I Structured questionnaires and pain rating scales have been shown to s.-. be valid and reliable research instruments to evaluate the efficacy of any given therapy in Excru:::iating attering pain and disability. Biopsychosodat factors are of significance in the Figure A.7.3 Twelve-point verbal rating management of patients with chronic spinal scale. pain and questionnaires allow quantification of these factors. The use of standardized lox A.1.1 Standardi;zed palpation of classification systems enables comparison of tenc:lerr'lPSs (Wolfe et all99()Cl') efficacy of treatment between professions and of therapeutic approaches within a Using 4 kg of pressure (enough to blanch the profession. tip of the thumbnail if you pressed on a References table): 1 Oonab«lian A. The quality of care: how Qn it Grade 0 No tenderness be asscssed~ lAMA 1988; 260:1743-1748. Grade I Tenderness with no physical 2 Bogduk N. Editorial. Scientific monograph of Grade II \"'po\",. the Quebec Task force on whiplash·associated Tenderness with grimace and/or disorders. Spine 1995; 20(8S):8-9. Grade III flindl 3 Moor D. Aspects of clinical research in Grade IV osleop.1thy. Au~t I Oslcopmhy 1992; 5( I ):6-14. Tenderness with withdrawal (+ jump sign) 4 Ward RC. Myoho;cial relea..c conccplS. In; Ba~majian IV, Nyberg R, cd~. R<1lional Manual Withdrawal to non·noxious stimuli Therapies. Baltimore. MD: Williams &. Wilkins; 1993:223-241. Many practitioners will encounter 6' patients with chronic spinal pain in clinical 5 Spallro K. Northup and loki ~pet..'(hc~ round practice. II is nOw recognized that a out research conference. DO 1984; 24:81-82. biopsychosocial model is useful in helping manage these patients.56 '111e Distress & Risk 6 Bogduk N, Mercer S. Sck,<:tion and application Assessment Method (DRAM) has been oftrcatmcllL In: Re[~hauge K. Ca~ E. eds. developed as an easily applied and non- Musculoskeletal Physiotherapy, 1st 0011. threatening tool that allows a practitioner Oxford.: Buuerwonh·lleinemann; to determine if a patient requires a more 1995:169-181. comprehensive psychological eva.luation.~7 7 Nalional Health &. Medical Research Council Questionnaires measuring depression and (NHMRC). Evidence Based Management of other mood states are available but have Acute Musculoskeletal Pain. National Health & been criticized as they were not developed Medical Research Council: in patient populations suffering from 2003:httrr.J/www.nhmrC-.p.au!publicalions/:>y IlOpsesJcp94syn.hun.

HVLA thrust techniques - an osteopathic perspective 8 CrQM A. Kay'r, Kennedye. et aI. Clinical 23 Maryas'l;t.. Bach 1M. The: ndi<lbility of selected lechniques in clinical anhrometrio. ....ust I prnc1ice guidclines on lhe ~ of manipulalion Physiolher 1985; 31:175-199. or mobilil'.lllion in the lreatment of aduhs with mechanical ncc::k disorders. Man Ther 2002; 2' Mior SA. King RS, McGregor M, Bernard M. 7(4):193-205. lnlra- and inler-ocamine:r reliabilit}' of moljon • McGuirk 8, King \\\\I, Govind J. lowfy I. Bogduk palpation in lhe cervical spine. I Can N. Safety, efficacy. and C05t effectiveness of o.iropractic t\\5SOC 1985; 29:195-198. lMdence·base<J guideline5 for the managemenl 25 lo\\oe RM. Brodeur RR. Inlel- and imraexaminer I. of anile low back pain in primlll}' care. Spine reliabilily of motion palpation for the 2001; 26(23):2615-2622. thorarolumbar spine. I Manipulaliw: Ph}'~ioI Leibenson e. )'eomans S. OutCOR1f5 ~l Ther 1987; 10:1-4. in musculoskeletal medicine. Man Ther 1997; 2(2):67-74. 2. Boline PO, Kealing}C, Brist J, Denver G. 11 Jamison III <Ateop.athy in Australia; a sur.oey lnterexaminer reliability of palpalOry of OfitOOpalhs recognizo:1 by the Australian evaluatjon of the lumbar 5f)ine. ....m I Osteopathic A5§0ciation. Aust I Osteopathy Otiropr.tetic Mm 1988; 1:5-11. 1991; 3(2):3-11. 27 Ktoating JC. Bergmenn 1F. Iambs GE, Finer BA. 12 Burton AK Back pain in osu:opalhic ptaetice. Rheumalol Rdtabil 1981; 20:239-246. lawson K Inlerexaminer reliability of eighl \" ~ating Ie. Seville I. t.iuker We. looaac RS. ewalualh\"l\" dimensions of lumbar segnte!:ntal Quitoriano 1.1\\, Dydo M, Leibd DP. Inuasvbject abnormality. I ManipuJath\"l\" Ph}'5iol Ther 1990; aperimemal dnigm in OfilOOpalhic medicine; 13:463-470. appUcllions in dinica.1 practice. In: Bea.I Me. ed. The Principles of PalpalOry Diagn05is and 28 IJ\\imm llJM Van. ~jn I. 0CkhU}~ AI.. Manipulative'IKhnlque. Newarlc ....merican \"ortman 81. 1he ,,,,,Jut: ofsome clinical lestS Acadwly of Ostoop.alhy: 1990;205-214, Oflhe sacroiliac joinL Man Med 1990; 5:96-99. 14 SlOddard ..... Manual of <Ateop<tthic Practice. 29 Illln'q' O. Byfield O. Prelimiruuy Mudies \"'ilh a London: Ilute:hinson Medkall\"ublicalions; mechanical model for lhe evaluation of spinal 1969:281-282. mOlion palpatioo. elin 8iomecltanks 1991; 6:79-82. IS Aldridge O. Single-case research designs. Compleme:l1lary Met! Res 1988; 3(1);37-46. 30 Panzer OM. The reliability of lumbar mocion PllpatiOft. I Manipulaliw Physiol1her 1992; •• Force qr. SCientific apprO\"lCh 10 the assessmem 15(8};S18-524. and n13nagemenl of activity.related spinal disorders. Spine: 1987; 12(75): 16-21. 31 lewit t<. Uebmson C. Palpation - problems .7 SChultz. AB, Warwick ON. IJe:rkson MH, and implicaLions. J Manipulative Physiol 1'her Na<:hemwn i\\L Mechanical properties of 1993; 16(9):586-590. human lumb.1r spine motion seg~nts. J Riomed Eng 1979; 101:46-52. 32 Nyberg R. Manipulation: definition. types,. applicaLion. In: I~majian IV. Nybe:rg R. eds. '8 Ca.'iS EM. The challenging role for Raliomll Manual Therapies, BaiLimore. MO: physiolhernpy in chronic musculoskeletal Williams & Wilkins; 1993:22-47, diwrders. In: He[\"hauge t<. Cas.\" E, eds. 33 1.a..~leli /l.i, William.~ M. The reliability of seleclcd pain provocalion 1e:';1$ forsacro-iliac Mu.\"Culoskelet.1l Physiolherapy, Oxford: joint palhology. In: Leemillg A. Mooney V, 13uuerworth-lleinemann; 1995:206-217. Dorman'l: Snijders C. cd!l, The Integrated Funrlion of lhe Lumbar Spine and I' sc.Nadll~msol1 AI_ 'nlt' nalura! course of low back Sacroiliac Joint. ROlterdam: ECO; 1995: pain. In: While AI\\, Gordon eds. American 485-498, Academy of Orthopaedic Surgeons Symposium 011 Idiopathic tow Back Pain. SL Louis. MO: 34 Vinc:elll-$mith 13, Giblx)I1s P. Inler-examiner Mosb}~ 1982:45-51, aud illlra-examiner reliability of palpalO!}' findings for lhe slanding flexion lest. Man TIler 2. Dillane JB. Fry I, KallOn G. Acute back 1999; 4(2):87-93. syndrome - a sludy from genera! pract.ice. BMJ 35 O'llaire C. Gibbons P, 111Ier-examiner and 1966; 2:82-84. intra-e:xaminer reliability for assessing sacroiliac: 21 Don'ligny RL Fw1Ction and pathomechanics of analomicallandmarks using palpalion and lhe: sacroiliac: joinL Phys Ther 1985; 65:35-43. observation: .... pilot study. Man Ther 2000; 5(1):13-20. 22 Connella e. Paris S. Kutner M. Reliability in 3. DC}'O RA. Clinical ConceplS in Regional 62 evaluating ~ive intel>WlebraJ motion. Ph}~ Musculo-ske1etal 1I1ness. London: Crune & 1her 1982; 62:436-444. Stratton; 1987:25-50.

Validation of clinical practice by research 37 DeRosa CP, Poneriield JA,. A pll)'Sical wrapy 4. l>infOld M, NN.ore K O'lnry F. I loving J, Green S. Buchbinder R. Validity and. intfmal model rOJ the lreaunent or low back pain. Ph)'S consistency or a whipiash-spKific disability Ther 1992; 72(4):261-269. meawre. Spine 2004; 29(3):263-268. 38 Force QT. Scientific moJlOgJ3pll of the Quebec SO Kopec JA,. Functional disability salt'S for back 1Ilsk Force on whiplash-assodated diliorder$: pain. Spine 1995; 20(17).1943-1949. redefining 'whiplash' and its maO¥JT'Ie'nL Spine 1995; 20(8S):1O-73. r.51 St.-tforo Gill C, W~away M, Binkley I. 3. Fowkes feR. Medical audit cycle. Med F..duc Msessing disability and change on individual 1982; 16(4):228-238. patients: a \"->pOrt of a patiem specific measure. Ph)'siOlher Can 1995; 47:258-263. 40 McDowell I. Newell C. Measuring Ilealth: A Guide to Rating SCale:- ilnd Questionllain!S. 52 WCSJa\\Vll)' M, Slratford P, Binkley I. 11le patient. New York; Oxford Pra~ 1987. spedfic functional scale: validation of its use in penollli with nt'<k dysfunrlion. J Onhop Sports 41 lX}'O R. Measuring the funcLional status of PII)'S Ther 1998; 27:331-338. p<\\lienlS with low back pain. Arch Phys Med Rehabi1198B; 69:1044-1053. 53 Korff M \\bn, Dq.o RA. Cherkin D, Barlow W. Back pain In primary OIre: OUtcomes at one 42 Fairbanks J, Davit'S J, Couper I, O'Brien J. The )'t'ar. Spine 1993; 18:85S-862- OSWC5IJ)' Low Back Pain Disability Que:slionnaire. Physiotherapy 1980; 54 Dq'O RA. o.ertdn DC. Franklin C. Nkhols }C. 66:271-272. Low Back Pain. Bloomington, MN: liralth Outcomes InsLitutr, 1992(October):forms 6.1 43 Meade 1W, Dyer S. 8rowne \\'I; Townstnd I, to 6.4. Frank AD. Low back pain of memaniG\\l origin: 55 Wolfe F. Smythe HA. Yunnus MR. The randomi7.ed compari<;On of chiropr;lCtic and hospital OUlpatiUlllreaunem. 8MI 1990; American College of Rheumatology 1990: 3OO:t431-1437. oheOa for classification of fibromya!gia. Anhritis Rheum 1990; 33:160-172. 44 Iisieh 0, Phillips RH, Adams AH, Pope MIl. Functional outcomes of low back pain: 56 llosier N, Pincus 1; Underwood M, Vogel S, comparison of four treatment groups in a l3leen A. I larding G. Understanding the proceM Tilndomi7.cd colllrolled trial. J Manipulativt\" of care for musculoskeletal conditions - why il Physio! Ther 1992; IS( I ):4-9. biomedical approach is [nildequate.. Rheumatology 2003; 42:401-403. 45 Roland M, Morris R A Study of (he natural hiStOf)' of back pain. Part I: development ofa 57 Maher C. Latimer I, Refdla. K. AlIas of reliable and. sensitive measure of disability in dinical1£Sts and measures for low bade pain. low-back pain. Spine 1983; 8:14t-I44. Melbourne: Australian Ph)'Siotherapy Association; 2000. 46 Fritz 1M, Irrgang JI. A comparison of a modified Oswesuy low Back Pain Disability 58 Pincus To williams A. \\'o8e1 S. Field A. The Questionnaire and the Quebec Back Pain Disability Scale. Phys 1hef\" 2001; daelopmenl and testing of Ih£ depression,. 81(2):776-788. anxiet): and posiiM outlook scale (DAPOS). I'ain 2004; 109(1/2):181-188. 47 \\\\lakhe D, ftlddifTe J. Pain beliefs and perceived physical disability of patients with 5. Jamison !R. Contemporary issues in chronic!ow bock pain.I\"ain 2002; 97:23-31. OSltoPillhy: a Delphi study. Aust J Osteop;!lhy 1991; 3(2):24-29. 48 Vernon H, Mior S. TIle Neck Disability Index: a slUdy of reliability and valid.ily. J Manipuliluve Physio! Ther 1991; 14(7):409-41S. 63

HVLA thrust PART techniques - sp•ine and thorax SECTION 1 Cervical and cervicothoracic spine 69 \"ieNote: Before reviewing up-slope and down-slope lIVLA rllnl5l techniques, the Introduction on CD-ROM should be viewed. 1.1 Atlanto-occipital joint (0-C1: contact point on occiput; chin hold; patient supine; anterior and superior thrust in a curved plane 71 1.2 Atlanto-occipital joint (0-(1: contact point on atlas; chin hold; patient supine; anterior and 5uperiOf thrust in a curved plane 77 1.3 Atlanto-axial joint (1-2: chin hold; patient supine; rotation thrust 81 1.4 Atlanto-axial joint (1-2: cradle hold; patient supine; rotation thrust 85 1.5 Cervical spine (2-7: up-slope gliding; chin hold; patient supine 89 1.6 Cervical spine 0-7: uJHlope gliding; chin hold; patient supine - variation 93 1.7 Cervkal spine 0-7: ulHlope gliding; cradle hold; patient supine 97 1.8 Cervical spine 0-7: up-slope gliding; cradle hold; patient supine; reversed primary and secondary leverage 101 1.9 Cervical spine 0-7: up-slope gliding; patient sitting; operator standing in front 107 1.10 Cervical spine 0-7: uJ)'\"slope gliding; patient sitting; operator standing to the side 111 1.1J Cervical spine C2-7: down-slope gliding; chin hold; patient supine 115 1.12 Cervical spine C2-7: down-slope gliding; cradle hold; patient supine 121 J.13 Cervical spine C2-7: down-slope gliding; patient sittIng; operator standing to the side 127 1.14 Cervicothoracic spine C7-n: rotation gliding; patient prone; operator at side of couch 131 J.15 Cervicothoracic spine 0-n: rotation gliding; patient prone; operator at head of couch 135 1.1G Cervicothorack spine C7-n: rotatton gliding; patient prone; operator at head of couch - variation 139 J. J 7 Cervicothoracic spine 0-TI: sidebending gliding; padent sitting 143 I. J8 Cervicothoradc spine C7-TI: sidebending gliding; patient sitting; ligamentous myofasdal tension locking 147

HVLA thrust techniques - spine and thorax 1.19 Cervicothoradc spine O-T3; sidebending gliding; patient side-lying 151 , .20 Cervicothoraclc spine 0-T3: sidebending gliding: patient side-lying; ligamentous myofascial tension locking 1SS 1.21 Cervicothoracic spine Cl-T3: extension gliding; patient sitting; ligamentous myofascial tension locking 159 SECf/ON 2 Thoracic spine and rib cage 163 2. J Thoracic spine T4-9: extension gliding; patient sitting; ligamentous myofasciat tension locking 167 2.2 Thoracic spine T4-9: flexion gliding; patient supine; ligamentous myofasdal tension locking 171 2.3 Thoracic spine T4-9: rotation gliding; patient supine; ligamentous myofascial tension locking 177 2.4 Thor-acic spine T4-9: rotation gliding; patient prone; short lever technique 183 2.5 Ribs Rl-3: patient prone; gliding thrust 189 2.6 Ribs R4-10: patient supine; gliding thrust; ligamentous myofascial tension locking 193 2.7 Ribs R4-10: patient prone; gliding thrust 197 2.8 Ribs R4-10: patient sitting; gliding thrust 201 SEC110N 3 Lumbar and thoracolumbar spine 205 Note: Before retliewing side-lying HVLA dttlLSr rechnu,ues in rhe lumbar mul dlClr\"acolumoor spine. rhe hlt.TlXluaitm on the CO-ROM 51tould be viewed. 3. J Thoracolumbar spine Tl ~12: neutral positioning; patient side-lying; rotation gliding thrust 209 3.2 Thoracolumbar spine Tl o-l2: flexion positioning; patient side-lying; rotation gliding thrust 213 3.3 lumbar spine ll-S: neutral positioning; patient side-lying; rotation gliding thrust 217 3.4 lumbar spine ll-S: flexion positioning; patient side-lying; rotation gliding thrust 221 3.5 lumbar spine 11-5: neutral positioning; patient sitting; rotation gliding thrust 225 3.6 lumbosacral joint l5-$1: neutral pOSitioning; patient side-lying; thrust direction is dependent upon apophysial joint plane 229 3.7 lumbosacral joint L5-51: flexion positioning; patient side-lying; thrust direction is dependent upon apophysial joint plane 233 Introduction Part B includes 36 manipulative techntques techniques applied to spinal joints. HVlA applied to the spine from the atlanto-occipital thrust techniques are also known by a to the lumbosacral joint. Ml techniques are number d different names, e.g. adjustment, described using a variable hetght high-velocity thrust,. mobilization with manipulation couch. impulse, grade Vmobifization. Despite the 66 different nomenclature, the common feature in techniques of this type is that they are This part of the bl:x)k relates to spedftC high- velocity low-amplitude (HVlA) thrust

Introduc=tio:n....._-~ designed to achieve a joint cavitation (pop the limit of its available range and not at its 67 or cracking sound) within synovial joints of anatomical barrier. No text can teach the the spine. The cause of the popping Of subtle nuances of HVlA thrust techniques. For cracking sound is open to some speculation. example. the sense of appropriate pre-thrust tension is difficult to describe and acquire. Information gained from a thorough history. Experienced practitioners often use c1iniccM examination and segmental analysis compression as an additional lever. Extensive will direct the practitioner towards any practice under the supervision of skilled and possi~ somatic dysfunction and/or experienced clinicians is strongly pathology. The use d HVlA techniques is recommended. dependent on a diagnosis of somatic dysfunction. The majority of techniques are described using facet apposition IoclOng. In broad Somatic dysfunction is identified by the terms, facet apposition kxking uses 5-T-A-R-T of diagnosis: combinations of sidebending and rotation. An understanding of the biomechanics • S relates to symptom reproduction assodated with coupled movements of the • T relates to tissue tenderness spine in different postures allows the operator • A relates to asymmetry to decide on optimal leverages. While rotation • R relates to range of motion and sidebending are the principal leverages • T relates to tissue texture changes used, the more experienced manipulator may include elements of flexion, extension. The manual is designed in a format that translation. compression or traction to presents a standardized approach to each enhance localization of forces and patient region of the spine. If the instructions are comfort. follOVoled conscientiously, the novice manipulator will be well placed to achieve a Patient relaxation is an essential prerequisite positive outcome from the procedure. The for effective HVlA thrust techniques. This may nature of manipulative pl\"aetice is such that be facilitated by the use of respiration and there are many different ways to achieve joint other distraction methods. cavitation at any given spinal segment. Many clinicians achieve extremely high levels of After making a diagnosis d somatic expertise and competence in the use of HVLA dysfunction and prior to proceeding with a thrust techniques. This Is the result of many thrust.. it is recommended that the following years of individual clinical experience and checklist be used for each of the techniques practice. described in this section: This manual is designed to be a safe and • Have I excluded all contraindicatlons? effective starting point upon which • Have I explained to the patient what Iam practitioners can build basic. and then more refined. technical skills. The text lays out the going to do? primary and secondary joint leverages • Do I have informed consent? required to facilitate effective localization of • Is the patient well positioned and forces to a specific segment of the spine prior to application of the thrust. If the instructions comfortable? are followed. the resultant thrust is likely to • Am I in a comfortable and balanced achieve joint gliding and cavitation with the use of minimal force. The joint to be thrust position? should not be locked by facet apposition, but • Do I need to modify any pre-thrust physical remain free so that the practitioner can direct a gliding thrust along the joint plane. or biomechanical factors? Appropriate pre-thrust tension is then • Have I achieved appropriate pre-thrust developed by positioning the joint towards tissue tension? • Am I relaxed and confident to proceed? • Is the patient relaxed and wilting for me to proceed?

Cervical and SECTION cervicothoracic spine CERVICAL SPINE HOLDS AND GRIPS The hold or wrist position selected for any paniOllar techniqu~ is that which enables the operator to effectively locali7..e forces to a specific segment of the spine and deliver a high-velocity low-amplitude (HVLA) thrust in a controlled manner. Patient comfort mllSt be a major consideration in selecting the most appropriate hold. Chin hold • Operator's left forearm must be over, or slightly in fronl of, the patient's left ear. • Operator's fingers lightly clasp lhe patielll's dlin. • Operator's cltest should be in (on tad with the vertex of the patient's head. • Operator's right hand applies applicator to (on tad point. 69 _ _ _ _ _------=-1

., HVlA thrust techniques - spine and thorax Cradle hold Wrist position • Patient's left ear resting in the palm of Operators can select from either the pistol opc.>. rator's left hand. grip or wrist extension grip. • Operator's left hand spread oul for maximum conlact. • Operators right hand applies applicator to contact point and gives support to the patient's OCcipuL • The \\veight of the patient's head and neck is balanced between the operator's left and right hands. Pistol grip Note: radius in line with first metacarpal. Wrist e.xtension grip Note: wrist extension. 70

Atlanta-occipital joint (0-(1 Contact point on occiput Chin hold Patient supine Anterior and superior thrust in a curved plane Assume somatic dysfimcliolJ (S-T-A-R-T) is identified and)'ou wisl1 to use a tllmsl in the plane of the CO-Cl apophysial joim to produce caviWtiOll 011 til. rigllt (Fig. BI. 1.1) Figure 81.1.1 1. Contact point KEY RighI posterior occiput. Medial and >t: Stabilization posterior to the mastoid process. • Applicator 2. Applicator - Plane of thrust (operator) Laleral border, proximal or middle phalanx E::> Direction of body movement of the operator's right index finger. (patient) 3. Patient positioning Note: The dimensions for the arrows are not a pictorial representation of Supine: \\vith the neck in a neutral relaxed the amplitude or force of the thrust. position. If necessary. remove pillow or adjust pillow heighL The: neck should not be in any significant amount of flexion or 71 extension. 4. Operator stance Head of couch. feet spread Slighlly. Adjust couch height so lhat the operator can stand

...1--------HV.l.A:th.r.us;t,te.c.hn.i.qu.e:s .- .sp.i.ne;a.n,d;th\"or,ax.........;..;,..--------- as erect as possible and avoid crouching conlro)kd by balancing forces bel....'t'eTl lhe over the patient. as this will limit lhe right palm and left forearm. Maintain lhe tt.'Chnique and restrict delh!ff)' of lhe thrust. applicator in position. S. Palpation of contact point 8. Vertex contact Place fingers of both hands gently under lhe MO\\'e your body forward slightly so that occiput. Uft the head slightl),. and gently your chest is in contact with the vertex of rotate it to the left. taking the weight of the the patient's head. The head is now securely head in your left hand. Remove )'Our right cradled between the left forearm. the flexed hand from the occiput and palpate the left elbow, the right palm and )'Our chest. contact point on lhe occiput wilh the tip of Vertex contact is often useful in a heavy, stiff your index or middle finger. Ensure lhat you or difficult case but can. on occasions. be an:..;nediaLtp, and not on,.the mastoid omitted. procns. Slowly but firmly slide your right index finger. in close approximation to 9. Positioning for thrust the suboccipital musculatur~ downward Step to the right and stand across the right (towards lhe couch) along the occiput until corner of the couch. keeping lhe hands it approximates the middle or proximal firmly in position and taking care not to phalanx. Severnl sliding pressures may be lose pressure on the contact poinL Gently necessary to establish close approximation introduce a little rotation of the head to the to the contact point. It is imponant to left. Straighten your right wrist so that the obtain a contact point as far along lhe radius and first metacarpal are in line. While underside of lhe occiput as possible and maintaining firm applicator pressure,. allow into lhe suboccipital musculature. 1bis lhe right index finger to roll slightly on lhe thrust uses a cwved plane of movement to comaa point as you move your right elbow produce a cavitation and this positioning towards the patient's right shoulder. This ensures that the applicator will not slip facilitates optimal alignment for the thrust, during the thrLl5t. which is in a curved plane because of the 6. Fixation of contact point shape of the apophysial joint. It is important that your applicator is well Keep your right index finger firmly pressed beneath the OCcipUl so that you do not slip on the contact point whiJe you flex the when applying the thrust along a curved other fingers and thlUllb of lhe right hand facet plane. Keep your right elbow close to so as to clasp the back of the occiput and the couch in order to keep the contact point head, thereby locking the applicator in on the occiput (Fig. 81.1.2). position. You must now kE..'€p the applicator on the contact point until the technique is Add extension and slight side~nding to complete. Keeping the hands in position, the right to provide a feeling of tension at return the head to the neutral position. the contact point. 'Ihe extension and right side~llding are introduced by pivoting slightly via lhe legs and trunk so that your 7. Chin hold trunk and upper body rotate to the left. Do not attempt to introduce sidebending by Keep )'our right hand in position and slide moving the hands or arms as this will lead the left hand. slowly and carefully. forwards to loss of contact and inacrurate technique. until lhe fingers lightly clasp the chin. \"Ibis technique does not use facet apposition Ensure that your left forearm is over or locking. \"Ihe pre-thrust tension is achieved slightly anterior to the ear. Placing lhe by positioning lhe occipito-atlantal joint 72 forearm on or behind the ear polS lhe neck towards the end range of available joint into too much flexion. The head is now gliding while avoiding excessive rotation

Cervical and cervicothoracic spine Figure 81.1.2 and sid€bending J€\\'efages. ExtensiV€ operator and patierll are relaxed and not praClic€ is necESSary to d€V€lop an holding themselves rigid. This is a common appreciation of th€ required tension. impediment to achieving effective cavitation. 10. Adjustments to ac:hieve appropriate pre-thrust tension Ensure th€ patient's head and neck remain on the pillO\\\" as this facilitates the Ensure the patient remains relaxed. arrest of the technique and limits excessive Maintaining all holds, make any necessary amplitude of thrust. minor changes in flexion, extension, sidebending or rOlation until you can sense 12. Delivering the thrust a stat€ of appropriate tension and leverage at th€ contact point. TIle paoem should not This is a difficult technique to master, as the be aware of any pain or discomfort. You thrust mU~1 be appli€d aJong a curved plane. should introduce these finaJ adjustments by Apply a HVLi\\ thrust to the occipUl, using slight movements of the ankles, knees, hips both hands, in an ant€rior and superior and trunk, nOl by altering the position of direction along a curved plane which your hands or arms. follows the shape of the occipito~atlalHaJ articulation (Fig. 81.1.3). 11. Immediately pre-thrust The thrust, although V€ry rapid, must Relax and adjust your balance as necessalY. never be ex((.'SSiv€ly forcible. llle aim Keep your head up; looking down impedes should be to use the absolute minimum of the thrust and can cause embarrassing force necessary to achi€ve joint cavitation. proximity to the patient. An effective HVlA A common fault arises from the use of thrust technique is best achieved if the excessive amplitude with insufficient velocity of thrust. 73

HVlA thrust techniques - spine and thorax Figure 81.1.3 74

Cervical and cervicothoradc spine SUMMARY Atlanta-occipital joint (0-(1 Contact pOint on occiput Chin hold Patient supine • Contact point: Right posterior occiput • Applicator: Lateral border. proximal or middle phalanx • Patient positioning: Supine with the neck in a neutral relaxed position • Operator stance: Head of couch. feet spread slightly • Palpation of contact point: Ensure that you are medial to, and not on, the mastoid process • Fixation of contact point • Chin hold: Ensure your left forearm is over or slightty anterior to the ear • Vertex contact Optional • Positioning for thrust: Step to the right and stand across the right corner of 0 /the ~. Optimal alignment for the thrust is in a curved plane. Keep your right Ibow close to the couch in order to keeeJhe contact ~int on the ~ oeciput (Fig. Bl.1.2) ~ t\\f'{}• Adjustments to achieve appropriate pre::thruslte.nsioo / • Immediately pre-thrust: Relax and adjust yo~ balance • Delivering the thrust: The thrust must be applied, using both hands, along a curved plane that follows the shape of the occipita-atlantal articulation.(Fig. B1.1.3) 75 I

Atlanto-occipital joint CO-C1 Contact point on atlas Chin hold Patient supine Anterior and superior thrust in a curved plane Assume somatic dysfunction (S-T-A-R-T) is identified and you wish to use a thrust in the plane of the CO-Cl apophysial joint to produce cavitation on the right': KEY 1. Contact point ~* Stabilization Right posterior arch of atlas. ~ • Applicator 2. Applicator - Plane of thrust (operator) Lateral border, proximal or middle phalanx of operator's right index finger. r;) Direction of body movement (patient) 3. Patient positioning Note: The dimensions for the arrows Supine with the neck in a neutral relaxed are not a pictorial representation of position. If Of.\". Ct'Ssary, remove pillow or the amplitude or force of the thrust. adjust pillow height. \"The neck should not be in any significant amount of flexion or extension. 77 4. Operator stance Head of coud\" feet spread slightly. Adjust couch height so that the operator can stand

HVlA thrust techniques - spine and thorax as erect as possible and avoid crouching cradkxl. between the left foreann, tht: flexed over the patient as this will limit the left elbow, the right palm and your chest. technique and restria delivery of the thrust. Venex contact is essemial in this technique. 5. Palpation of contact point 9. Positioning for thrust Place fingers of both hands gently lmder the Step to the right and stand across the right occiput. Uft the head slightly and gently comer of the couch. keeping the hands rotate it to the left. taking the \\veight of the finnly in position and taking care not to head in your left hand. Remove )'our right lose pressure on the COntact point. Gently hand from occiput and palpate the contan introduce a little rotaLion of the head to the point on the right posterior arch oflhe atlas left. Straighten )'OUT right wri~1 so that the with the tip of your index or middle finger_ radius and first metacarpal are in line. While Slowly but firmly slide YOUT right index maintaining finn applicator pressure allow finger. in dose approximaLion to the the right index finger to roll slightly on the suboccipital musculature,. downwards comaa point as you move your right elbow (to\\vards the couch) along the posterior to\\vards the patient's right shoulder_ This arch of the atlas unlil it approximates the facilitates optimal alignment for the thrust. middle or proximal phalanx. Several sliding which is in a auvro plane because of the pressures may be necessary to establish dose shape of the apophysial joint. It is approximation to the contact point. important that your applicator has a firm contact on the atlas so that you do not slip 6. Fixation of contact point when applying the thrust along a anved Keq> your right index fiJlgeT finnly pressed facet plane. Keep )'OlIr right elbow dose 10 on the cOlltaa point while )'OU flex the the couch in order to keep the contad point other fingers and thumb of the right hand on the atlas (Fig. B1.2. J). so as to clasp the back of the occiput and head. thereby locking the applicator in Add extension and slight sidebrnding 10 position. You must now keq> the applicalor tlle right to provide a feeling of tension at on tht: contaa point until the technique is tlle contact point. The extension and right complett:. Keeping the hands in position, sidebending are introduced by pivotjng return the head to the neutral position. slightly via the legs and trunk so your trunk and upper body rotate to tht: left. Do not attempt to introduce sid~bendingby 7. Chin hold moving the hands or anns, as this will lead to Joss of contact and inaccurate tt:chnique. Keep your right hand in position and slide This technique does not use facet apposition the left hand, slowly and carefully, fOl'\\vards locking. 11lt: pre-thrust tension is achieved until the fingers lightly clasp the chin. by positioning the occipito-atlantal joint Ensure that your left forearm is over or towards the end range of available joint slightly anterior to the ear. Placing the gliding while avoiding excessive rotation forearm on or behind the ear puts the neck and sidebending leverages. Extensive into too much flexion. The head is now practice is necessary to deveJop an controlled by balancing forces between the appreciation of the required tension. right palm and left forearm. Maintain the applicator in position. 10. Adjustments to achieve appropriate pre-thrust tension B. Vertex contact Ensure the patient remains relaxed. Move your body fonvard slightly so that Maintaining all holds, make any necessary 78 your chest is in cOnlaa with the \\'eI1ex of minor changes in nexion. e>..1.t'Jlsion, the patient's head. The head is nO\\v securely sidebending or rotation until )00 can sense

.Cervical and cervicothoracic spine 1.2 Figure 81.2.1 Figure 81.2.2 a state of appropriate tension and leverage thrust technique is best achieved if the 79 at the contact point The patient should not operator and patient are relaxed and not be aware of any pain or discomfort. You holding themselves rigid. This is a common should introduce these final adjustmentS by impediment to achieving effective slight movements of the ankles. knees. h.ips cavitalion. and trunk. not by altering the position of your hands or arms. Ensure the patient's head and neck remain on the pillow as Ihis fadJitates the 11. Immediately pre-thrust arrest of the technique and limits excessive amplitude of thrust Relax and adjust your balance as necessary. Keep your head up; looking dow'll impedes 12. Delivering the thrust the thruSt and can cause embarrassing proximity to the patient. An effectiw HVLA This is a difficult technique 10 masler, as the thrust must be applied along a curved plane.

HVLA thrust techniques - spine and thorax Apply a HVLA thrust to the posterior arch of 'the thruSl, although very rapid, mUsl never the atlas in an anle.rior and superior be excessively forcible. The aim should be to direction along a curved plane. which use Ihe absolute minimum force necessary follows the shape of the ocdpito-atJantal to achieve joinl ci1Vilation. A common faul! articulation. Apply no simultaneous rapid arises from the use of excessive amplilude increase of celVic:a1 rotation. extension or with insuffidelll velocity of thrust. sidebending with the left hand (Fig. 81.2.2). SUMMARY Atlanta-occipital joint (0-(1 Contact point on atlas Chin hold Patient supine • Contact point: Right posterior arch of atlas • Applicator: Lateral border, proximal or middle phalanx • Patient positioning: Supine with the neck in a neutral relaxed position • Operator stance: Head of couch, feet spread sltghtly • Palpation of contact point • Fixation of contact point • Chin hold: Ensure your left forearm is over or slightly anterior to the ear • Vertex contact: Essential in this technique • Positioning for thrust: Step to the right and stand across the right corner of the couch. Optimal alignment for the thrust is in a curved plane. Keep your right elbow close to the couch in order to keep the contact point on the atlas (Fig. 61.2.1) • Adjustments to achieve appropriate pre-thrust tension • Immediately pre-thrust: Relax and adjust your balance • Defivering the thrust: The thrust must be applied along a curved plane. which follows the shape of the ocdpito-atlantal articulation (Fig. Bl.2.2) 80

Atlanta-axial joint (1-2 Chin hold Patient supine Rotation thrust Assume somatic dysfunction (S-1:A-R-T) is identified and rou luisll I,D use a IhnlSl in the plane of the aI/mIlo-axial (CI-2) apophysial joint 10 produce cavililtiOlI Oil l1Ie rig111 (Figs 81.3.1. 81.3.2) Figure B1.3.1 Figure 813.2 KEY 1. Contad point Right posterior arch of alias. .:;, Stabilization • Applicator 2. Applicator .. Plane of thrust (operator) Lateral border, proximal or middle phalanx ¢ Direction of body movement of operator's right index finger. (patient) 3. Patient positioning Note: The dimensions for the arrows Supine with Ihe neck in a nama I relaxed are not a pictorial representation of position. If necessary. remove pillow or the amplitude Of force of the thrust. adjust pillow height. \"Ine neck should not be in any significant amount of flexion or extension. 8'

HVLA thrust techniques - spine and thorax 4. Operator stance the patient's head. The head is now securely cradled between the left forearm, the flexed I lead of couch, feet spread slightly. Adjust len ell>O\\..... the right palm and your chest. Vertex contact is onen useful in a heavy, sLiff couch height so that the operator can stand or difficult case but can. on occasions. be as erect as possible and avoid crouching over the patient as this will limit the omitted. technique and restrict delivery of the thrust. S. Palpation of contact point 9. Positioning for thrust Place fingers of both hando; gently under the Step to the right and stand across the right occiput. Uft the head slightly and gently comer of the couch, keeping the hands rotate it to the left, taking the weight of the firmly in position and taking care not to head in your left hand. Remove your right lose pressure on the contact point Cently hand from the occiput and palpate the introduce rOlation of !.he head to the left.. region of the right posterior arch of the atlas to the point at which the posterior arch with the tip of your index or middle finger. becomes more obvious under your contad Slowly but finnly slide your right index point. Straighten your right wrist SO that the finger downwards (towards the couch) radius and first me:taea.Jpal are in line. While along the posterior arch of the atlas until maintaining finn applicator pressure. allow it approximates the middle or proximal the right index finger to roll slightly on the phalanx. Several sliding pressures may be contact point as you mO\\'e your right ell>O\\.... necessary to establish dose approximation towards the patient's right shoulder to reach to the contact point. that point when your line of thrust is 6. Fixation of contact point directed towards the comer of the patient's mouth. The thrust plane is into rotation. Keep your right index finger finnly pressed Ensure that yOU maintain a firm comact upon the contact point while you flex the point on the posterior arch of the atlas and other fingers and thumb of the right hand. that your applicator is in line with )'our foreann. so as to clasp the back of the neck and (a) Primary 'etremge of rotahOri. Maintaining all holds and contact points. occiput.. thereby locking the applicator in complete full rotatjon of the head and neck position. You must now keep the applicator to the left until slight tension is palpated in on the contact point until the technique is the tissues at your contact point (Fig. complete. Keeping the hands in position, return the head to the neutral position. 7. Chin hold 81.3.3). Maintain firm pressure against the contact point. A common mistake is to use Keep your right hand in position and slide insufficient head and neck rotation. the left hand, slowly and carefully, forwards (b) Secorldnry k'lICmge. This technklue uses until the fingers lightly clasp the chin. minimal secondary leverage. This technique Ensure that your left forearm is over, or does not use facet apposition locking. slightly anterior to, the ear. Placing the Extensive practice is necessary to dC\\oclop an foreann on or behind the ear putS the neck appreciation of the required tension. into too much flexion. The head is 110\\.... controlled by balancing forces bet\\\\ttr1 the 10. Adjustments to achieve appropriate right palm and left forearm. Maintain the pre-thrust tension applicator in position. This is almost a pure rotation thrust but 8. Vertex contact the appropriate tension can be achiC\\'Cd Move your body forward slightly so that by adjusting flexion, extension and 82 your chest is in contact with the venex of sidebending. The patient should not be aware of any pain or discomfort. Introduce

I 7.3 Cervical and cervicothoracic spine Figure 81.33 Figure 81.3.4 any sidebending. flexion or extension by proximily to the palient. An effective HVLA 83 pivoting slightly via the legs and trunk. Do thrust technique is best achieved if the not attempt to introduce these leverages by operntor and patient are relaxed and not moving the hands or arms as tJlis will lead holding themselves rigid. 'I'his is a common to loss of contaa and inaccurate technique. impediment to achieving effective cavitation. 11. Immediately pre-thrust Ensure the patient's head and neck Relax and adjust your balance as necessary. remain on the pillow as this facilitates the Keep your head up; looking down impedes arrest of the technique and limits excess.iw the thrust and can cause embarrassing amplitude of thrust.

HVLA thrust techniques - spine and thorax 12. Delivering the thrust thrust The alias rotates about the odontoid peg of the axis and cavitation occurs at the Apply a I-IVI.A thrust to the posterior arch of right CI-2 articulation. A very rapid Ihe alIas directed towards 111e comer of the cont.rn.clion of the flexors and adduaors of patient's mouth. Simultaneously, apply a the right shoulder induces the thrust. 'Ibe rapid 100'V·amplitude increase of head thrust. although ''elY rapid. must never be rotation to the left by supinating the left excessively forcible. 'lbe aim should be to foreaml (Fig. 81.3.4). 1bis rotation use the absolute minimum force necessary movement of the head is very small but of to achieYe jo;nt aMtat;on. A common fault high velocity. This ensures that the occiput and atlas mO\\'e as one unit during the arises from the use of excessive amplitude with insufficient velocity of thrust. SUMMARY Atlanto-axial joint (1-2 Ch,\" hold Patient supine Rotation thrust • Contact point: Right posterior arch of atlas • Applicator: Lateral border, proximal or middle phalanx • Patient positioning: Supine with the neck in a neutral relaxed position • Operator stance: Head of couch, feet spread slightly • Palpation of contact point • Fixation of contact point • Chin hold: Ensure your left forearm is over or slightly anterior to the ear • Vertex contact: Optional • Positioning for thrust: Step to the right and stand across the right corner of the couch. Use primary leverage of rotation with minimal secondary leverage. Your direction of thrust is towards the patient's mouth and into rotation (Fig. B' .3.3) • Adjustments to achieve appropriate pre-thrust tension • Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: The thrust is directed towards the comer of the patient's mouth. Simultaneously, apply a rapid low·amplitude increase of head rotation to the left. The occiput and atlas move as one unit during the thrust (Fig. B1.3.4) 84 I

Atlanto-axial joint (1-2 Cradle hold Patient supine Rotation thrust Assume somatic dysfunaio\" (5-T-A-R-T) is identified a\"d you wish to use a Ihrnsl ill Ihe pla\"e of Ihe 0110\"'0-11.\\;01 (Cl-2) apophysial joi\", In produce Clwitation on Ute right: KEY 1. Contact point Right posterior arch of alias. * Stabilization 2. Applicator • Applicator Lateral border, proximal or middle phalanx of operator's right index finger. - Plane of thrust (operatOf) 3. Patient positioning ¢ Direction of body movement Supine with the neck in a neutral relaxed (patient) position. If necessary, remove pillow or adjust pillO\\v height. The neck should not Note: The dimensions for the arrows be in any significant amount of flexion or extension. are not a pictorial representation of the amplitude or force of the thrust. 4. Operator stance I-lead of couch, feet spread slightly. Adjust couch height so thaI lhe operator can stand 85

HVLA thrust technIques - spine and thorax as erect as possible and avoid crouching 8. Vertex contact over the patient as this will limit the None in this technique. technique and restrid delivery of the thrust. 5. Palpation of contad point 9. Positioning for thrust Place fingers of both hands gently undcr the 'llle elbows are held dose to or only sHghtJy ocdpul. lift the head slightly and gently away from your sides. This is an essential rotate it to lhe left. taking the weight of the feature of the cradle hold method. Stand head in your left hand. RemO\\'t' your right easily upright at the head of the couch and hand from the occiput and palpate the do not step to lhe right as in the chin hold region of the right posterior arch of the atlas method. with the tip of your index or middle finger. Slowly but finnly slide your right index (a) Primary' leveToge of rorarion. finger downwards (towards the couch) Maintaining all holds and conlaa points,. along the posterior arch of the atlas until complete the rotation of the head and ned: it approximates the middle or proximal to the left until tension is palpated at the phalanx. Several sliding pressures may be contact point Supination of the left wrist necessary to establish dose approximation and foreann and simultaneous pronation to the contact poinL of the right wrist and forearm achieve the rotation mo,lement (Fig. 81.4.1). Do not 6. Fixation of contact point lose finn pressure on the contact point Do not force rotation; take it up fully but Keep your right index finger firmly pressed upon the contact point while you flex !.he carefully. A common mistake is to use other finger.; and thumb of the right hand so as to clasp the back of the neck and insufficient primary Ie\\~rage of head and occiput, thereby locking the applicator in neck rotalion. position. You must now keep the applicator (b) Seamdttr}' laremge. This technique uses on the contact point ulllil the technique is minimal secondary Ievt\"rage. 'Ibis technique complete. Keeping the hands in position, does not use facet apposition locking. return the head to the neutral position. Extensive praQice is necessary to de\\'Clop an appreciation of the required tension. 7. Cradle hold Keep your left h:'lnd under the he:'ld and sprc:'Id the fingers out for maximum contact. Keep the paticnt's ear resting in the palm of your left hand. Flex the left wrist, allowing you to cradle the patient's head in your palm, flexed wrist and anterior aspect of forearm. Keep your right index finger finnly on the contact point and press the right palm against the occiput 'Ibe weight of the patient's head and neck is nmV' balanced between your left and right hands with the celVical positioning controlled by 86 the converging pressures of your nva hands and anns. Figure 81.4.1

.. 1.4 Cervical and cervicothoracic spine t Figure 81.4.2 10. Adjustments to achieve appropriate 12 Delivering the thrust pre-thrust tension Apply a HVlA thrust to the posterior arch of This is aJmost a pure rotation thrust,. but the atlas directed towards the comer of the the appropriate tension can be achie'\\'ed pat.ient's mouth. 11lis thrust is generated by adjusting flexion, extension and by rapid pronation of your right forearm. sidebending. The patient should not be Simultaneously, apply a rapid low· aware of any pain or discomfort. '£be amplitude increase of head rOlation to the operator makes final minor adjuslments left by supinating the left forearm (Fig. by inuoducing any sidebending. flexion or 81.4.2).11lis rOLation movement of the extension with slight movements of the head is very small but of high velocity. This wrists. arms and shoulders. ensures that the occiput and atlas move as one unit during the thrusl. The atlas rotates 11. Immediately pre-thrust about the odontoid peg of the axis and cavitation occurs at the right CI-2 Relax and adjust your balance as necessary. aniculation. This is a HVLA 'flick' type Keep your head up; looking down impedes thrust. Coordination between the left and the thrust and can cause embarrassing right hands and forearms is criticaJ. proximity t.o lhe patient. An effective HVLA thrust technique is best achieved if the The thrust, although very npid, must opera lor and patient are relaxed and not never be excessively forcible. The aim holding themselves rigid. 'Ihis is a common should be to use the absolute minimum impediment to achieving effective force necessary to achieve joint caviUltion. cavitat.ion. A common fauh arises from the use of excessive amplitude with insuffident Ensure the patient's head and neck velocity of lhrust. remain on the pillO\\v as this facililates the arrest of the technique and limits excessive amplilude of thrust. 87

HVLA thrust techniques - spine and thorax SUMMARY Atlanto-axial joint (1-2 Cradle hold Patient supine Rotation thrust • Contact point Right posterior arch of atlas • Applicator: Lateral border, proximal or middle phalanx • Patient positioning: Supine with the neck in a neutral relaxed position • Operator stance: Head of couch, feet spread slightly • Palpation ofcontact point I • Fixation of contact point • Cradle hold: The weight of the patient's head and neck is balanced between I your left and right hands with cervical positioning controlled by the converging pressures I • Vertex contact: None I • Positioning for thrust: Stand upright at the head of the couch. The elbows are held close to or only slightly away from your sides. Use primary leverage of rotation with minimal secondary leverage. Your direction of thrust is towards the patient's mouth and into rotation (Fig. 81.4.1) • Adjustments to achieve appropriate pre-thrust tension • Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: The thrust is directed towards the corner of the patient's mouth. Simultaneously, apply a rapid low-amplitude increase of head rotation to the left. The occiput and atlas move as one unit during the thrust (Fig. 81.4.2) 88

Cervical spine C2-7 Up-slope gliding Chin hold Patient supine Assume somatic dysfunaion (5-T-A-R-T) is identified and }'Ou wish to use an upwards and forwards gliding thrust, parallel w the apophysial joint plane, w produce cavitation at C4-5 on tile right (Fig' 8J.5. J, 8J .5.2). Figure 81.5.1 Figure 81.5.2 KEY ,. Contad point .;t; Stabilization Posterolateral aspect of right C4 artiQllar • Applicator pillar. 2. Applicator Lateral border, proximal or middle phalanx of operator's right index finger. - Plane of thrust (operator) 3. Patient positioning l:) Direction cl body movement Supine wilh the neck in a neutrnl relaxed (patient) position. If necessary, remOve pillow or adjust pillow height 'Inc neck should not Note: The dimensions fOf the arrows be in any significant amount of flexion or are not a pkt01ial representation of extension. the amplitude Of force of the thrust. 4. Operator stance ./ 8' Head of couch. feet spread slighliy. Adjust l _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _.COU_.d.,.h.e.igh_l_SO_lh_3_1_Y\"_U_Gl_\"_'_la_\"_d_as_e_'_ect

HVLA thrust techniques - spine and thorax as possible and avoid crouching over !.he heavy, stiff or difficult case but can, on patient as !.his will limit the technique and occasions, be omitted. restrict delh'U)' of the thrust. 9. Positioning for thrust 5. Palpation of contact point Step to the right and stand across !.he right Place fingers of bolh hands geTltty under the comer of !.he couch. keeping the hands OCcipUL Rotate the head to the left. taking finnly in position and taking care not ils weight in your left hand. Remove your to lose pre5SUre on !.he contact poinL right hand from lhe occiput and palpate Straighten the right \\\\'nst so that the radius !.he right articular pillar of C4 wilh lhe tip and first metacarpal are in line. Maintaining of your index or middle finger. Slowly applicator pressure, allow lhe right index but finnly slide your right index finger finger to roll slightly on lhe contact point to downwards (to\\...ards the couch) along the align your right wrist and foreann wilh !.he anicular pillar until it approximates !.he thrust plane, which is upwards and towards middle or proximal phalanx. Several sliding 11le midline in Ihe direction of !.he patient's pressures may be necessary to establish dose left eye. Keep the right elbow dose to the approximation to the contact poinL couch in order to maintain the COntad point on 11le posterolateral aspect of the 6. Fixation of contact point articular pillar. (a) Primary leverage of roration. Keep your right index finger finnly pressed Maintaining all holds and contact points, upon lhe contact point while you flex the complete lhe rotation of the head and neck other fingers and lhumb of the right hand 10 the left until tension is palpated at lhe so as to dasp the back of the neck and contact point (Fig. 81.5.3). Do not lose finn thereby lock the applicator in position. pressure at the contact point. A common You must nO\\... keep the applicator on lhe mistake is to use insufficient primary contact point until the technique is 1C\\'ttage of head and neck rotation. complete. Keeping the hands in position, (b) &coruIary lezlfmJge. Add a very small retum the head to Lhe neutral position. degree of sidebending to the right. down to and including C4. The operator pi\\'Oting 7. Chin hold slighdy, via the legs and trunk, introduces the right sidebending. so that the lrunk: and Keeping your righl hand in position, slide upper body rotate to !.he lefl. enabling Ihe left hand slowly and carefully forwards llle hands and anus 10 remain in position until the fingers lightly clasp the chin. (Fig. HI.5A). Do nOI attempt to introduce Ensure that your left forearm is over or sidebending by moving the hands or arms slightly anterior to the e<'lr. Placing the as this will lead to loss of contact and forearm on or behind the elr puts the ned< in(lcomue technique. into 100 much flexion. The head is now controlled by balancing forces between the 10. Adjustments to achieve appropriate right palm and lell foreann. Maintain the pre-thrust tension appl icator in position. 8. Vertex contact Ensure your patient remains relaxed. Maintaining all holds. make any necessary MCJ\\.·e your body forw:ard slightly so that changes in flexion. extension. sidebending your chest is in contact with the \\,ertex of or rotation until you can sense a state of the patient's head. The head is now securely appropriate tension and lC\\uage. The cradled between your left forearm, the patient should not be aware of any pain 90 (]exed left elbow, the right palm and your or discomfort. You make these final chesL Vertex contact is often useful in a adjustments by slight movemenls of your

Cervical and cervicothoracic spine 1.5 : Figure 81.5.3 Figure 81.5.4 ankles, knet'S, hips and trunk, not by 12. Delivering the thrust 91 altering the position of the hands or arms. Apply a HYl.A thrust to the right articular 11. Immediately pre-thrust pillar of C4. l1\"le thmst is up\\vards and towards the midline in the direction of the Relax and adjust your bal<lI1ce as necessal)'. patient's left eye. parallel to the apophysial Keep your head up; looking down impedes joint plane. Simultaneously, apply a slight, the thrust and can cause embarrassing rapid increase of rotation of the head and proximity to the patient. An effective HVlA neck to the left but do not inaease thrust technique is best achieved if both the the sidebending leverage (Fig. BI.S.S). operator and patient are relaxed and not The increase of rotation to the left is holding themselves rigid. <Ibis is a common accomplished by slight supination of the impediment to achieving effective left wrist and foreann. The thrust is induced cavitation. by a very rapid contraction of the flexors and adduetors of the right shoulder and. if Ensure the patient's head and neck necessary. trunk and lower limb movement. remain on the pillow as this facilitates the arrest of the technique and limits excessive The thrust.. although very rapid. must amplitude of lhrusL never be excessiveiy forcible. The aim

HVLA thrust techniques - spine and thorax should be (,0 use the absolute minimum force necessary to achieve joint cavitation. A common fault arises (rom the use of excessive amplitude with insufficient velocity of thrusL Hgure 81.5.5 SUMMARY Cervical spine (2-7 Up-slope gilding Chin hold Patient supine • Contact point: Posterotateral aspect of right (4 articular pillar • Applicator. Lateral border, proximal or middle phalanx • Patient positioning: Supine with the neck in a neutral relaxed position • Operator stance: Head of couch, feet spread slightly • Palpation of contad point • Fixation of contact point • Chin hold: Ensure your left forearm is over or slightly anterior to the ear • Vertex contact: Optional • Positioning for thrust Step to the right and stand across the right corner of the couch. Introduce primary leverage of rotation left (Fig. 81.5.3) and a small degree of secondary leverage of~ndio.9.right: Keep the right elbow close to the couch in order to maintain the contact point on the posterolateral aspect of the C4 articular pillar (Fig. 815.4) • Adjustments to achieve appropriate pre-thrust tension • Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: The thrust is directed towards the patient's left eye. Simultaneously. apply a slight. rapid increase of rotation of the head and neck to the left with no increase of sidebending to the right (Fig. 81.5.5) 92

Cervical spine C2-7 Up-slope gliding Chin hold Patient supine - variation Assume somatic dysfunction (S-T-A-R-T) is identified and yOIl wish to use an upward and fonuard gliding thnlSt, parallel to the apophysial join! plane, to produce cavitnr:ion at C4-5 on the right KEY ,. Contact point .~,\" Stabilization Posterolateral aspect of right C4 articular pillar. • Applicator 2. Applicator - Plane of thrust (operator) Lateral border, proximal or middle phalanx <> Direction of Ix>dy movement of operator's right index hnger. (patient) 3. Patient positioning Note: The dimensions for the arrOWs Supine with lhe neck in a neutnll relaxed are not a pictorial representation of position. [f necessary. remove pillmv or the amplitude or force of the thrust. adjust pillow heighl \"'ne neck should not be in any significant amount of flexion or extension. 93 4. Operator stance Head of couch. feet spread slightly. Adjust couch height so that you can stand as erect

HVLA thrust techniques - spine and thorax as possible and .woid crouching over the until the fingers lightly clasp the cllin (Fig. patient as this will limit !.he technique and HI .6.1). Ensure that your left foreann is over restrict delivery of the thrust. or slightl), anterior to the ear. Placing the foreann on or behind the ear puts the neck S. Palpation of contact point into too much flexion. The head is now controlled by balancing forces betwttn !.he Place fingers of both hands gently under the right palm and left foreaml. Maintain the occiput. Rotate the head to lhe left.. laking applicator in position. its weight in }'Our left hand. RemO\\'e your right hand from the occiput and palpate 8. Vertex contact the right articular pillar of C4 with the tip of your index or middle finger. Slowly MO\\'e your bod)' fonovard slightly SO that but firmly slide )'OUr right index finger your chest is in contact with the vertex of dO\\vnwards (IO\\Y3rds the couch) along the the patient's head. 'l1le head is now serurely articular pillar until it approximates the cradled between )'Our left forearm. !.he middle or proximal phalanx.. Several sliding flexed left elbow, the right palm and )'Our pressures may be necessary to establish dose chesL Vertex contact is often useful in a approximation to the contael poinL heavy, stiff or difficult ca.se but can. on 6. Fixation of contact point OCC3Stons, be omitted. Keep your right index finger firmly pressed upon the contact point while you flex the g. Positioning for thrust olher fingers and thumb of the right hand so as to clasp the back of the neck and Keeping !.he hands firmly in position and Ihereby lock Ihe applicator in position. taking care not to lose pressure on the You must now keep the applicalor on the comact poim, straighten the right wrist so con tad point until the technique is that the radius and first metacarpal are in complete. Keeping the hands in position, line. Maimaining applicator pressure. allow return the head to the neutral position. the right index finger to roll slightly on the contad point to align )'Our right wrist and 7. Chin hold forearm with the thrust plane. which is upwards and to\\vards the midline in the Step to the right while allowing your direction of the patient's left eye. Keep the applicator to roll on the contact poinL right elbO\\.. dose to the couch in order to Keeping your right hand in position. slide maintain lhe (Ontad point on Lhe the lefl hand slowly and carefully forwards posterolateral aspect of the articular pillar. ((I) Prim(lry levemge of rolfltioll. Maintaining all holds and contact points, 94 Figure 81.6.2 Figure 81.6.1

Cervical and cervicothoracic spine complete the rotation of the head and neck the thrust and can cause embarrnssing to the left until tension is palpated at the proximity to the patient. An effective 11VlJ\\ coniao poim (Fig. BI.6.2). Do not lose finn thrust technique is best achi~'ed if both the pressure at the contao point. A common operator and patient are relaxed and not mistake is to use insufficient primary holding themselves rigid. This is a common leverage of head and neck rolation. impediment 10 achieving effective (b) Secondary lCl/Ierage. Add a \\'CJ)' small cavitation. degree of sidebending 10 the righL down to and including C4. 'Ioe operator pivoting Ensure the patient's head and neck slightly, via the legs and trunk. introduces remain on the pillow as this facilitates the the right sidebending. so then the trunk and arrest of the technique and limits excessive upper body rotale to the left. enabling the amplitude of thrusL hands and arms to remain in position (fig. B1.6.3). Do not anempt to introduce 12, Delivering the thrust sidebending by moving the hands or anns as this will lead to loss of contact and Apply a IIVLA thrust to the right ankular inacoll7lte technique. pillar of C4. ·rne thrust is upwards and towards the midline in the direction of the , O. Adjustments to achieve appropriate patient's lert eye, parallel to the apophysial pre-thrust tension joint plane. Simultaneously. apply a slight, rapid increase of rotation of the head and Ensure your patient remains relaxed. neck to the left but do not increase Maintaining all holds. make any necessary the sidebending le\\'ernge (Fig. BLGA). changes in flexion. extension. sidebending The increase of rotation to the lefl is or rotation until )'Ou can sense a slate of accomplished by slight supination of the appropriate tension and leverage The left wrist and foreann. The thrust is induced patient should not be aware of any pain by a \\'er)' rapid contraetion of the flexors or discomfort. You make these final and adduClors of the right shoulder and, if adjuslments by slight movements of )'OUT necessary. trunk and lower limb movement. ankles. knees, hips and trunk. not by 1he thrust.. although very rnpid. must never altering the position of the hands or anus. be exCESSively forcible. The aim should be to use the absolute minimum force necessary 11. Immediately pre-thrust to achieve joint cavitation. A common fault arises from the use of excessive amplitude Relax and adjust your balance as necessary. with insufficient velocity of thrust. Keep your head up; looking down impedes Figure 81.6.3 Figure 81.6.4 J95

HVLA thrust techniques - spine and thorax SUMMARY Cervical spine C2-7 Up-slope gliding Chin hold Patient supine • Cooted point: Posterolateral aspect of right C4 articular pillar • Applicator: lateral border. proximal or middle phalanx • Patient positioning: Supine with the neck in a neutral relaxed position • Operator stance: Head of couch. feet spread slightly • Palpation of contad point Fixation of contad point • Chin hold: Step to the right before taking up chin hold (Fig. 81.6.1). Take up chin hold and ensure your left forearm is over or slightly anterior to the ear • Vertex contact: Optional • Positioning for thrust: Introduce primary leverage of rotation left (Fig. 81.6.2) and a small degree of secondary leverage of sidebending right. Keep the right elbow close to the couch in order to maintain the contact point on the posterolateral aspect of the (4 artkular pillar (Fig. 81.63) • Adjustments to achieve appropriate pre-thrust tension • Immediately pre-thrust: Relax and adjust your balance • Delivering the thrust: The thrust is directed towards the patient's left eye. Simultaneously. apply a slight. rapid increase of rotation of the head and neck to the left with no increase of sidebending to the right (Fig. 81.6.4) 96

Cervical spine C2-7 Up-slope gliding Cradle hold Patient supine &slime somatic d)ls[unaion (5-'f.-A-R-T) is identified and you wis/l to use an upward and forward gliding linus', parallel to the apophysial joint plane, to produce caviUltion at C4-5 on the rlglll: KEY 1. Contact point ';T:' Stabilization Poslerol:1.1eral aspect of the right articular pillar of C4. • Applicator 2. Applicator - Plane of thrust (operator) Lateral border, proximal or middle phalanx 1:) Direction of body movement of operator's right index finger. (pattent) 3. Patient positioning Note: The dimensions for the arrows Supine wilh the neck in a neutral relaxed are not a pictorial representation of position. If necessary. remove or adjust pillow height. The technique should not the amplitude or force of the thrust. normally be executed in any significant degree of flexion or extension. 97 4. Operator stance Head of couch, feet spread slightly. Adjust couch height so rnat )'OU can stand as erect _ _ _ _ _1

HVLA thrust techniques - spine and thorax as possible and avoid crouching over the 8. Vertex contact patient as this will limit the technique and None in this technique. restrid delivery of the thrust 5. Palpation of contact point 9. Positioning for thrust Place fingers of lx>th hands gently under the The elbows are held dose to or only sJightly occiput. lift the head to throw the anicular away from your sides. lllis is an essential pillars into prominence. Rotate the head fealu~ of the cradJe hold method. Stand slightly to the left. taking its weight in your easily upright at the head of the couch and left hand. Remove your right hand from the do not step to the right as in the chin hold occiput and palpate the right articular pillar method. of C4 with the tip of your right index finger. (a) Primary letrerage of rotatioll. Slowly but firmly slide your right forefinger Maintaining all holds and COntad points, dO\\\\lnwards (towards the couch) along the complete the rotation of the head and neck articular pillar until it approximates the to the left until tension is palpated at the middle or proximal phalmlX. Several sliding contact point. Supination of the left wrist pressures may be necessa.ry to establish close and forearm and simultaneous pronation of approximation to the contact point the right wrist and forearm achieve the rotation movement {Fig. B1.7.1}. Do not 6. Fixation of contact point lose firm pressure on the contad point. Do not force rotation; take it up fully but Keep your right index finger fimlly pressed carefully. A common mistake is to use upon the Contad point while you flex the insufficient primary leverage of head and Other fingers and thumb of the right hand neck rotation. so as to clasp the back of the neck and (b) S«orufary lea.reragtt Add a very small thereby lock the applicator in position. degree of sidebending to the right. dO\\ffl You must now keep the applicator on the to and including C4. This is achieved by COntad point until the technique is moving the right arm a little forward and complete. Keeping the hands in position. the left ann a little back or by rotating the return the head to the neutral position. trunk and upper body to the left (fig. 81.7.2). NDfe: strong sidebending will lock the neck. 7. Cradle hold , O. Adjustments to achieve appropriate Keep your left hand under the head and pre-thrust tension spread the fingers out for maximum contact Ensure your patient remains relaxed. Keep the patient's ear resting in the palm Maintaining all holds, make any necessary of the your left hand. Flex the left wrist, changes in flexion, extension, sidebending or rotation until you can sense a state of allO\\\\ling you to cradle the patient's head in appropriate tension and leverage.. 'llIe your palm, flexed wrist and anterior aspea patient should not be aware of any pain of foreann. Keep your right index fmger or discomfort. You make these final finnlyon the contad point and press the adjustments by slight movements of your ankles. knees. hips and trunk. not by right palm against the OCCipuL 'Ibe weight altering the position of the hands or arms. of the patient's head and neck is now balanced between your left and right hands with the cerviClI positioning controlled by the converging pressures of your two hands 11. Immediately pre-thrust and arms. When treating the lower cervical 98 segments, the middle or distal phalanx may Relax and adjust your balance as necessary. be used as the applicator. Keep your head up; looking dO\\ffl impedes