Techniques For The Cervicothoracic Junction Area

The cervico-thoracic, or cervico-dorsal, region can be a source of more frustration in attempting to achieve successful technique results than almost any other area. There are many reasons for this. The area is junctional which means that there will be a change in orientation of anatomical curves. There is a mobile area of the neck meeting a less mobile area of the thoracic spine and ribs. There are emotional factors which manifest in the area relating to stress and tension. The use of the arms puts mechanical strains on the area, requiring it to be stable, and this very stability means that the range of movement of the joints is somewhat limited. This can lead to a greater susceptibility to mechanical strain in these joints if they are taken out of their normal range in an uncontrolled fashion.

Particular care should be taken with regard to the possibility of pathological conditions in the area affecting bone strength, such as secondary deposits from primary carcinoma in the lung and thyroid. Severe brachial nerve entrapment syndromes require particular caution if the neck is going to be used as a lever. The presence of extreme hypertension can manifest as a very hypertonic state in the muscles of the cervico-thoracic area. Inability to get adequate relaxation in the area should alert the practitioner to this possibility. As a precursor to incipient cardiac infarction there can also be a characteristic feel to this area, presumably due to aberrant viscero-somatic reflex patterns. This manifests as an increasing state of tension with a 'sheet like' nature in that there is no specific point of tension. There is, rather, a generalized state that partly resolves with manual treatment only to recur very rapidly. This is difficult to describe, but once it has been felt, will never be forgotten. This muscular state disappears almost immediately after a myocardial infarction, presumably due to the changes in the reflex patterns. There may be other factors in operation here such as changes in life-style, the shock to the system, and many others, but it is, nevertheless, quite characteristic.

Some of the techniques are modified versions of cervical holds, some modified thoracic ones, and some are specific to the area itself. There is no inherent benefit in any one over another, except there may be times when it is necessary to avoid the neck or the thorax for some reason. It is, therefore, necessary to have a range of techniques available to affect the area by a variety of means.

20.1 • Kneading sidelying The patient is side-lying nearer you than the back of the table. Fix the upper scapula with your forearm and hand and apply the kneading to the trapezius and rhomboids towards the spine with the thenar eminence.

Tips: More useful for patients who might find prone lying a problem. Better for tight-muscled subjects where the action of pushing the muscles toward the spine may be easier than pulling away using the more traditional methods.

20.2 • Kneading prone The patient is prone with her arms over the sides of the table and her face in a breathing hole in the table if available. Fix the nearer side of the spine with the lower hand into a slight rotation toward you. Use the thenar eminence of the kneading hand to push against the muscles on the opposite side toward the table and away from the spine.

Tips: Try using the expiration phase of breathing to give the best relaxation effect.

20.3 • Kneading prone The patient is prone with her face in a breathing hole in the table if available. Her arms are over the sides of the table. Fix the spine with the upper hand to prevent too much rolling of the spine into rotation and apply the kneading with the other hand. Take up some skin slack and use the thumb or thenar eminence to perform the kneading to trapezius and rhomboids.

Tips: Least useful if the operator has any problem of thumb instability.

20.4 • Articulation sitting Stand behind the seated patient and have her place one hand behind her neck. Fix with your thumb against a spinous process directed toward her other axilla so that the thumb forms a fulcrum for a sidebending movement. Reach under her flexed arm with your arm and fix against the side of her head. Keep the vertex in the midline and introduce the sidebending movement with both hands simultaneously.

Tips: Try circumducting the patient's body around the fixed vertebra to make a stronger and more variable force. Avoid continuing this movement for a long duration as there will be a tendency for ulnar nerve irritation from your arm pressure under her flexed arm.

20.5 • Articulation sidelying The patient clasps her hands behind her neck in the sidelying position. Fix on the spinous process of the target vertebra with the fingers of one hand. Clamp the patient's flexed arms between the side of your thigh, hand and forearm. Introduce flexion and extension with small amounts of any other movements by making a small rotation movement of your body.

Tips: Least useful where there is any shoulder condition which may make this position difficult for the patient. Try using only one arm flexed and gripping the neck rather than both.

20.7 • Articulation sidelying Fix the patient's flexed arms between your body and abducted upper arm. Grip around her hands with your upper hand so that the movements of flexion, extension and small amounts of rotation and sidebending can be introduced. Fix the spinous process of the target vertebra with the other hand to act as a counter-force to the movement induced.

Tips: Least useful in nervous patients as this position is somewhat claustrophobic. Not very useful if there is any shoulder condition which may make the position difficult to attain. Try using only one flexed arm instead of two. Most useful where it is desired to block out cervical movement.

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