Assume somatic dysfunction (A-R-T-T) is identified and nmtT^^ you wish to use a thrust in the plane of the atlantoaxial 111 / / if*'' (Cl-2) apophysial joint to produce cavitation on the right !(UJ (Figs Bl.3.1, Bl.3.2)
1 Contact point
3 Patient positioning
4 Operator stance
5 Palpation of contact point
6 Fixation of contact point
7 Chin hold
8 Vertex contact
Right posterior arch of atlas.
Lateral border, proximal or middle phalanx of 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.
Place fingers of both hands gently under the occiput. Lift 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 region of the right posterior arch of the atlas with the tip of your index or middle finger. Slowly but firmly slide your right index finger downwards (towards the couch) along the posterior arch of the atlas until it approximates the middle or proximal phalanx. Several sliding pressures may be necessary to establish close approximation to the contact point.
Keep your right index finger firmly pressed upon the contact point while you flex the other fingers and thumb of the right hand so as to clasp the back of the neck and occiput, 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.
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.
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 for Step to the right and stand across the right corner of the couch, thrust keeping the hands firmly in position and taking care not to lose pressure on the contact point. Gently introduce rotation of the head to the left, to the point at which the posterior arch becomes more obvious under your contact point. 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 to reach that point when your line of thrust is directed towards the corner of the patient's mouth. The thrust plane is into rotation. Ensure that you maintain a firm contact point on the posterior arch of the atlas and that your applicator is in line with your forearm.
(a) Primary leverage of rotation. Maintaining all holds and contact points, complete full rotation of the head and neck to the left until slight tension is palpated in the tissues at your contact point (Fig. B1.3.3). Maintain firm pressure against the contact point. A common mistake is to use insufficient head and neck rotation.
(b) Secondary leverage. This technique uses minimal secondary leverage.
10 Adjustments to achieve appropriate pre-thrust tension
This is almost a pure rotation thrust but the appropriate tension can be achieved by adjusting flexion, extension and sidebending. The patient should not be aware of any pain or discomfort. Introduce any sidebending, flexion or extension by pivoting slightly via the legs and trunk. Do not attempt to introduce these leverages by moving the hands or arms as this will lead to loss of contact and inaccurate technique.
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 Apply a HVLA thrust to the posterior arch of the atlas directed the thrust towards the corner of the patient's mouth. Simultaneously, apply a rapid low-amplitude increase of head rotation to the left by supinating the left forearm (Fig. B1.3.4). This rotation movement of the head is very small but of high velocity. This ensures that the occiput and atlas move as one unit during the thrust. The atlas rotates about the odontoid peg of the axis and cavitation occurs at the right Cl-2 articulation. A very rapid contraction of the flexors and adductors of the right shoulder induces the thrust. 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.
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