Cervical spine C27

Down-slope gliding Cradle hold Patient supine

Assume somatic dysfunction (A-R-T-T) is identified and you wish to use a downward and backward gliding thrust, parallel to the apophysial joint plane, to produce cavitation at C4-5 on the right (see below)

1 Contact point

2 Applicator

3 Patient positioning

4 Operator stance

5 Palpation of contact point

6 Fixation of contact point

7 Cradle hold

8 Vertex contact

The lateral aspect of the right articular pillar of C4.

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 you 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. Rotate the head to the left, taking its weight in your left hand. Remove your right hand from the occiput and palpate the right articular pillar of C4 with the tip of your index or middle finger. Slowly but firmly slide your right index finger downwards (towards the couch) along the articular pillar until it approximates the middle or proximal phalanx. Several sliding pressures may be necessary to establish close approximation to the contact point.

Keep the right index finger firmly pressed on 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 thereby lock 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 the left hand under the head and spread the fingers out for maximum contact; keep the patient's ear resting in the palm of the your left hand. Flex the left wrist, allowing you to cradle the patient's head in your palm, flexed wrist and anterior aspect of forearm. Keep your right index finger firmly on the contact point and press the right palm against the occiput. The weight of the patient's head and neck is now balanced between your left and right hands, with the cervical positioning controlled by the converging pressures of your two hands and arms. When treating the lower cervical segments, the middle or distal phalanx may be used as the applicator.

None in this technique.

9 Positioning for The elbows are held close to or only slightly away from your sides. thrust This is an essential feature of the cradle hold method. Stand easily upright at the head of the couch and do not step to the right as in the chin hold method.

(a) Primary leverage of sidebending. Maintaining all holds and contact points, gently introduce sidebending of the head and neck to the right until tension is palpated at the contact point (Fig. Bl.ll.1). To introduce the right sidebending, the operator pivots slightly via the legs and trunk so that the trunk and upper body rotate to the left, enabling the hands and arms to remain in position. Do not lose firm contact with your contact point on the articular pillar of C4. A common mistake is to use insufficient primary leverage of head and neck sidebending.

(b) Secondary leverage. Add a little rotation to the left, down to and including C4 (Fig. Bl.ll.2). This requires extensive practice before one develops a refined 'tension sense'. Movement of your hands and forearms introduces the rotation.

10 Adjustments to Ensure your patient remains relaxed. Maintaining all holds, make any achieve necessary changes in flexion, extension, sidebending or rotation until appropriate you can sense a state of appropriate tension and leverage. The patient pre-thrust tension should not be aware of any pain or discomfort. You make these final adjustments by slight movements of your ankles, knees, hips and trunk, not by altering the position of the hands or arms.



11 Immediately Relax and adjust your balance as necessary. Keep your head up; pre-thrust looking down impedes the thrust and can cause embarrassing proximity to the patient. An effective HVLA technique is best achieved if both the operator and patient are relaxed and not holding themselves rigid. This is a common impediment to achieving effective cavitation.

Note that the final thrust is directed in a downward and backward direction parallel to the facet joint plane. The thrust is directed towards the patient's left shoulder as illustrated. The primary leverage is sidebending to the right and the secondary (lesser leverage) is rotation to the left.

12 Delivering the Apply a HVLA thrust to the right articular pillar of C4. The direction thrust of thrust is caudad in the direction of the patient's left shoulder and downwards towards the couch, parallel to the apophysial joint plane (Fig. Bl.ll.3). The operator rotating the trunk and upper body to the left, enabling the hands and arms to remain in position on the cervical spine, generates the thrust. Simultaneously, apply a very slight, rapid increase of sidebending of the head and neck to the right but do not increase the rotation leverage.

Fig. B1.11.3

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.


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