21.14 • Kneading of anterior tissues supine
Stand to the side of the table and stabilize the head on the pillow with the upper hand. Use the heel of the lower hand to push carefully into the scaleni until resistance is felt. Hold the muscles on this slight tension and roll the head away to bow the muscles over the thenar eminence.
Tips: As the scaleni are so sensitive to pressure, this allows quite strong stretch and kneading effect by using a lever rather than pressure.
21.16 • Stretching of lateral tissues supine
Stand to the side of the patient and cup the shoulder in the lower hand. Hook the upper hand around the occiput with the thenar eminence resting against the mandible. Stabilize the shoulder and rotate the head away from the shoulder until tension is felt to accumulate in the lateral tissues.
Tips: Try varied degrees of rotation to reach different depths of tissues. Try varied degrees of sidebending, either before or after the rotation to alter the tissue to be affected. Try reaching down the neck with the head hand to fix around the transverse process of a mid or even lower cervical segment. This will focus the force below the fingers to emphasize the stretch in the lower neck instead of the whole neck. Try varied directions of pressure on the shoulder, toward the table or toward the axilla for example. Try changing the order of application with each hand. Every minor change in order, amplitude or direction will vary the technique and only by experimenting in this way can you find the optimum for each case.
21.15 • Kneading of anterior soft tissues supine Stand at the side of the patient and stabilize the head with the upper hand. Reach round the throat with the lower hand and pull the tissues toward the midline. When a small amount of tension has been achieved, push the head away to focus the forces in the throat and anterior tissues.
Tips: A direct stretch and kneading on these tissues can be very uncomfortable so this technique allows them to be worked with far less discomfort.
21.17 • (see previous page, top left) Stretching of lateral tissues supine Stand at the head of the table and cup the occiput and upper neck in one hand. Fix on the distal part of the shoulder with the other hand. Apply a sidebending to the neck while rotating it away from the shoulder until a stretch is felt to accumulate in the tissues.
Tips: Try varied degrees of sideshift with the head hand to focus the forces at the area desired. See tips for photograph 21.16, as the same parameters apply.
21.18 • (see previous page, top right) Stretching of lateral posterior tissues supine Stand slightly to the side of the head of the table and support the head in the palm of the upper hand. Fix the tip of the shoulder with the other hand. Apply the stretch with the head hand pulling into a combination of flexion, sidebending and rotation until the tension is felt to accumulate in the area desired. Note that the head hand has pushed up into the neck in this view to focus the force more specifically to the lower neck.
Tips: See tips for photograph 21.16 as the same variations apply in this hold.
21.19 • (see previous page, bottom left) Stretching of posterior tissues supine (hand hold) Cross your forearms with the palms facing the floor. When they are placed under the head and the hands are against the shoulders it will be possible to lever downwards with the hands, and upward with the forearms to push the head into flexion. This will, therefore, stretch the posterior tissues.
21.20 • (see previous page, bottom right) Stretching of posterior tissues supine The hand hold shown in photograph 21.19 is applied. Induce the flexion movement by shrugging your shoulders, or by slightly straightening your arms.
Tips: Try sidebending your body to produce a rotation of the patient's head which will tend to focus the force on one side more than the other. Try changing which arm is on top to see which reaches the target structure and tissue best in each case.
21.21 • Functional technique or strain and counter-strain hold supine The patient lies with the head over the end of the table. Support the head in your palms with the fingertips of both hands contacting the articular pillars of the relevant segment. With this hold it is possible to introduce all possible movement parameters of the neck to find the optimum pathway of ease for the functional technique. See earlier section relating to functional techniques.
21.22 • Articulation into sideshifting, sidelying
Stand in front of the patient and stabilize the head into the pillow with the upper hand. Reach around the articular pillars with the lower hand and pull directly up toward the ceiling to induce a sideshifting movement. Focus the forces by emphasizing most of the lifting force with one finger while maintaining some pressure with the other fingers to reduce discomfort.
Tips: This hold allows an accurate test of individual segmental mobility as well as being a useful treatment technique. Restricted mobility will manifest as a distinct lack of sideshift capability.
21.23 • Articulation into sidebending supine The patient's head rests on the pillow. Push with the pads of the fingers of one hand over the transverse processes while pushing the head with the other hand in the same direction. Note that it is important to keep the vertex substantially in the central plane so that you do not induce excessive strain on the other side.
Tips: Least useful where the transverse processes are very tender for any reason. In this case, use the pads of the fingers and prise the head over them. This will be much less uncomfortable than pushing into the neck with the fingertips. Extra considerations: Paradoxically the operator performs rotation of his body to perform sidebending of the patient's neck.
21.24 • Articulation into extension supine Leave the head resting on the pillow and prise up toward the ceiling behind the articular pillars to induce extension. The backs of the hands remain on the pillow to act as a fulcrum for the movement.
Tips: Least useful in cases where extension movement may be a problem, such as postural hypotension or brachial neuritis syndromes.
21.26 • Articulation into localized extension supine Leave the head on the pillow and use the forearm as a fulcrum. Prise the target level up with the pads of the fingers into localized extension.
Tips: Avoid pressing too far laterally as the tips of the transverse processes are usually very tender. Extra considerations: Try adding sidebending to the extension movement to localize it even more specifically.
21.25 • Articulation into flexion supine Lift the head with the palms of the hands and rest it on your upper abdomen or lower chest. Pull up against the desired level with the pads of the fingers to induce flexion. Use a small straightening of the knees to aid the movement which will also help avoid excessive fatigue in the hands.
Tips: Note that the elbows remain close to the sides throughout so that the movement is performed by the operator's body, not the arms.
21.27 • Articulation into rotation supine Leave the head on the pillow and stand slightly to the side of the table. Rotate the head to the same side. Keep the vertex in the midline so that a pure rotation can be made. Support the head with one hand and allow it to slide under the head as the other hand pulls behind the transverse processes into rotation. Note that the index finger is applied at a target level to focus the force principally to one point.
Tips: Try standing in varied positions to find the best personal method, at the end of the table, to one side or the other. Extra considerations: Paradoxically the operator performs sidebending of his body to produce rotation in the patient's neck.
21.28 • Articulation into rotation supine Keep the head on the pillow and turn it to one side, allowing the underneath hand to slide under the head. Apply the other hand to the temporal and maxilla area of the upper side and pull into rotation.
Tips: It is easy to introduce different elements of sidebending along with rotation in this hold. Try rotating and then adding sidebending, or sidebending and later adding the rotation. The sum of the movement is similar, but the effect is completely different according to which tissue is put on tension first.
21.29 • Articulation into sidebending supine
For this alternative hold sit at the head of the table and use the fingertips of one hand to act as a fulcrum for the sidebending. Push with the other hand against the parietal area on the other side to induce the sidebending.
Tips: The sitting posture forms a useful variation for the operator who might find standing tiring, inconvenient or impossible.
21.30 • Springing into extension prone The patient lies prone, preferably with the face in a breathing hole in the table. Apply your pads of thumbs directly over the posterior aspect of the transverse processes of the target segment. Apply a direct posterior to anterior springing movement to produce localized extension.
Tips: Least useful where the patient may have a problem with prone lying. Least useful in cases where extension is best avoided due to any circulatory insufficiency causing potential obstruction of vertebral arteries.
21.31 • Traction supine This operator viewpoint photograph shows the hands applied to perform traction. The underneath hand has carefully gripped round the occiput with the head resting on the palm. The other hand is gripping around the chin and the heel of the hand is applied to the mandible. The wrist and forearm of the chin hand push slightly toward the opposite side to induce a slight side-shift. The occiput hand is introducing a variable quantity of sideshifting depending on the target segment. More sideshifting will drive the force lower in the neck. The wrist of the chin hand balances the pressure of the other hand. Once the sideshift is applied, the traction force can be brought into play. Remarkably little range of traction is available if the sideshift is maintained, which makes it very specific to a small number of segments.
21.32 • Traction unilaterally supine Sit at the head of the table and fix the head to the pillow with the wrist, forearm and lateral border of the hand. Slip the other hand under the head and hook the fingers under the occiput or around the spinous process of a vertebra. Maintain the pressure with both hands and pull gently in the long axis of the spine.
Tips: Note that some rotation and slight side-bending has been introduced to focus the movement to a specific area on the lower side.
21.33 • (see previous page, top left) Traction and sidebending articulation combined Stand at the head of the table and fix the head against your upper abdomen. Apply a slight lifting force with the index fingers to produce a small anterior shifting movement. Keep the arms fairly rigid and pivot your body into sidebending from side to side while leaning back slightly. The sum effect is to produce a sidebending and traction force that will vary in level according to how far down the neck you fix with the hands.
Tips: This can be rather hard work, but is capable of producing rapid changes in mobility, making it an extremely useful technique. Most useful in cases of brachial neuritis where the sidebending force will be introduced primarily in one direction to open the foramen on the convexity.
21.34 • (see previous page, bottom left) Thrust using cradle hold supine (hand position) Stand slightly to the corner of the table on the side that the thrust is to be applied. Supinate the lower hand and pronate the upper one so that they form a mirror image of each other. Note that the fingers are slightly splayed to spread the force over a larger area. Note also that the elbows remain fairly close to the operator's sides.
21.35 • (see previous page, top right) Thrust into rotation, cradle hold supine Use the hand position shown in photograph 21.34 and turn the head gently into the primary lever direction of rotation. There is unlikely to be a sense of barrier with this small amount of rotation, so add other components either individually or in combination to accumulate the most effective potential barrier. You need to constantly test the primary lever direction while adding the other components until the optimum barrier is sensed. Firm contact point pressure is important as it helps to further reduce the other components. Maintain all the secondary levers of sidebending, sideshifting, compression, anterior shifting and slight extension and apply the thrust into a small amplitude of rotation.
Tips: Note that the elbows are close to the sides, and the technique will be more efficient if you stand as upright as possible so that the arms move with the body. This technique is designed to slide the facet on the same side as the thrust is applied.
21.36 • (see previous page, bottom right) Thrust into rotation, cradle hold supine This operator viewpoint photograph shows the underneath hand acting in compression against the thrusting hand. The vertex is maintained in the midline. Note that the wrist of the thrusting hand is in a neutral position. At the end of the thrust the hands accentuate their positions of supination and pronation respectively. This should slide the facet on the same side as the thrust.
21.37 • Thrust using cradle hold into sidebending, supine Stand at the head of the table slightly to the corner behind the head. Take up the hold with the underneath hand supinated to support the head. Apply the thrusting hand with the arm close to your body and the lateral aspect of the middle interphalangeal joint of the index finger slightly behind and to the side of the transverse process of the target segment. Keep gently testing the primary lever of sidebending while adding all the other available components until a sense of barrier accumulates. When the optimum barrier has been found, maintain the secondary components and apply a low amplitude thrust with the index finger directed toward the opposite shoulder.
The secondary components most often useful in this technique are contra-rotation, sideshifting, compression of the head between the hands, slight extension and localized pressure over the contact point with the finger. It is important that the underneath hand does not allow the head to move away from the barrier when the thrust is performed, as otherwise excessive torsion can result.
Tips: Most useful in cases of brachial neuritis on the side to which the neck is being rotated as the foramina on that side will be opened by this thrust. This thrust is designed to gap the facet on the opposite side to the thrusting hand.
21.38 • Thrust using cradle hold into sidebend-ing, supine This operator viewpoint photograph shows the hold described in photograph 21.37. Note the buckling of the neck over the operator's thrusting hand and that the vertex is almost in the midline. The hands are applying a compression toward each other to minimize the quantities of the other secondary levers. This should gap the facet on the opposite side to the thrust hand.
21.39 • Thrust using cradle hold into sidebend-
ing This illustration is of the sidebending thrust applied to a lower cervical segment. The hold is taken up in the usual way, but instead of applying more levers, the head is being compressed between the hands so that the effect of the sidebending force is amplified. Note that the thrusting forearm is almost horizontal so that the neck is not being forced into a painful direction, and that the thumb is applied to the mandible to help block out upper cervical movement. This is designed to gap the facet on the opposite side to the thrusting hand.
21.40 • Thrust into rotation using chin hold
Stand at the head of the table, slightly at the corner behind the head. Gently rotate the head to one side and slide the chin hand under the side of the head to take up the hold. Take a small step to the back corner of the table and slide the thrusting hand into place with the metacarpo-phalangeal joint of the index finger applied behind the articular process. Keep testing the primary lever direction of rotation while adding the contra-sidebending and other components until a suitable barrier has been accumulated. Thrust with the hand behind the head while stabilizing the head and chin with the other hand. Note that the thrusting hand wrist should be in line with the forearm, and both elbows close to the sides. Note also that the forearm of the thrusting arm is almost horizontal. The most useful secondary components to focus this technique are compression between the hands, slight sideshifting in the opposite direction to the sidebending, and a slight anterior shift of the whole assembly. This is designed to slide the facet on the same side as the thrusting hand.
21.41 • Thrust using chin hold into rotation, supine This operator viewpoint photograph shows the hold illustrated in photograph 21.40. Note the midline position of the head, and the straight position of the wrist of the thrusting arm. Note the position of the supporting forearm under the head is in front of the patient's ear. This technique is designed to slide forward the facet on the side being thrust.
21.43 • Thrust using chin hold into rotation of atlanto-axial joint Take up the chin hold in the manner previously described fixing behind the transverse process of the atlas with the thrusting hand. As the principal movement possible of this joint is rotation, only slight sidebending will be required. Introduce a very small extension to take the posterior tissues off tension, and apply the thrust in pure rotation through a small amplitude to gap the facet on the same side.
Tips: Most regions of the body can be treated in any order, but if it is necessary to thrust the atlantoaxial joint, it is often found to be best left to the last manipulation of a treatment session. This is not an absolute rule, but has sound reasoning. This joint is very susceptible to becoming hypermobile and therefore suffering recurrent lesioning. If it is manipulated first, it is liable to be stressed when any other thrusts are done in the area, thereby irritating it further.
21.42 • Thrust using chin hold into sidebending This photograph shows the hold applied to a lower cervical segment from a different viewing angle. Take up the hold in the way previously described. Apply the lateral border of part of the index finger or metacarpal to the posterior part of the transverse process of the segment. Buckle the neck over the thrusting hand so that the sidebending and sideshifting occur at the same time. Introduce a small amount of controlled rotation with the other hand, and then balance all the secondary components against the primary lever of sidebending. At the optimum moment apply the thrust with one hand while maintaining the head position with the other. Note that the thrusting forearm is almost horizontal and that the vertex remains in the midline. This is designed to gap the facet on the opposite side to the thrust hand.
21.44 • Thrust using chin hold into rotation or sidebending This photograph is to show the overall posture usually adopted for these types of techniques. Note that although the operator is bent from the waist, he has not flexed his spine. Note that the leg on the thrusting side is behind the other so that the operator's body is brought into the thrust. Note that the forearm of the thrusting hand is horizontal and that the patient's head has been left on the pillow.
21.45 • Thrust using pulling hold supine Stand to the side of the table and grip around the transverse process of the target segment with the middle phalange of the index or middle finger of the thrusting hand. Balance the forces with the other hand applied to the side of the forehead closest to you. Introduce part of the primary lever of rotation and slowly oscillate in the primary lever direction while adding the secondary levers until a satisfactory barrier accumulates. Maintain the secondary levers, and apply the thrust with a short sharp pulling action with the thrusting hand into rotation.
Tips: Some operators find that pulling techniques are easier for them than pushing ones. This technique is most useful in these cases. It is also useful where the operator has a problem in using one particular hand for any reason. The left side of the neck is usually thrust with the left hand of the operator, but with this technique the right hand is thrusting the left side of the patient's neck.
21.46 • Thrust into rotation prone Stand to the side of the prone patient and stabilize the head with the upper hand. Use the thrusting hand as a fulcrum to sidebend the neck. Maintain the head in the midline and carefully push the lateral side of the index finger into the neck against the posterior aspect of the articular process of the target segment. The primary lever of rotation is going to be a force directed in the line of the forearm as shown. Maintain the position with the stabilizing hand and apply the thrust behind the articular process through a very small amplitude.
Tips: Note that there is a tendency to introduce extension, and that this is potentially dangerous and must be avoided. Although a sidebending thrust could be applied with this hold, it is even more likely to produce an unwanted hyperextension. If a table with a breathing hole is being used, either plug it up for this technique, or have the patient move slightly to one side so that the chin can act as a pivot directly on the table. Least useful for patients over 40 years of age.
21.47 • Thrust into rotation sitting Have the patient sit across the table toward one end. Stabilize the head with the front hand, and apply the pads of the fingers behind the articular process of the target segment with the other. Introduce sidebending toward the thrusting hand, and rotation away. Keep testing the primary lever of rotation while adding the secondary components of the composite lever until a suitable barrier accumulates. Maintain the secondary levers and apply a short sharp thrust into rotation with the hand applied to the neck.
Tips: This is a rather difficult technique to control as the neck tends to try to escape from the tension induced unless it is very carefully managed. Many operators may find it difficult to generate the sharpness needed to break facet fixation with this hold. It is, nevertheless, useful as some patients will not relax well in a supine position, and may find this hold more comfortable.
21.48 •(see previous page, top right) Thrust into rotation sitting (hand hold) The hand reaching in front of the patient is supinated, and either the index or the middle finger is flexed to make it more prominent and ready to apply behind the articular process. The other hand is spread slightly and is applied to the nearside of the head to act as a stabilizer for the thrusting hand. Note that the operator's elbows are close to his sides.
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