20.6 • Articulation sidelying Fix the under-surface of the patient's flexed upper arms against your side and hold her elbows. Use a firm grip on the spinous process of the target vertebra with the other hand. Introduce flexion and extension by rocking your body into rotation, thereby carrying her arms back and forth.
Tips: Least useful where the patient has any condition of her shoulders making the flexed position difficult. Try using one flexed arm only. Most useful where it is desired to eliminate neck movement from the equation as her hands will help do this.
20.8 • Articulation sidelying Flex both of the patient's arms to pull the scapulae apart. Support her head and mid neck with your upper hand. Use the fingertips of the other hand to push against the spinous processes of the area to introduce a sidebending articulation with some possible rotation. Lift the head using the tips of the fingers under the neck to limit the movement to the lower cervical and upper thoracic area.
Tips: The lower down the neck you fix with the upper hand, the more localized the force becomes, and the more the upper neck is protected from strain. Avoid having your upper arm biceps against the patient's eyes; rather, fix against the forehead. Use some downward compression through the upper scapula to stabilize the body. Least useful where there may be any neck instability, as however much protection is introduced, there will be some strain induced.
20.9 • Articulation sidelying Flex the patient's neck and grip as far down as possible with the upper hand to avoid neck strain. Use the fingers of the other hand to pull the spinous processes against the movement of the upper hand. Most movement directions are possible with this hold.
Tips: The fixing hand protects the neck and allows reasonable localization of the articulation. Avoid crowding the patient's face with your upper arm or chest.
20.10 • Articulation sitting The patient sits across the table at one end. Stand at the end of the table and reach around her clasped hands to hold her far shoulder and pull her against you. Use the thumb of the rear hand to pull the spinous process of the target vertebra toward you. Keep the head in the midline and rock the patient into sidebending, making this vertebra a focus and fulcrum for the movement.
Tips: Firm compression toward you will allow induction of movement to be produced by a rocking back of your body. Try introducing circum-duction movements as well as simple sidebending. Least useful if the operator has an unstable thumb. In this case try substituting a thenar hold.
20.11 • Articulation sitting The patient sits across the table at one end. Stand at the end of the table and reach around her clasped hands to hold her far shoulder and pull her against you. Use the heel of the rear hand to push the spinous process of the target vertebra toward you. Keep the head in the midline and rock the patient into sidebending making the vertebra a focus and fulcrum for the movement.
Tips: Firm compression toward you will allow the induction of movement by a rocking back of your body. Try introducing circumduction movements as well as simple sidebending. Least useful if the movement needs to be very specific to only one segment as this pushing movement will inevitably involve several vertebrae.
20.12 • Thrust prone Sidebend the neck and head of the prone patient at the same time as you induce a slight rotation to the other side. Fix as low down on the neck as possible with the head hand to avoid excessive neck strain. Apply a compression force against the transverse process of the target vertebra toward the table and axilla with the thrusting hand. Gently rock the head on the chin to find the optimum barrier accumulation under the thrusting hand. At the point of optimum barrier, apply a very short amplitude thrust to the transverse process to gap the joint on the same side.
Tips: Least useful for patients who find the prone position a problem. Least useful for most patients over 45 years of age, as normal degenerative changes in the neck will make the lever uncomfortable. If a table with a dropping head leaf is available, it is possible to perform this technique on a wider range of patients as the slightly flexed position will remove some of the strain. Avoid pulling the head harder when the thrust is performed as this is often painful. Try varied balance between rotation and sidebending to find the best mix of effectiveness and comfort. Try moving the thrusting hand laterally to the angle of the rib to make this into a rib gapping technique.
20.13 • Thrust prone Stand at the side of the table with the prone patient's head in rotation away from you. Fix the scapula with your lower hand and gently fix the head into rotation and a small amount of sidebending. Apply the heel of the thrusting hand against the side of the spinous process of the target vertebra toward the patient's axilla. Balance the forces so that the head hand does not move when the thrust is applied with the spinal hand to gap the facet on the far side of the patient's spine.
Tips: The direction of thrust governs which side will be gapped. If the force is toward the axilla, the other side will gap as the facets on the nearside are in apposition. If the force is predominantly into the table, there will be a tendency for the same side to gap. Avoid this position in patients over about 45 years of age as the strain on the neck may be unacceptable. Avoid the tendency to introduce excessive extension as this can be traumatic and, moreover, renders the technique less effective. Move the thrusting hand more laterally onto the angle of the rib to make this into a rib gapping technique.
20.14 • Thrust prone Stand at the head and slightly to one corner of the table with the patient's head turned away from you. Carefully fix the neck as low down as you can reach with the upper hand. Fix the spinous process of C7 with the thumb of this hand to limit movement to the upper thoracic area. Apply the thenar eminence of the thrusting hand to the transverse process of the target vertebra, pushing it toward the axilla. Stabilize the rotation with the head hand, and increase the pressure with the thrusting hand until a suitable barrier accumulates. Apply the thrust with the lower hand only to gap the facet on the thrusting side.
Tips: Apply the thrust to the angle of the rib to make this into a rib gapping technique. Avoid this position in patients over about 45 years of age as the neck extension may be uncomfortable. It is possible to perform this at a more advanced age if a drop leaf table is available.
20.15 • Thrust prone (shown on skeleton) The technique shown in photograph 20.14 is demonstrated here on the skeleton to show the position of the hands more accurately.
20.16 • Thrust prone Stand at the side of the prone patient and apply the hypothenar eminences of both hands to opposite sides of the spine at adjacent segmental levels. Apply some pressure onto the transverse processes to induce some compression and sidebending. Rotate your body to emphasize this movement and vary the pressure with the hands to introduce some rotation to the movement until a suitable barrier is found. The thrust can be applied with one hand, the other hand, or both.
Tips: Try reversing the hand position to find the optimum for each case. As each vertebra has multiple joints, every change in angle or pressure will vary which will be the target joint. A sidebend-ing thrust rather than a compression thrust will be more comfortable, and less potentially traumatic in cases of possible rib fragility.
20.17 • Thrust prone Fix the scapula with the forearm and the head into rotation away from you with the lower hand. Introduce a very small element of extension and sidebending with the head hand. Push against the spinous process of the target vertebra with the thumb of the thrusting hand into sidebending and slight compression into sideshift-ing. The thrust is applied into sidebending with the thrusting hand while maintaining the head position with the other hand. This will gap the facet on the far side. If the force is directed more toward the table with the thrusting thumb, it will tend to gap the facet on the nearside.
Tips: Least useful where the operator has problems with thumb stability. The fixation of the scapula and head gives some protection to the neck providing they are held steady during the thrust.
20.18 • Thrust prone Rest the patient's head on her chin and gently support it with one hand avoiding throat pressure. Cup one spinous process with the area between the thenar and hypothenar eminences of the other hand and apply a pressure toward the sternum. Carefully oscillate between the hands until a suitable barrier accumulates under the thrusting hand. The thrust is a very short amplitude force while maintaining the head steady. Avoid excessive neck extension that can become traumatic.
Tips: This is a technique that is potentially dangerous, and must only be used with great care in suitable subjects.
20.20 • Thrust sitting This hold is substantially similar to photograph 20.19 except that the patient has placed her arm over a suitable pad on the operator's knee to act as a fulcrum. It is easier to induce sideshifting with this hold, and some patients feel more stable and secure. It is, however, more difficult for the operator to balance the forces as he is standing on one leg.
20.19 • Thrust sitting Stand behind and slightly to one side of the seated patient. Apply the thumb against the side of a spinous process of the target vertebra to induce sidebending and rotation. Support the patient by pulling her against your abdomen with the hand, and introduce slight rotation by pulling back against the clavicle. Flex your other arm and apply the inside of the forearm against the side of the head and face to produce a direct sideshifting force. Form a fulcrum of the vertebra and thumb while performing slight circumduction to the body to accumulate the best thrust barrier. When the tension is optimum, apply the thrust with the thumb toward the opposite axilla while the neck is fixed by the other hand.
Tips: Least useful for operators who might have instability in the thumb. Try using the thenar or hypothenar eminence instead. Vary the flexion and extension of the head, and try antero-posterior shifting to aid the focus of forces. If the thrust is applied against the spinous process toward the opposite axilla, it will gap the facet on the opposite side. If the thrust is applied more in a forward direction it will tend to gap the facet on the same side. In this case there will need to be a vector of downward pressure introduced as well.
20.21, 20.22, 20.23 and 20.24 Thrust sitting This hold is very specific for the C7 to T1 joints. The sequence of photographs shows the order of application of the hold. Have the patient place one hand behind her neck and reach under the other arm with your thrusting hand. When you have reached as far as possible, flex your elbow to bring the heel of your hand against the fingertips of the patient that are flexed over the lower neck. Maintain some pressure there, and reach around her chest to grasp her wrist with your other hand. Apply some sidebending toward your thrusting hand, and rotate slightly away from this hand by pulling on the wrist. Pull the patient firmly against your chest to produce a direct antero-posterior compression. This will better help focus the other vectors of force. Apply the thrust vertically through the patient's fingers to gap the facet on the same side. (Note the astride position is shown for clarity only; it is not an essential part of the technique.)
Tips: This is a complex technique, and several things can cause it to fail. The thrust must be vertical not anterior. The pull on the wrist must be quite firm to maintain the sidebending. Some extension is necessary, but too much will block the technique.
20.25, 20.26 and 20.27 Thrust sidelying Fix against the side of the spinous process with the thumb, heel of the hand or thenar eminence according to your preference. Lift the head into sidebending away from the table. Abduct the arm holding the head so that the patient's face is not obstructed and so it is possible to reach down to support the neck with the ulnar border of the hand. Introduce some sideshifting away from the table as well as a slight anterior shift of the neck. Fix against the upper scapula with your chest. Accumulate the barrier with a combination of sideshifting and sidebending away from the table, slight rotation toward the table, and compression against the shoulder. Apply the thrust with the chosen applicator to produce a rotation and sidebending of the target vertebra.
Tips: Note that the direction of the thrust can be varied to gap the lower or upper facet. Force directed toward the table will tend to gap the lower one, while force toward yourself will tend to gap the upper one. The lower down the neck you grip, the more the neck protection, and the less uncomfortable for the patient. The selection of applicator is dependent on operator thumb strength and ability to focus with the other parts of the hand.
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