Assume somatic dysfunction (A-R-T-T) is identified and you wish to use a thrust in the plane of the CO-Cl apophysial joint to produce cavitation on the right (Fig. Bl.l.V
1 Contact point
3 Patient positioning
4 Operator stance
Right posterior occiput. Medial and posterior to the mastoid process.
Lateral border, proximal or middle phalanx of the operator's right index finger.
Supine with the neck in a neutral relaxed position. If necessary, remove pillow or adjust pillow height. The neck should not be in any significant amount of flexion or extension.
Head of couch, feet spread slightly. Adjust couch height so that the operator can stand as erect as possible and avoid crouching over the patient, as this will limit the technique and restrict delivery of the thrust.
5 Palpation of Place fingers of both hands gently under the occiput. Lift contact point the head slightly and gently rotate it to the left, taking the weight of the head in your left hand. Remove your right hand from the occiput and palpate the contact point on the occiput with the tip of your index or middle finger. Ensure that you are medial to, and not on, the mastoid process. Slowly but firmly slide your right index finger, in close approximation to the suboccipital musculature, downward (towards the couch) along the occiput until it approximates the middle or proximal phalanx. Several sliding pressures may be necessary to establish close approximation to the contact point. It is important to obtain a contact point as far along the underside of the occiput as possible, and into the suboccipital musculature. This thrust uses a curved plane of movement to produce a cavitation and this positioning ensures that the applicator will not slip during the thrust.
6 Fixation of Keep your right index finger firmly pressed on the contact point while contact point you flex the other fingers and thumb of the right hand so as to clasp the back of the occiput and head, thereby locking the applicator in position. You must now keep the applicator on the contact point until the technique is complete. Keeping the hands in position, return the head to the neutral position.
7 Chin hold Keep your right hand in position and slide the left hand, slowly and carefully, forwards until the fingers lightly clasp the chin. Ensure that your left forearm is over or slightly anterior to the ear. Placing the forearm on or behind the ear puts the neck into too much flexion. The head is now controlled by balancing forces between the right palm and left forearm. Maintain the applicator in position.
8 Vertex contact Move your body forward slightly so that your chest is in contact with the vertex of the patient's head. The head is now securely cradled between the left forearm, the flexed left elbow, the right palm and your chest. Vertex contact is often useful in a heavy, stiff or difficult case but can, on occasions, be omitted.
9 Positioning Step to the right and stand across the right corner of the couch, for thrust keeping the hands firmly in position and taking care not to lose pressure on the contact point. Gently introduce a little rotation of the head to the left. Straighten your right wrist so that the radius and first metacarpal are in line. While maintaining firm applicator pressure, allow the right index finger to roll slightly on the contact point as you move your right elbow towards the patient's right shoulder. This facilitates optimal alignment for the thrust, which is in a curved plane because of the shape of the apophysial joint. It is important that your applicator is well beneath the occiput so that you do not slip when applying the thrust along a curved facet plane. Keep your right elbow close to the couch in order to keep the contact point on the occiput (Fig. Bl.l.2).
10 Adjustments to achieve appropriate pre-thrust tension
Add extension and slight sidebending to the right to provide a feeling of tension at the contact point. Extensive practice is necessary to develop an appreciation of the required tension. The extension and right sidebending are introduced by pivoting slightly via the legs and trunk so your trunk and upper body rotate to the left. Do not attempt to introduce sidebending by moving the hands or arms as this will lead to loss of contact and inaccurate technique.
Ensure the patient remains relaxed. Maintaining all holds, make any necessary minor changes in flexion, extension, sidebending or rotation until you can sense a state of appropriate tension and leverage at the contact point. The patient should not be aware of any pain or discomfort. You should introduce these final adjustments by slight movements of the ankles, knees, hips and trunk, not by altering the position of your hands or arms.
Relax and adjust your balance as necessary. Keep your head up; looking down impedes the thrust and can cause embarrassing proximity to the patient. An effective HVLA technique is best achieved if the operator and patient are relaxed and not holding themselves rigid. This is a common impediment to achieving effective cavitation.
12 Delivering This is a difficult technique to master, as the thrust must be applied the thrust along a curved plane. Apply a HVLA thrust to the occiput, using both hands, in an anterior and superior direction along a curved plane which follows the shape of the occipto-atlantal articulation (Fig. B1.1.3).
The thrust, although very rapid, must never be excessively forcible. The aim should be to use the absolute minimum of force necessary to achieve joint cavitation. A common fault arises from the use of excessive amplitude with insufficient velocity of thrust.
Contact point on occiput Chin hold Patient supine
♦ Contact point. Right posterior occiput.
♦ Applicator. Lateral border, proximal or middle phalanx.
♦ Patient positioning. Supine with the neck in a neutral relaxed position.
♦ Operator stance. Head of couch, feet spread slightly.
♦ Palpation of contact point. Ensure that you are medial to, and not on, the mastoid process.
♦ Fixation of contact point.
♦ Chin hold. Ensure your left forearm is over or slightly anterior to the ear.
♦ Vertex contact. Optional.
♦ Positioning for thrust. Step to the right and stand across the right corner of the couch. Optimal alignment for the thrust is in a curved plane. Keep your right elbow close to the couch in order to keep the contact point on the occiput (Fig. B1.1.2).
♦ Adjustments to achieve appropriate pre-thrust tension.
♦ Immediately pre-thrust. Relax and adjust your balance.
♦ Delivering the thrust. The thrust must be applied, using both hands, along a curved plane that follows the shape of the occipto-atlantal articulation (Fig. B1.1.3).
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