Techniques For The Lumbar Area

Accurate and efficient techniques for the lumbar area are extremely important. The highest percentage of patients presenting to osteopathic practitioners are suffering with low back pain, and techniques for the lumbar spine will probably be used more often than any others. The practical difficulties for a small operator in reaching a facet joint no bigger than the thumb nail, in the back of a patient weighing anything up to around 200 pounds, can be considerable. The sheer depth of the joints, the difficulty of controlling the area in many subjects, and the common complicating factor of an underlying acute or chronic disc lesion add to the problems. For treatment to be more specific, accurate mechanical diagnosis is essential. There is, therefore, a requirement for techniques designed to be efficient and feasible for the operator to perform without undue stress on his own structure.

It can be a problem to localize a force to a segment or segments while attempting to 'protect' adjacent areas that may be hypermobile. It is often difficult to manipulate a specific segment, but in some cases unless this is achieved, the relief from a particular pain and dysfunction syndrome will not occur. General mobilizing can be extremely helpful, but the nature of release achieved with a well-timed, accurate and specific thrust can be not only a short cut, but the only way to get full restoration of function. Although size of operator should not be a critical factor, it must be said that in some cases a larger operator will have a distinct advantage. The use of excessive force rather than accuracy, however, conceals a weakness in approach.

Cases of possible disc injury require particular care to avoid worsening the situation. An educated, aware practitioner should be conversant with neurological symptoms and signs. Extreme antalgic posture is present for a reason and consideration should be given to that reason before attempts to 'correct' the posture are made. Many pathological states in the body can manifest as low back pain and the reader is referred to literature on pathology and diagnostic screening as an essential prerequisite to treatment in this area. A patient should be fully investigated when they are clearly ill, have lost weight for no apparent reason, or have intractable pain that does not subside on rest.

13.1 • Kneading soft tissues lumbar area prone

The operator is working on the muscles on the side furthest from him. The near hand is holding back on the area to apply a small compressive force toward the table and to prevent rotation of the spine and to sense the best resistance from the tissues. Push with the active hand into the muscle belly until a sense of resistance is felt, and then maintain this position for a few moments until a sense of activation is felt. There should be a sense of 'melting' as the muscles relax, and then you can follow this sense until the muscle is gently but fully eased. The direction of the pathway may be in a curve, and it is important to allow the tissues sufficient time to guide the force direction rather than to impose on them. The pressure is then slowly released until the cycle can be repeated on an adjacent area. The whole cycle can take up to about six or seven seconds. Most operators will not use such a long cycle, but paradoxically it is often found that the slower one works, the quicker and more effective the results.

Tips: Least useful in cases where prone lying is a problem and in acute cases where there may be a tendency for the muscles to go into a greater spasm when the patient subsequently moves. Extra considerations: Note that a pillow is placed under the patient's abdomen to reduce excessive hyperextension of the lumbar spine.

13.2 • Kneading soft tissues lumbar area prone

Perform the technique with the near hand while the other stabilizes. There is no particular advantage in which hand is used. However, it may be easier to reach right down to the sacral attachments of the erector spinae using the caudal hand rather than the cephalic one, as in technique photograph 13.1.

Tips: Least useful in cases where lying prone may be a problem. Extra considerations: Try asking the patient to turn the head to one and then the other side to assess which produces the most useful tension. Combining phases of breathing with the technique may be useful. The pillow is optional to increase patient comfort if necessary. Most patients find that a pillow underneath the abdomen is preferred when prone lying.

13.3 • Kneading soft tissues lumbar area side-lying The patient has the knees and hips flexed to increase stability on the table. Stabilize the patient's body with your cephalic hand and apply the kneading force to the muscles nearest the table.

Tips: Most useful in cases where prone lying may be a problem. Least useful in large patients where the reach for the operator may be too great. Extra considerations: In acute cases this may be the only way to work on the lumbar muscles as prone lying may be impossible due to spasm. Try varied angles of hip and knee flexion. Try working on the muscles by pulling up instead of pushing down. Try performing the same procedure when standing behind the patient.

13.5 • Articulation into sideshffting lumbar area prone Grip the transverse processes of the vertebra concerned with the pads, not the tips, of the fingers and thumb and use a direct sideshifting force from side to side. The oscillation can be quite firm when used carefully, and this will act as a useful test as well as a mobilizing force. As the hands are applied to adjacent vertebrae, differences in mobility can easily be felt, and this hold can be used to mobilize, or other techniques can be applied to deal with the restriction in movement.

Tips: This is a movement of the whole of the patient's body around the vertebra, and needs quite a long amplitude to be effective. Least useful in cases of antalgic sidebent posture as this movement will cause pain when working against the curve.

13.4 • Stretching superficial fascia lumbar area prone Gather skin and superficial fascia over upper lumbar area, and then apply a lifting force so that a gapping is produced. In some cases this can be made into a thrust, and the fascia will separate with a vacuum gapping sound.

Tips: Most useful in cases of tightness in the superficial fascia which can be a factor in maintenance of pain syndromes. Least useful where the skin is very tender.

13.6 • Harmonic technique lumbar area prone

Fix the sacrum in some traction towards the patient's feet and fix the thoraco-lumbar area towards the head. The harmonic technique is performed by a rhythmic oscillation of the patient's whole body in a caudal and cephalic direction. See earlier section relating to harmonic technique.

Tips: The range of mobility available in a longitudinal plane is going to be smaller than in a rotary plane, but is, nevertheless, often useful in reestablishing rhythm and mobility. Least useful in cases where prone lying is a problem. Extra considerations: It is also possible to perform rotary harmonic technique if the tension is maintained between the hands, and the whole body oscillated into rotation. The pillow under the abdomen often makes the position more comfortable for the patient.

13.7 • Sacral springing and traction prone Flex the sacrum as far as is comfortable, and fix the thoraco-lumbar area with the other hand. Aid the flexion of the sacrum with the elbow of the one hand by pressing the other hand into the table.

Tips: Try adding various amounts of rotary movement of the pelvis or the body as a preliminary before the sacral flexion. This can enable forces to be directed to either side of the lumbo-sacral joint rather than simply flexing the sacrum. Most useful in cases of very tight lumbar fascia where this position removes some of the soft tissue tension and allows the force to reach the facet joints. Least useful in cases where prone lying is a problem.

13.8 • Harmonic technique pelvis and lumbar spine supine Take up any slack in the tissues of the pelvis by pressing firmly into the table with both hands. Perform the oscillation with alternating pressure towards the table with the heel of each hand on the anterior superior spines. This induces a rotatory movement in the lumbar spine. See earlier section relating to harmonic technique.

Tips: Try using varied amounts of traction as an additional movement. Most useful in fairly small patients where the stretch to reach is not too far. Least useful in large patients, or for small operators where the reach is a problem.

13.9 • Harmonic technique lumbar spine and pelvis prone Apply pressure above the crests of the ilia and a variable traction force towards the patient's feet. A harmonic oscillation is induced into rotation, sidebending and traction. See earlier section relating to harmonic technique.

Tips: Least useful where prone lying would be a problem.

13.11 • Functional technique typical hold The operator is controlling all possible vectors of patient movement while monitoring the sense of ease and bind at a particular segment. The controlling hand is directing the body towards accumulating ease at the target segment. See earlier section relating to functional technique.

13.10 • Traction supine Fix the patient's legs against your chest and push gently downwards so that the feet are fixed to the table. Lean back to produce a traction force in the lumbar spine. This hold can also be used in a harmonic fashion.

Tips: Most useful where a gentle traction force is required. Extra considerations: Try varying the angles of hip and knee flexion to focus the force to different areas.

3.12 • Articulation into flexion sidelying Flex the patient's hips until a sense of gapping is felt at the target segment. Rock from foot to foot and turn this diagnostic procedure into an articulation with an increase of pressure with either hand to localize the force.

Tips: Most useful in almost all cases of lumbar vertebral dysfunction. Least useful in extremely large patients or in the presence of any disorder preventing hip flexion. Extra considerations: Try using one hand to pull the pelvis into more flexion or the other hand to hold back above the target vertebra or both.

13.14 • Articulation into flexion supine Sit on the table and hold over one or more spinous or transverse processes. Flex the hips with the other hand. Hold the patient's legs against your chest so that as you rock back and forth, the force causes a flexion movement of the lumbar area.

Tips: Least useful if there is any hip disorder preventing flexion. Extra considerations: Try using varied degrees of sidebending or rotation at the same time to enhance localization.

13.13 • Articulation into reinforced flexion Pull the sacrum directly toward you while bracing the ribs towards the table. The upper hand fixes above the target segment while you pull the sacrum into flexion.

Tips: Try varied amounts of compression of the thighs toward the table and adding elements of sidebending or rotation to the flexion, to focus on particular parts of the segment. Most useful where a strong localized force is required. Least useful where the patient is very large and the reach around them would be too great.

13.15 • Articulation supine Stand at the side of the table and fix over one or more of the spinous or transverse processes. Cross the patient's thighs and apply a flexion and sidebending force as you lean forward. This hold makes it easy to introduce some element of sidebending to the primary movement of flexion.

Tips: Least useful in any patient with hip mobility restriction. Most useful in very flexible subjects where the position automatically absorbs some of the excess movement. Extra considerations: Try using a fisted hand to form a stronger fulcrum in suitable cases.

13.17 • Articulation into sidebending sidelying

Compress toward yourself, and down into the table. Sidebend the pelvis away from the table with the caudal hand as the other hand pushes down on the spinous processes.

Tips: Most useful where very localized articulation is necessary, and in cases where a firm lever through the hips may be undesirable.

13.16 • Articulation supine (alternative view) The hold is as in photograph 13.15, but shows hand placement from the other side.

13.18 • Articulation into extension sidelying

Fix the patient's shoulder girdle to the table with a compressive force and apply a direct posterior to anterior force over the lumbar spine.

Tips: Most useful where a very localized force is required. Least useful in large subjects where a small operator may find it difficult to develop sufficient leverage. Extra considerations: Try varying the initial patient position on the table to find the optimum in each case.

13.19 • Articulation into extension sidelying

Fix the patient's knees against your thigh, and fix the patient's feet to the table with your caudal hand. Pull against the lumbar area to produce a direct force into extension.

Tips: Least useful in very stiff subjects who would be very difficult to move with this hold as it would require great strength in the pulling hand to overcome the stiffness. Extra considerations: As extension is elicited from above, try asking the patient to extend the head and upper back to enhance the action of the technique.

13.20 • Articulation into extension supine Pull upward on the transverse processes on both sides. The patient has interlaced the hands behind her head to enhance the extension force.

Tips: Most useful in small subjects and children, and when directing the force into the upper lumbar area. Extra considerations: Try extending and then adding an oscillatory rotation force as an additional vector.

13.21 • Articulation into extension sidelying

Overlap the hands and pull directly on the area to introduce extension. The patient's knees are directly fixed by your thigh to form a counter-force. Keep the patient's hips at 90°.

Tips: Most useful where a fairly strong force is desired. Extra considerations: Try introducing an element of sidebending or rotation to assist the primary movement.

13.22 • Articulation into extension sitting Take up the slack of the area with crossed hands and as the patient is rocked back and forth an extension force is produced. By placing the cephalic hand on either side of the area, a rotation or sidebending force can also be introduced. The patient is astride the table to stabilize the pelvis.

Tips: Least useful in elderly patients or those where the astride position may be a problem. Extra considerations: Try asking the patient to move the hands further forward to change the angle of approach to the area.

13.23 A Articulation into extension sitting Apply thumb pressure to the paravertebral area of the segment to be mobilized. The patient is asked to hold the edge of the table and then you can push against the area rhythmically to introduce the extension force. The natural recoil of the tissues will bring the spine back to neutral.

Tips: Least useful in cases where astride sitting can be a problem. Extra considerations: Try staggering the thumbs on either side of the spine to introduce a rotation element to the movement.

13.24 • Articulation into sidebending sidelying

Push down with one hand on the legs while pulling up on the spinous processes to induce sidebending. Increase the angle of hip flexion to direct the force to higher segments as desired.

Tips: Least useful in patients who have any hip disorder as this position may be a problem. Where the table has a hard edge the pressure may be uncomfortable for the thigh on the table. Extra considerations: Try introducing an element of extension to the technique to change the effect of the pure sidebending if necessary.

13.25 • Articulation into flexion/sidebending sidelying Pull up with one hand on the spinous processes while the patient's pelvis is sandwiched between your body and arm and lean away from the spinal hand to produce sidebending. Varied degrees of flexion are applied by rocking against the patient's knees.

Tips: Most useful where very localized articulation is desired.

13.26 • Articulation into sidebending sidelying

Lift the patient's feet until tension is felt to accumulate under the other hand which pushes toward the table to produce sidebending.

Tips: Most useful where a strong generalized force is required. Least useful in the presence of any hip joint dysfunction. Extra considerations: Try varied degrees of hip flexion.

13.27 • Articulation into sidebending sidelying

Take the patient's feet in the crook of your arm and fix against the upper thigh with your wrist. Your other hand pushes against the spinous processes toward the table. Varied degrees of flexion of the hips are applied to focus the forces to the segment desired.

Tips: Least useful in the presence of any hip disorder. Most useful where a very strong stretch is desired.

13.28 • Articulation into sidebending sidelying

The patient is sidelying in a neutral position of slight hip flexion and you can push on the rib cage toward her head, on the pelvis toward her feet and on her spine toward yourself. The articulation movement is either a fixation with one hand and a pulling with the other or a movement of both. Varied degrees of rotation or flexion can be introduced as part of the overall leverage.

Tips: Most useful where any hip disorder prevents use of the hip as a lever and where strong localized forces are required. Extra considerations: A high compressive force toward the table helps to focus the technique.

13.29 • Articulation into sidebending prone

Apply the fingers to the side of the spinous processes and push away from yourself to produce a sidebending and rotation force. This is most applicable in the upper lumbar area.

Tips: Least useful where the patient may find the prone position a problem. Extra considerations: Try placing the patient in some sidebending before the initiation of the technique.

13.30 • Articulation into sidebending sidelying

The patient is lying in a neutral position with hips only slightly flexed. Apply a compressive force to the pelvis with your body and caudal hand to produce sidebending away from the table. With the other hand apply a downward force toward the table to localize the sidebending.

Tips: Most useful where a localized force is required and it is necessary to avoid using the hips in the leverage. Extra considerations: Try using varied amounts of compression through either arm and rotation to enhance the sidebending force.

13.31 • Generalized rotation mobilization supine Pull the flexed hip of the patient toward you while holding the thorax of the patient toward the table and away from you. This will produce a rotational mobilization focused primarily in the thoraco-lumbar region. Varying the angle of hip flexion will change the localization to some extent.

Tips: Least useful where specific localization is required.

13.32 • Generalized articulation into rotation supine Apply a force with your lower hand through the patient's hip using your wrist as a fulcrum. Use the other hand to hold the patient's folded arms away from you.

Tips: Least useful where specific localization is required. Extra considerations: Try placing the patient in some sidebending before the onset of the technique to enhance the effect.

13.33, 13.34 and 13.35 Thrust sidelying, building of upper lever component. There are many ways of introducing the upper component to the lumbar roll position for applying a thrust. Each has its advantages and disadvantages. Individuals will have to experiment to find their own preferred method. Photograph 13.33 shows the operator clasping the patient's forearm under his arm. While pushing the other shoulder toward the table he is pulling the lower scapula out of the way. The pull can be either into pure rotation or sidebending either way according to the direction he takes the arm. In photograph 13.34 the patient's arms are folded and the operator is lifting on the lower elbow while holding down on the upper shoulder. It is less easy to introduce a sidebending component with this hold. In photograph 13.35 the operator is sliding the lower scapula forward while holding down on the upper shoulder. This hold allows sidebending to either side to be introduced if necessary and does not involve any strain on the patient's shoulder.

13.36 • Thrust using lumbar roll sidelying rear view The operator is applying a classical combined lever and thrust technique. This rear view shows operator posture and how both feet are pointing to the head of the table with the rear heel just off the floor. Note that the weight is applied to the patient's pelvis with the thrusting hand. The other arm is only lightly fixing on the lateral aspect of the thorax and NOT the anterior aspect of the shoulder. The patient's body is rolled toward the operator who is, therefore, only slightly flexed and is able to apply the rotary force of the technique simply by a flexing of his knees.

13.37 • Thrust using minimal leverage side-lying The patient is positioned in a balanced side-lying position and a very small element of rotation has been introduced from above. Apply the hand to the patient's shoulder to produce a compressive force toward the table and your other arm is then flexed to 90° and held close to your side. Gather some skin from your forearm and the patient's buttock by gripping the buttock with the forearm and pulling it into you before applying the downward compression force. The force is applied as a combination of (a) compression to the table, (b) localized compression over the segment, (c) rotation of the pelvis by you flexing your knees and (d) a sidebending of the pelvis away from the shoulder. In minimal leverage thrust the amplitude is very short and the velocity is high.

Tips: Most useful where it is desired to produce facet separation with minimal distortion of the spinal area or torsion through the rib cage. Extra considerations: The final vectors of force direction will be slightly different in each subject. Although the directions given will apply in most cases, it must be remembered that an increase of one force direction will automatically reduce the quantity necessary for others. The order in which they are applied may also be changed to suit the circumstances. Considerable experimentation will be necessary to find the optimum for each operator's particular skill, the patient's morphology and the facet orientation. This depends to a large extent on palpatory awareness.

13.38 • Thrust, upper hand hold, combined leverage and thrust, sidelying The operator has placed the patient in position for the thrust, and this photograph shows the rotation of the upper lever. Note that the patient's upper shoulder is behind the lower one, but only by a small amount. The operator's head is vertically over the lumbar spine although the abducted arm is going to apply the thrust. A compression force is applied to the shoulder with only enough backward pressure to act as an equal and opposite force to the thrusting hand. It does NOT enter into the thrust other than as a stabilizer.

13.39 • Thrust, lower hand hold, combined leverage and thrust, sidelying Roll the patient's body toward you and apply the heel of your hand to the ilium so that it is possible to produce a rotation and extension force as necessary. Your pelvis and side must be applied to the patient's thigh, and you must fix the patient's thigh to the table with your thigh.

Tips: Most useful for larger operators, and where an extension force is needed. This hold can also be used for a direct sacral thrust. Extra considerations: Some of the thrust force comes from a downward movement of the operator's body along with the hand force.

13.40 • Thrust using minimal leverage, alternative shoulder hold Apply a downward pressure through the pelvis, after gathering some tissue under the applied forearm to induce compression and some rotation. Place your hand in direct contact with the vertebra at the apex of the force. Your other arm compresses the patient's thorax through the shoulder toward the table. The final thrust direction is a combination of compression, rotation and some sidebending as necessary.

Tips: More useful in larger patients where it may be too far to reach up to the axilla with the stabilizing hand. Less useful for operators with long arms, who may find it difficult to apply the hand to the spine at the same time as the usually applied part of the forearm to the ilium. This action will cause hyperflexion of the elbow and if repeated many times will make the risk of injury to it extremely high!

13.41 • Thrust into flexion using combined lever and thrust sidelying The initial patient positioning involves using some flexion and afterwards you apply a compressive, rotary and flexion force to the pelvis. Note that the patient's lower leg is off the edge of the table and that you must be square to the table rather than in the usual position of facing toward the opposite top corner. The combined effect of this is to produce a flexion gapping force that may be very useful in hyper-extended patients.

Tips: The final flexion is the gapping force and sufficient free play must be left to allow this to operate.

13.42 • Thrust into rotation combined lever and thrust sidelying The hold used here is specific for the lumbo-sacral and L4/5 levels. The difference in this hold is that your lower hand is not in contact with the patient. The upper hand is threaded through and is palpating the relevant spinal level. The upper hand is used to apply a compression force at the target segment. If the lower hand were to be in contact with the spine the thrusting elbow would become excessively flexed and liable to injury.

Tips: The optimum plane for the thrust will be easier to find if the patient, as a whole, is rolled gently back and forth on the table within the thrust position. This does not mean that the levers alter at all, but that a momentum force is being used in rolling while keeping the levers the same. It is also easier to apply the thrust from a dynamic rather than a static position.

13.43 • Thrust into rotation combined lever and thrust sidelying This view shows the lower arm hold used in photograph 13.42. The medial aspect of the elbow is applied to the small plateau on the lateral aspect of the ilium between gluteus maximus and gluteus medius. The soft tissues have been gathered first and the forearm muscles have been rolled to form a cushion between your ulna and the patient's pelvis.

Tips: It is worth spending some time experimenting to find the most comfortable way of applying the lower hand hold. It is often useful to apply the arm, and then, keeping contact with the patient, adduct it so that your forearm muscles are rolled between your ulna and the patient. Avoid using the back of the ulna or the point of the elbow. The forearm will be at approximately 60° to the long axis of the table. If it is at 90° this is likely to be very uncomfortable for the patient.

13.44 • Thrust into rotation combined lever and thrust sidelying This view shows the upper arm hold used in photograph 13.42. Notice that the operator is standing fairly upright and that his arm pressure is not on the shoulder but rather the antero-lateral aspect of the thorax. He is using ulnar deviation of the wrist to bring the ulnar border of the hand against the lower ribs. To avoid the force dissipating when the thrust is applied, ensure your shoulders are pulled down by active contraction of your latissimus dorsi muscles on both sides. A useful rule is that if you can see your shoulders, except out of the corner of your eyes, they are too high.

13.45 • Thrust into rotation combined lever and thrust sidelying The hold shown here is for a pure rotary thrust where the operator is focusing the forces and then will simply flex his knees to introduce the rotation. This direction of force is most useful in patients who have very sagittal lower lumbar facet planes.

Tips: The optimum plane and timing for the thrust will be found if the patient's body is kept slowly rolling back and forth.

13.46 • Thrust into sidebending combined lever and thrust The normal position of the patient's legs for HVT (high velocity thrust) techniques is reversed in that the upper leg is straight. This will introduce a sidebending toward the table and you can apply forces to emphasize this fact. The final thrust uses rotation and flexion or extension as necessary but will be primarily into rotation.

Tips: Most useful in cases where the sidebending force is desired to open an inter-vertebral foramen and possibly decompress a nerve root.

13.47 • Thrust into rotation combined lever and thrust sidelying Hold directly on the spinous process of L4 or L5 to help make the force specific. Apply the thrusting arm to produce a direct compression and rotation force through a very small amplitude.

Tips: The stabilizing hand is not applied to the anterior of the thorax in this case but more to the lateral side of the ribs as the force should not reach much above the segment concerned. Most useful where excessive rotation of the thoracic spine is best avoided.

13.48 • Thrust into extension combined lever and thrust sidelying Pull the lumbar spine into extension with your stabilizing hand and then while maintaining this vector perform the thrust into rotation and compression, avoiding flexion. If it is desired to gap the facet nearer the table, this is possible with the following vectors. Extension is maintained and a sidebending force is applied away from the table and then a compression thrust is used.

Tips: Most useful in patients who have very tight fascia, as their superficial posterior tissues will come on tension too early in flexion and prevent the technique reaching the facet joints. Paradoxically this is also effective in some very flexible patients where extension will produce an easier localization than flexion. This is because they automatically fall into extension and, rather than trying to fight this, the extension can be used as one of the components of the technique. The ability to gap the lower facet is very useful where there is nerve root impingement, as rotation, with the patient lying with the painful side uppermost, may be impossible.

13.49 • Thrust using combined lever and thrust with patient assistance Focus forces in the usual way to the lumbo-sacral facet and then ask the patient to turn her head to look over her shoulder. This will often cause the barrier sense in the joint to be enhanced which may aid the thrust.

Tips: Most useful in patients who are very flexible where it is difficult to produce an accurate focus. It is also a useful distraction for patients who find it very difficult to relax. Extra considerations: Try asking the patient to look toward the table - this will have the effect of slackening the levers.

13.50 • Thrust combined lever and thrust side-

lying Fix behind the patient's knee and against the upper shoulder and apply a rotary force to the lumbar spine. The patient's body is rocked back and forth until a sense of focusing of forces is produced. The thrust is applied with a short amplitude, high velocity force toward the floor with the knee hand. Although this hold can be a very generalized manipulation, some operators find it is possible to be very specific to a particular segment. The tendency, however, may be for any relatively hypermobile segments to gap leaving the restricted ones unaffected.

13.51 • Thrust into sidebending combined lever and thrust sidelying Place a pillow under the patient's side which will produce sidebending toward the table. Accumulate the forces at the target segment and apply the final thrust directly into sidebending by pulling up on the spinous process with the fixing hand and thrusting toward the feet with the other.

Tips: Most useful where there may be nerve root pressure or foraminal encroachment and it is desired to open the foramen during the technique. Some treatment tables have moveable sections capable of producing the initial positioning rather than needing to use a pillow.

13.53 • Thrust using sciatic stretch sidelying

This hold uses similar principles to photograph 13.52 except that you hook your leg around the patient's foot. At the time of thrust you can straighten your leg to increase the traction component through the patient's leg. This clearly has disadvantages, as you are standing on one leg, but is sometimes a useful technique. It is often possible to produce a force specific to the sacro-iliac with this hold.

13.52 • Thrust using sciatic stretch sidelying

Sandwich the patient's leg between your thighs and after accumulating tension at the facet joint flex the thigh until sciatic stretch begins. Apply the thrust into rotation while maintaining the sciatic stretch. This can be useful in cases of long-term sciatica where it may be possible to break some adhesions around the nerve root. Great care must be taken not to overstretch the nerve and traumatize it. Some adhesions will be stronger than the normal tissues, and if this is the case, damage can occur if excess force is used.

13.54 • Thrust into flexion using minimal lever and thrust sidelying Compress the lateral wall of the thorax into the table with the stabilizing hand. Apply a compressive force directly over the sacrum with the other and then the thrust is performed as a short, sharp flick into flexion of the sacrum to specifically gap the lumbo-sacral facets.

Tips: Most useful in cases of acute spasm where any torsion is best avoided. Extra considerations: This is an extremely difficult technique to perform effectively. However, it is well worth the effort of practising it, as it is then possible to manipulate cases where most other techniques would be too painful due to the leverages necessary.

13.55 • Thrust lumbo-sacral facets prone Apply a three-phase force to the sacrum. The first phase is pressure toward the table. Maintain the pressure and apply the second phase that carries the whole sacrum toward the head. The third phase is to flex the sacrum until resistance is felt and then sharply apply a small force into further flexion while maintaining the other vectors.

Tips: Most useful where specific lumbo-sacral gapping is required without spinal torsion. Least useful in patients where prone lying is a problem for any reason. Try adding a sidebending or rotation vector to direct the forces more specifically to one side or the other.

13.56 • Thrust lumbo-sacral supine Hold the pelvis firmly down onto your hand, cupping the sacrum, and apply a traction force to the sacrum until some sense of resistance is achieved. Flex the distal interphalangeal joints of your sacral hand to pull effectively toward the feet with the fingers. Then use a short, sharp tug on the sacrum to specifically gap the lumbo-sacral facets.

Tips: Most useful in heavy or pregnant patients where torsional manipulation would be a problem. Extra considerations: Try varying the hip flexion and initial sidebending position of the patient as well as the phase of respiration.

13.57 • (see facing page, top right) Thrust into rotation combined lever and thrust sitting The patient sits astride the table to help stabilize the pelvis and places her folded arms over the operator's padded shoulder. Keep the patient's head vertically over her pelvis throughout. Introduce sidebending of the spine away from you and then, while maintaining this, rotate the spine until tension accumulates under your hand applied to the spinous processes. You and the patient turn as a unit and the thrust is performed during this turn by the spinal hand accelerating slightly into rotation.

Tips: Most useful in large heavy patients where their weight in compression on the spine assists the technique. Least useful where the sitting astride position may be a problem. Extra considerations: Try varying the compressive force forward toward you to minimize the rotation element. Do not lose the sidebending when applying the rotation or the focus of tension will be lost, and strain can occur at the sacro-iliac joints.

13.58 • Thrust into rotation combined lever and thrust sitting This shows an alternative hold for the same technique as photograph 13.57. It may be more useful in large subjects where you may prefer to avoid taking the weight through your shoulder. This technique may be useful where no treatment table is available as it can be performed on a chair with the patient sitting astride the chair.

Tips: Keep the patient's head vertically over the sacrum throughout the technique.

13.59 • Thrust into rotation combined lever and thrust standing Fix the sacrum with your hip on the forward leg and rotate the patient to that side with your hand interlaced between the patient's clasped hands. Your other hand holds back on the ilium and then you sidebend the patient toward your fixing hand. When tension accumulates, sharply increase the pull with both hands.

Tips: Most useful in flexible subjects where the slight pull of psoas in this position will help limit spinal movement and aid focusing the forces. This technique may be useful where no treatment table is available.

13.60 • Vertical adjustment position standing

This shows the most common hold used where the operator is cupping his hands to clasp the patient's folded arms by the elbows. Note that one foot of the operator is in front of the other and that although he is flexed from the hips his spine is relatively straight.

13.61 • Vertical adjustment standing The hold shown in photograph 13.60 is applied and the patient is lifted so that your sacrum fits into her lumbar spine. Maintain firm compression of the patient's back against yours. You rise onto your toes and the adjustment is performed by dropping to your heels and firming your grip at the same moment. Your knees should never fully extend.

Tips: Ensure that the patient can extend her lumbar spine before performing this technique or it is likely to produce a lot of pain, as she will be in quite a considerable amount of extension at completion. Most useful where there is a vertical compressive component to any dysfunction such as disc herniation or overriding of facets. It is also useful in heavy patients where some element of traction can be very beneficial. This technique can often undo fixations that rotary techniques will leave partly unresolved and is usually best applied after rotary techniques. Least useful when the operator is shorter than the patient unless he stands on a suitable platform or step. Extra considerations: It is important that the operator pulls firmly through the elbows toward himself to add a compressive element. This helps to limit upper lumbar movement and increases friction so that the lifting force is less of a strain. The movement in the technique is synonymous with shaking the feathers down in a pillow. This technique would appear to be quite a strain on the operator but if performed properly the weight is taken mostly on his sacrum. There is not necessarily a big vertical compressive force on the operator's spine. With practice small amounts of sidebending and rotation can be used to focus the forces to particular locations within the lumbar spine.

13.62 • Vertical adjustment sitting Lift the torso of the patient through the folded arms, possibly using a pillow in the lumbar lordosis as a fulcrum. The adjustive force is a short sharp lift at the end of the accumulation of tension. There are several other hand holds for this procedure that may be tried. You could have the patient clasp the hands behind her neck. The patient could grip opposite shoulders, or she could be clasped around the lower thorax.

Tips: Most useful in small, light patients and where a narrow table is available so that the operator can bring the patient close to him. Extra considerations: Small elements of sidebending and rotation can be introduced by pulling differentially on the elbows or by the patient crossing the ankles or knees.

13.63 • Adjustive traction supine Clasp above the patient's wrists and apply a steady pull until force is felt to accumulate at the lumbo-sacral joint. This is confirmed by watching the pelvis tilt. Keep the arms at approximately 30° from the horizontal. Apply a short, sharp tug through the patient's arms without releasing any of the tension produced.

Tips: Most useful in very tall subjects where a standing adjustment may be difficult. Least useful in the presence of any shoulder dysfunction that may be irritated by the traction force. It is essential to pre-load with the initial traction or the force will be dissipated before it reaches the lumbo-sacral.

13.64 • Thrust sidelying using second operator Apply forces in the normal way to focus to a particular joint. The second operator applies a slowly increasing traction force through the ankle until you tell him to stop. You will be able to do this as you should feel an enhancement of localization during this traction component. The thrust can then be performed while the traction is maintained.

Tips: Most useful in very flexible subjects where it is difficult to accumulate tension unaided. This is also a useful method where there is some nerve root impingement as the traction may allow a rotary force to reach the facet while the foramen is being opened slightly. Extra considerations: The second operator, with a minimum of practice, will also be able to feel tension accumulating as the levers are applied.

13.65 • Thrust sidelying using second operator This technique uses exactly the same principles as those in photograph 13.64, except the second operator is applying traction to the neck until the required tension is felt by the first operator.

Tips: With a third operator this technique can be combined with the previous technique in photograph 13.64 if even more traction is required.

13.66 • Thrust sidelying two operator technique

The patient is in a semi-Simms position and the first operator has lifted the patient's flexed knees while pushing toward the floor with the heel of his hand applied to the spinous processes. The second operator rests his thorax on the patient's scapula and while applying traction through the patient's wrist, is fixing under the spinous processes with his other hand. The forces are accumulated by the contra-rotation of the upper part of the patient's body toward the table and the lower part away. The thrust is performed by the second operator fixing while the first operator presses down on the spinous processes and sharply lifts the patient's knees toward the ceiling. Varied angles of hip flexion in the patient will direct the force higher or lower in the lumbar spine. It is critical to keep the patient's hips flexed throughout or the tension is very easily lost.

Tips: See photograph 13.67 for clarification of hand positions. Most useful where conventional rotary techniques are ineffective as this technique works on the principle of backward rotation of the lower component that will sometimes break fixation in a way not previously achieved. Least useful in very heavy patients where the strain on the operator lifting the legs may be too great. Extra considerations: This technique needs some practice to achieve appropriate coordination between operators.

13.67 • Thrust sidelying two operator technique The rear view shown here of photograph 13.66 clarifies the hand hold and patient position.

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