Down-slope gliding Chin 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
3 Patient positioning
4 Operator stance
5 Palpation of contact point
6 Fixation of contact point
1 Chin hold
8 Vertex contact
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 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 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.
Keeping your right hand in position, 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 your 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 slightly to the right, keeping the hands firmly in position and for thrust taking care not to lose pressure on the contact point. This introduces an element of cervical sidebending to the right. Straighten your right wrist so that the radius and first metacarpal are in line. Align your body and right arm for the thrust plane which is caudad in the direction of the patient's left shoulder and downwards towards the couch.
(a) Primary leverage of sidebending. Maintaining all holds and contact points, sidebend the patient's head and neck to the right until tension is palpated at the contact point (Fig. Bl.10.1). The operator pivoting slightly, via the legs and trunk, introduces the right sidebending, so that the trunk and upper body rotate to the left, enabling the hands and arms to remain in position. Do not attempt to introduce sidebending by moving the hands or arms alone, as this will lead to loss of contact and inaccurate technique. 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.I0.2). This requires extensive practice before one develops a refined 'tension sense'. Movement of your hands and forearms introduces the rotation.
10 Adjustments to achieve appropriate pre-thrust tension
Ensure your patient remains relaxed. 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. 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.
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.
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. Simultaneously, apply a slight, rapid increase of sidebending of the head and neck to the right but do not increase the rotation leverage (Fig. B1.10.3). The increase of sidebending is induced by a slight rotation of the operator's trunk and upper body to the left. A very rapid contraction of the flexors and adductors of the right shoulder joint induce the thrust; if necessary, trunk and lower limb movement may be incorporated.
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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