An Osteopathic Perspective

with accompanying CD-ROM

Peter Gibbons MB BS DO DM-SMed

Associate Professor, Osteopathic Medicine; Head of the School of Health Sciences, Victoria University, Melbourne, Australia

Philip Tehan DO DipPhysio

Senior Lecturer, Osteopathic Medicine, School of Health Sciences, Victoria University, Melbourne, Australia

Foreword by

Philip E. Greenman dofaao

Emeritus Professor, Department of Osteopathic Manipulative Medicine; Emeritus Professor, Department of Physical Medicine and Rehabilitation, Michigan State University College of Osteopathic Medicine, Michigan, USA

Photographs by Tim Turner

Churchill

LIVINGSTONE

EDINBURGH LONDON NEW YORK PHILADELPHIA ST LOUIS SYDNEY TORONTO 2000

CHURCHILL LVTNGSTONE An imprint of Harcourt Publishers Limited

© Harcourt Publishers Limited 2000

b is a registered trademark of Harcourt Publishers Limited

The right of Peter Gibbons and Philip Tehan to be identified as authors of this work has been asserted by them in accordance with the Copyright, Designs and Patents Act 1988

All rights reser'ed. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any fonn or by any means, electronic, mechanic^, photocopying, recording or otherwise, without either the prior pe^mssion of the publishers (Harcourt Publishers Limited, Harcourt Place, 32 Jamesto^i Road, London 7BY), or a licence permitting restricted copying in the United Kingdom issued by the Copyright Licensing Agency, 90 Tottenham Court Road, London Wl P OLP.

First published 2000 ISBN 0 443 06262 5

British Library Cataloguing in Publication Data

A catalogue record for this book is avaJable from the British Library

Library of Congress Cataloging in Publication Data

A catalog record for this book is available from the Library of Congress

Note

The publisher and authors do not ass^e any responsibility for any injury and / or damage to persons or property arising out of or related to any use of the material contained in this book. It is the responsibility of the treating practitioner, relying on independent experience and knowledge of the pati ent, to detennine the best treatment and method of application for the patient.

The publisher's policy Is to use pa^r manufactured from sustainable foruts

Printed in China I

Contents

The CD-ROM accompanying this text includes video sequences of all the techniques described in Part B and the first four techniques described in Part C. These are indicated in the text by the following symbol . To look at the video for a given technique, click on the relevant icon in the contents list on the CD-ROM.

The CD-ROM is designed to be used in conjunction with the text and not as a stand-alone teaching aid.

Foreword vb Preface ix Acknowledgements x

PART A: HVLA thrust techniques - an osteopathic perspective 1

1 Introduction 3

2 Osteopathic philosophy and technique 5

3 Kinematics and coupled motion of the spine 9

4 Spinal positioning and locking 17

5 Safety and HVLA techniques 23

6 Rationale for the use of HVLA techniques 37

7 Validation of clinical practice by research 43

PART B: ^ HVLA thrust techniques - spine and thorax 51

SECTION 1 Cervical and cervicothoracic spine 55

1.1 Atlanto-occipital joint CO-Cl: contact point on occiput 57

1.2 Atlanto-occipital joint CO-Cl: contact point on atlas 63

1.3 Atlantoaxial joint Cl-2: chin hold 69

1.4 Atlantoaxial joint Cl-2: cradle hold 75

1.5 Cervical spine C2-7: up-slope gliding; chin hold; patient supine 81

1.6 Cervical spine C2-7: up-slope gliding; cradle hold; patient supine 87

1.7 Cervical spine C2-7: up-slope gliding; cradle hold; patient supine; reversed primary and secondary leverage 93

1.8 Cervical spine C2-7: up-slope gliding; patient sitting; operator standing in front 99

1.9 Cervical spine C2-7: up-slope gliding; patient sitting; operator standing to the side 105

1.10 Cervical spine C2-7: down-slope gliding; chin hold; patient supine 111

1.11 Cervical spine C2-7: down-slope gliding; cradle hold; patient supine 117

1.12 Cervical spine C2-7: down-slope gliding; patient sitting; operator standing to the side 123

1.13 Cervicothoracic spine C7-T3: rotation gliding; patient prone; operator at side of couch 129

1.14 Cervicothoracic spine C7-T3: rotation gliding; patient prone; operator at head of couch 135

1.15 Cervicothoracic spine C7-T3: sidebending gliding; patient sitting 141

1.16 Cervicothoracic spine C7-T3: sidebending gliding; patient side-lying 147

SECTION 2 Thoracic spine and rib cage 151

2.1 Thoracic spine T4-9: extension gliding; patient sitting 155

2.2 Thoracic spine T4-9: flexion gliding; patient supine 161

2.3 Thoracic spine T4-9: rotation gliding; patient supine 167

2.4 Thoracic spine T4-9: rotation gliding; patient prone; short lever technique 173

2.5 Ribs Rl-3: patient prone 179

2.6 Ribs R4-10: patient supine 185

2.7 Ribs R4-10: patient prone 189

2.8 Ribs R4-10: patient sitting 195

SECTION 3 Lumbar and thoracolumbar spine 201

3.1 Thoracolumbar spine TlO-L2: neutral positioning; patient side-lying 205

3.2 Thoracolumbar spine TlO-L2: flexion positioning; patient side-lying 209

3.3 Lumbar spine Ll-5: neutral positioning; patient side-lying 213

3.4 Lumbar spine Ll-5: flexion positioning; patient side-lying 219

3.5 Lumbar spine Ll-5: neutral positioning; patient sitting 225

3.6 Lumbosacral joint L5-Sl: patient side-lying 231

PART C: HVLA thrust techniques - pelvis 237

1 Sacroiliac joint: left innominate posterior; patient prone 239

2 Sacroiliac joint: right innominate posterior; patient side-lying 243

3 Sacroiliac joint: left innominate anterior; patient supine 247

4 Sacroiliac joint: sacral base anterior; patient side-lying 251

5 Sacrococcygeal joint: coccyx anterior; patient side-lying 255

References 259

PART D: Technique failure and analysis 261

Index 267

Foreword

Manipulation is one of the oldest continuing forms of patient treabnent in use primarily for musculoskeletal pain syndromes. It predated Hippocrates, the father of medicine. The techniques of manipulation are used by a number of practitioners of different professions within the scope of practice of their profession. It is incumbent upon every manipulating health care provider to be as knowledgeable about the field as possible.

High velocity low amplitude (HVLA) thrust technique is one of the oldest forms of manipulation and one of the more commonly used. It can, however, be used inappropriately, and there are potential complications of its use that all practitioners should be aware of.

The authors of this text have chosen to limit the scope to HVLA thrust techniques, and have geared it towards both new students and experienced practitioners. They have limited the techniques to the more commonly used in the areas of the spine and pelvis, and have included sixteen for the cervical spine, eight for the thoracic spine and ribs, six for the lumbar spine and five for the sacroiliac region.

The authors have provided the most current information about vertebral motion and spinal coupling - a much needed update. Their descriptions of the principles of spinal positioning and locking are clear and accurate. They provide a sound rationale for the use of HVLA technique and clearly describe the potential problems of its use and how to prevent the common complications. The material is well referenced, and the reader can find more information about the issues presented by reading the referenced material.

The techniques are clearly described in a format that remains consistent throughout and provides a step-by-step approach that the neophyte can easily follow, and the experienced practitioner can refine techniques used daily. Experience is necessary to identify which techniques are indicated for each patient's presentation.

This book fills a need in the manipulation literature for a single text on one of the many types of manipulation available in the practitioners' armamentarium. It is clear, concise, accurate, easily readable and highly recommended.

Philip E. Greenman

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Preface

Thrust techniques are widely used in the treatment of musculoskeletal dysfunction by osteopaths, physiotherapists, chiropractors and medical practitioners with increasing evidence of their effectiveness. For a commonly used treatment approach it is surprising that there are such limited resources to support learning and skill refinement in High Velocity Low Amplitude (HVLA) thrust techniques. Most of the learning of HVLA thrust techniques has been dependent upon personal instruction and demonstration.

There are only a handful of osteopathic technique books and manuals, and few of these relate solely to thrust techniques. The material presented in this text has been developed in response to the learning needs of undergraduate and postgraduate students over a 25-year period. The novice has to acquire the basic skills, and experienced practitioners should reflect upon their performance and constantly refine each thrust technique. It has been our experience that the structured step-by-step format used in the text and the visual reinforcement offered by the accompanying CD-ROM have been successful in assisting both initial development and subsequent refinement of the psychomotor skills necessary for the effective delivery of HVLA thrust techniques.

Thrust techniques are considered to be potentially more dangerous when compared to other osteopathic techniques. Patient safety is a major consideration when selecting a treatment approach. Our goal has been to prepare a text that will provide the necessary information relating to all aspects of the delivery of HVLA thrust techniques in one comprehensive volume, so that practitioners can use these techniques safely and in the appropriate circumstances.

Melbourne 2000 Peter Gibbons

Philip Tehan

Acknowledgements

We are grateful to those colleagues who knowingly or unknowingly assisted in the development of the book. We also acknowledge that the constant questioning by students has significantly contributed to the development of the material in the text.

Tim Turner provided the photographs. We would like to thank him for his patience and understanding during the many photographic sessions. We are indebted to Andrea Robertson for her good humor and endurance during the long sessions spent as the model for the photographs and CD-ROM. The teaching potential of the text has been greatly enhanced by the visual material and their contribution.

A special thanks is extended to Mary Emmerson Law and Dinah Thom at Churchill Livingstone for their continued help and support.

Our greatest debt of gratitude goes to those family members and special friends whose tireless support made the writing of the book possible.

CONTENTS

1 Introduction

2 Osteopathic philosophy and technique

3 Kinematics and coupled motion of the spine

4 Spinal positioning and locking

5 Safety and HVLA techniques

6 Rationale for the use of HVLA techniques

7 Validation of clinical practice by research

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