Down-slope gliding Patient sitting Operator standing to the side
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
3 Patient positioning
4 Operator stance
Lateral aspect of the right articular pillar of C4.
Palmar aspect, proximal or middle phalanx of operator's left index or middle finger.
Sitting with the neck in a neutral relaxed position. The neck should not be in any significant amount of flexion or extension.
Stand to the left of the patient, 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 (Fig. Bl.12.1).
5 Palpation of Place the fingers and palm of your right hand over the left side of the contact point patient's head and neck, gently covering the left ear. Reach in front of the patient with your left hand and palpate the right articular pillar of C4 with the tip of your left index or middle finger. Slowly but firmly slide your applicator along the articular pillar of C4 until it approximates the proximal or middle phalanx. Several sliding pressures may be necessary to establish close approximation to the contact point.
Fixation of contact point
Keep your left index or middle finger firmly pressed upon the contact point while you spread the other fingers and thumb of the left hand to securely support the head, mandible and neck, thereby locking the applicator in position. You must now keep the applicator on the contact point until the technique is complete. The weight of the head and neck is now balanced between your right and left hands, with the cervical spine positioning controlled by the converging pressures of your two hands.
The elbows are held close to or only slightly away from your sides.
(a) Primary leverage. Ensure that the patient's head is securely supported between your two hands. Maintaining all holds and contact points sidebend the head and neck to the right until tension is palpated at the contact point (Fig. B1.12.2). Do not lose contact between your applicator and the articular pillar of C4. Do not force sidebending; take it up fully but carefully. A common mistake is to use insufficient primary leverage of head and neck sidebending.
(b) Secondary leverage. Add a very small degree of rotation to the left, down to and including C4. Slight movements of the operator's hands and arms introduce the rotation.
8 Adjustments to achieve appropriate pre-thrust tension
9 Immediately pre-thrust
Ensure your patient remains relaxed. It is important to keep your elbows close to your sides. Maintaining all holds, make any necessary changes in flexion, extension, sidebending or rotation until you can sense a state of appropriate tension and leverage. The patient should not be aware of any pain or discomfort.
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 both the operator and patient are relaxed and not holding themselves rigid. This is a common impediment to achieving effective cavitation.
Apply a HVLA thrust to the right articular pillar of C4. The thrust is caudad and towards the patient's left shoulder, parallel to the apophysial joint plane (Fig. Bl.12.3). Simultaneously, appiy a slight, rapid increase of sidebending to the right but do not increase rotation leverage. This is a HVLA 'flick' type thrust. Coordination between the left and right hands and arms is critical.
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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