The occipital and upper cervical regions are areas where extreme caution is necessary in preliminary assessment before techniques are applied. Care is required in all areas, but in the occipital region this is even more critical. There is the possibility of damage to the vertebro-basilar system if instability is present. Precautions need be undertaken before performing any thrust technique that is in any way liable to put the area under mechanical stress. As in the rest of the neck, the patient is often fearful of manipulation, and as light a force as will achieve the required result is essential. It is often difficult for students to achieve the required acceleration and subsequent braking force necessary in thrust technique in this area, and there is no substitute for practice and practical experience.

The reader is referred specifically to the section on contra-indications. However, suffice it to say that anything that can compromise the integrity of the ligamentous structures of the area requires extreme caution in the choice of technique. Some will say that all thrust technique should be avoided in the area if there is so much potential danger. However, this would be to deny the possibility of aid in many cases where almost nothing else will work as well.

Occipital thrust techniques performed without excessive force require a well-developed barrier sense. The angles through which any given technique will succeed are very small. Slightly too much leverage will block the techniques and more force is then often mistakenly applied to counteract the lack of ability to focus accurately. Maximum safety is paramount and too much force jeopardizes this. If a given technique is not working, try reducing levers and forces rather than increasing them. It may seem paradoxical, but this often works much better. It is often necessary to make many subtle changes in direction or plane to find the optimum for each technique. Every patient will differ, and changes in table height, operator position in relation to the patient, and quantities of the varied components of a composite lever vary. Many cases will respond well to general mobilizing and articulation. Some, however, will only achieve full and lasting relief from treatment when a specific thrust is successfully performed to fully liberate a facet fixation.

Although specific positions of lesion fixation are often described, the techniques shown here are simply designed to break fixation. If positional correction is deemed necessary, the fixation is dealt with first, and then the joint is coaxed into the direction required afterwards with articulatory technique.

If a barrier does not seem to accumulate in one direction, another is sought. This removes some of the fear of many students that they may be performing the technique in the 'wrong' direction. If this does not satisfy the purist in relation to lesion directions, then several of the techniques shown can be applied in a 'correction' direction if required. I have included the details of these under the 'Extra considerations' headings.

22.1 • Articulation into flexion supine Pushthe head into flexion with your thumbs on the mandible while you pull under the occiput with your fingertips.

Tips: Try adding traction to the movement. Try adding sidebending to the movement. Ensure the patient has time to breathe between repetitions as the flexed position may obstruct the ability to breathe.

22.2 • Articulation supine (hand hold) Form a pivot with the pad of thumb and index or middle finger. Rest the back of the hand on the pillow. Apply the other hand to the forehead of the patient to be able to tip the head into all the directions that the technique allows.

22.3 • Articulation into extension supine Apply the hand hold shown in photograph 22.2 and tip the head into extension with the forehead hand while pivoting it over the occiput hand. Once the head is in extension it can be rolled into sidebend-ing to either side to focus the force to each condyle of the occiput.

22.4 • (bottom left) Articulation into flexion supine

This operator viewpoint photograph shows the hold from photograph 22.3 in use for flexion. Note that the pillow is retained, partly to allow it to be used as a fulcrum, and partly as most patients seem to prefer the security and familiarity of a pillow.

Tips: Allow the patient time to breathe between pressures as the trachea can be obstructed in extreme passive flexion!

22.5 • (bottom right) Articulation into extension supine In this operator viewpoint photograph the head is pushed up with the lower hand while tipping it into extension with the frontal hand. Note that this is an extension focused to the occiput rather than an extension of the whole neck.

Tips: Try alternating this movement with flexion and sidebending to focus forces to one specific condyle of the occiput. Try varying the spacing of the lower hand to find the optimum for efficiency and comfort.

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