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Fig. B3.0.3
Fig. B3.0.4

LUMBAR AND THORACOLUMBAR SPINE LOWER BODY HOLDS ♦

LOWER BODY HOLDS FOR SIDE-LYING TECHNIQUES

There are a variety of lower body holds available. The hold selected for any particular technique is that which enables the operator to effectively localize forces to a specific segment of the spine and deliver a HVLA force in a controlled manner. Patient comfort must be a major consideration in selecting the most appropriate hold.

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Thoracolumbar spine T10-L2

Neutral positioning Patient side-lying

Rotation gliding thrust

Assume somatic dysfunction (A-R-T-T) is identified and you wish to use a rotation gliding thrust to produce cavitation at T12-Ll on the left (Figs B3.1.1, B3.1.2)

Fig. B3.1.1
Fig. B3.1.2

1 Patient positioning

2 Operator stance

Lying on the right side with a pillow to support the head and neck. The upper portion of the couch is raised 10-15° to introduce left sidebending in the lower thoracic and upper lumbar spine. Experienced practitioners may choose to achieve the left sidebending without raising the upper portion of the couch.

Lower body. Straighten the patient's lower (right) leg and ensure that the leg and spine are in a straight line, in a neutral position. Flex the patient's upper hip and knee slightly and place the upper leg just anterior to the lower leg. The lower leg and spine should form as near a straight line as possible, with no flexion at the lower hip or knee.

Upper body. Gently extend the patient's upper shoulder and place the patient's left forearm on the lower ribs. Using your right hand to palpate the T12-Ll interspinous space, introduce left rotation of the patient's upper body down to the T12-Ll segment. This is achieved by gently holding the patient's right elbow with your left hand and pulling it towards you, but also in a cephalad direction towards the head end of the couch. Be careful not to introduce any flexion to the spine during this movement. Left rotation is continued until your palpating hand at the T12-Ll segment begins to sense motion. Take up the axillary hold. This arm controls the upper body rotation.

Stand close to the couch with your feet spread and one leg behind the other (Fig. B3.1.3). Maintain an upright posture, facing slightly in the direction of the patient's upper body. Keep your right arm as close to your body as possible.

THORACOLUMBAR SPINE T10-L2 NEUTRAL POSITIONING; PATIENT SIDE-LYING ♦

3 Positioning for thrust

4 Adjustments to achieve appropriate pre-thrust tension

5 Immediately pre-thrust

Apply your right forearm to the region between gluteus medius and maximus. Your right forearm now controls lower body rotation. Your left forearm should be resting against the patient's upper pectoral and rib cage region and will control upper body rotation. Firstly rotate the patient's pelvis and lumbar spine towards you until motion is palpated at the T12-L1 segment. Rotate the patient's upper body away from you using your left arm until a sense of tension is palpated at the T12-L1 segment. Be careful to avoid undue pressure in the axilla. Finally roll the patient about 10-15° towards you while maintaining the build-up of leverages at the T12-L1 segment.

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 at the T12-L1 segment. The patient should not be aware of any pain or discomfort. Make these final adjustments by slight movements of the shoulders, trunk, ankles, knees and hips.

Relax and adjust your balance as necessary. Keep your head up; looking down impedes the thrust. 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.

6 Delivering the Your left arm against the patient's pectoral region does not apply a thrust thrust but acts as a stabilizer only. Keep the thrusting (right) arm as close to your body as possible. Apply a HVLA thrust with your right forearm against the patient's buttock. The direction of force is down towards the couch accompanied by a slight exaggeration of pelvic rotation towards the operator (Fig. B3.1.4).

Fig. B3.1.4

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.

SUMMARY

Neutral positioning Patient side-lying Rotation gliding thrust

• Patient positioning. Right side-lying with the upper portion of the couch raised 10-15° to introduce left sidebending in the lower thoracic and upper lumbar spine.

Lower body. Right leg and spine in a straight line. Left hip and knee flexed slightly and placed just anterior to the lower leg.

Upper body. Introduce left rotation of the patient's upper body until your palpating hand at T12-L1 begins to sense motion. Do not introduce any flexion to the spine during this movement. Take up the axillary hold.

• Operator stance. Stand close to the couch, feet spread and one leg behind the other. Maintain an upright posture, facing slightly in the direction of the patient's upper body (Fig. B3.1.3).

• Positioning for thrust. Place your right forearm in the region between gluteus medius and maximus. Rotate the patient's pelvis and lumbar spine towards you until motion is palpated at the T12-L1 segment. Rotate the patient's upper body away from you until a sense of tension is palpated at the T12-L1 segment. Roll the patient about 10-15° towards you.

• Adjustments to achieve appropriate pre-thrust tension.

• Immediately pre-thrust. Relax and adjust your balance.

• Delivering the thrust. The direction of thrust is down towards the couch accompanied by exaggeration of pelvic rotation towards the operator (Fig. B3.1.4). Your left arm against the patient's axillary region does not apply a thrust but acts as a stabilizer only.

Thoracolumbar spine T10-L2

Flexion positioning Patient side-lying

Rotation gliding thrust

Assume somatic dysfunction (A-R-T-T) is identified and you wish to use a rotation gliding thrust to produce cavitation at T12-Ll on the left (see below)

Lying on the left side with a pillow to support the head and neck. A small pillow, or rolled towel, should be placed under the patient's waist to introduce left sidebending in the thoracolumbar spine. Experienced practitioners may choose to achieve the left sidebending without the use of a small pillow or rolled towel.

Lower body. Straighten the patient's lower (left) leg at the knee joint while keeping the left hip flexed. Flex the patient's upper hip and knee. Rest the upper flexed knee upon the edge of the couch, anterior to the left thigh, and place the patient's right foot behind the left calf. This position provides stability to the lower body.

Upper body. Gently extend the patient's upper shoulder and place the patient's right forearm on the lower ribs. Using your left hand to palpate the T12-Ll interspinous space, introduce right rotation of the patient's upper body down to the T12-Ll segment. Rotation with flexion positioning is achieved by gently holding the patient's left elbow with your right hand and pulling it towards you, but also in an caudad direction towards the foot end of the couch. Left rotation is continued until your palpating hand at the T12-Ll segment begins to sense motion. Take up the axillary hold. This arm controls the upper body rotation.

2 Operator stance Stand close to the couch with your feet spread and one leg behind the other. Maintain an upright posture, facing slightly in the direction of the patient's upper body. Keep your left arm as close to your body as possible.

3 Positioning for Apply the palmar aspect of your left forearm to the sacrum and thrust posterior superior iliac spine. Your left forearm now controls lower body rotation. Your right forearm should be resting against the patient's upper pectoral and rib cage region and will control upper body rotation. Firstly rotate the patient's pelvis and lumbar spine towards you until motion is palpated at the T12-Ll segment. Rotate the patient's upper body away from you using your right arm until a sense of tension is palpated at the T12-Ll segment. Be careful to avoid undue pressure in the axilla. Finally roll the patient about 10-15° towards you while maintaining the build-up of leverages at the T12-Ll segment.

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 at the T12-Ll segment. The patient should not be aware of any pain or discomfort. Make these final adjustments by slight movements of the shoulders, trunk, ankles, knees and hips.

1 Patient positioning

4 Adjustments to achieve appropriate pre-thrust tension

THORACOLUMBAR SPINE T10-L2 FLEXION POSITIONING; PATIENT SIDE-LYING ♦

5 Immediately Relax and adjust your balance as necessary. Keep your head up;

pre-thrust looking down impedes the thrust. 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.

6 Delivering the Your right arm against the patient's pectoral region does not apply a thrust thrust but acts as a stabilizer only. Keep the thrusting (left) arm as close to your body as possible. Apply a HVLA thrust with your left forearm against the patient's sacrum and posterior superior iliac spine. The direction of force is down towards the couch accompanied by slight exaggeration of pelvic rotation towards the operator (Fig. B3.2.1).

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.

SUMMARY

Thoracolumbar spine T10-L2

Flexion positioning Patient side-lying Rotation gliding thrust

• Patient positioning. Left side-lying with a small pillow or rolled towel placed under the patient's waist to introduce left sidebending in the thoracolumbar spine.

Lower body. Left hip flexed with knee extended. Right hip and knee flexed with patient's right foot behind the left calf.

Upper body. Introduce right rotation of the patient's upper body until your palpating hand at T12-L1 begins to sense motion. Introduce flexion to the spine during this movement. Take up the axillary hold.

• Operator stance. Stand close to the couch, feet spread and one leg behind the other. Maintain an upright posture, facing slightly in the direction of the patient's upper body.

• Positioning for thrust. Place the palmar aspect of your left forearm against the patient's sacrum and posterior superior iliac spine. Rotate the patient's pelvis and lumbar spine towards you until motion is palpated at the T12-L1 segment. Rotate the patient's upper body away from you until a sense of tension is palpated at the T12-L1 segment. Roll the patient about 10-15° towards you.

• Adjustments to achieve appropriate pre-thrust tension.

• Immediately pre-thrust. Relax and adjust your balance.

• Delivering the thrust. The direction of thrust is down towards the couch accompanied by exaggeration of pelvic rotation towards the operator (Fig. B3.2.1). Your right arm against the patient's axillary region does not apply a thrust but acts as a stabilizer only.

Lumbar spine L1-5

Neutral positioning Patient side-lying

Rotation gliding thrust

Assume somatic dysfunction (A-R-T-T) is identified and you wish to use a rotation gliding thrust to produce cavitation at L3-4 on the right (Figs B3.3.1, B3.3.2)

Fig. B3.3.2

1 Patient Lying on the left side with a pillow to support the head and neck.

positioning

Lower body. Straighten the patient's lower leg and ensure that the leg and spine are in a straight line, in a neutral position. Flex the patient's upper hip and knee slightly and place the upper leg just anterior to the lower leg. The lower leg and spine should form as near a straight line as possible, with no flexion at the lower hip or knee.

Upper body. Gently extend the patient's upper shoulder and place the patient's right forearm on the lower ribs. Using your left hand to palpate the L3-4 interspinous space, introduce right rotation of the patient's upper body down to the L3-4 segment. This is achieved by gently holding the patient's left elbow with your right hand and pulling it towards you, but also in a cephalad direction towards the head end of the couch (Fig. B3.3.3). Be careful not to introduce any flexion to the spine during this movement. Right rotation is continued until your palpating hand at the L3-4 segment begins to sense motion. Take up the axillary hold. This arm controls the upper body rotation.

Fig. B3.3.3

2 Operator stance Stand close to the couch with your feet spread and one leg behind the other (Fig. B3.3.4). Maintain an upright posture, facing slightly in the direction of the patient's upper body. Keep your left arm as close to your body as possible.

3 Positioning for Apply your left forearm to the region between gluteus medius and thrust maximus. Your left forearm now controls lower body rotation. Your right forearm should be resting against the patient's upper pectoral and rib cage region and will control upper body rotation. Firstly rotate the patient's pelvis and lumbar spine towards you until motion is palpated at the L3-4 segment. Rotate the patient's upper body away from you using your right arm until a sense of tension is palpated at the L3-4 segment. Be careful to avoid undue pressure in the axilla. Finally roll the patient about 10-15° towards you while maintaining the build-up of leverages at the L3-4 segment.

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 at the L3-4 segment. The patient should not be aware of any pain or discomfort. Make these final adjustments by slight movements of the shoulders, trunk, ankles, knees and hips.

4 Adjustments to achieve appropriate pre-thrust tension

Immediately Relax and adjust your balance as necessary. Keep your head up;

pre-thrust looking down impedes the thrust. 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.

6 Delivering the Your right arm against the patient's pectoral region does not apply a thrust thrust but acts as a stabilizer only. Keep the thrusting (left) arm as close to your body as possible. Apply a HVLA thrust with your left forearm against the patient's buttock. The direction of force is down towards the couch accompanied by slight exaggeration of pelvic rotation towards the operator (Fig. B3.3.5).

Fig. B3.3.5

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.

LUMBAR SPINE L1-5 NEUTRAL POSITIONING; PATIENT SIDE-LYING ♦

SUMMARY

Lumbar spine L1-5

Neutral positioning Patient side-lying Rotation gliding thrust

• Patient positioning. Left side-lying.

Lower body. Left leg and spine in a straight line. Right hip and knee flexed slightly and placed just anterior to the lower leg.

Upper body. Introduce right rotation of the patient's upper body until your palpating hand at L3-4 begins to sense motion. Do not introduce any flexion to the spine during this movement (Fig. B3.3.3). Take up the axillary hold.

• Operator stance. Stand close to the couch, feet spread and one leg behind the other. Maintain an upright posture, facing slightly in the direction of the patient's upper body (Fig. B3.3.4).

• Positioning for thrust. Place your left forearm in the region between gluteus medius and maximus. Rotate the patient's pelvis and lumbar spine towards you until motion is palpated at the L3-4 segment. Rotate the patient's upper body away from you until a sense of tension is palpated at the L3-4 segment. Roll the patient about 10-15° towards you.

• Adjustments to achieve appropriate pre-thrust tension.

• Immediately pre-thrust. Relax and adjust your balance.

• Delivering the thrust. The direction of thrust is down towards the couch accompanied by exaggeration of pelvic rotation towards the operator (Fig. B3.3.5). Your right arm against the patient's axillary region does not apply a thrust but acts as a stabilizer only.

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Lumbar spine L1-5

Flexion positioning Patient side-lying

Rotation gliding thrust

Assume somatic dysfunction (A-R-T-T) is identified and you wish to use a rotation gliding thrust to produce cavitation at L3-4 on the right (see below)

1 Patient Lying on the left side with a pillow to support the head and neck. A

positioning small pillow, or rolled towel, should be placed under the patient's waist to introduce left sidebending in the lumbar spine. Experienced practitioners may choose to achieve the left sidebending without the use of a small pillow or rolled towel.

Lower body. Straighten the patient's lower (left) leg at the knee joint while keeping the left hip flexed. Flex the patient's upper hip and knee. Rest the upper flexed knee upon the edge of the couch, anterior to the left thigh, and place the patient's right foot behind the left calf. This position provides stability to the lower body.

Upper body. Gently extend the patient's upper shoulder and place the patient's right forearm on the lower ribs. Using your left hand to palpate the L3-4 interspinous space, introduce right rotation of the patient's upper body down to the L3-4 segment. Rotation with flexion positioning is achieved by gently holding the patient's left elbow with your right hand and pulling it towards you, but also in an caudad direction towards the foot end of the couch (Fig. B3.4.1). Right rotation is continued until your palpating hand at the L3-4 segment begins to sense motion. Take up the axillary hold. This arm controls the upper body rotation.

Fig. B3.4.1

2 Operator stance

Stand close to the couch with your feet spread and one leg behind the other (Fig. B3.4.2). Maintain an upright posture, facing slightly in the direction of the patient's upper body. Keep your left arm as close to your body as possible.

3 Positioning for Apply your left forearm to the region between gluteus medius and thrust maximus. Your left forearm now controls lower body rotation. Your right forearm should be resting against the patient's upper pectoral and rib cage region and will control upper body rotation. Firstly rotate the patient's pelvis and lumbar spine towards you until motion is palpated at the L3-4 segment. Rotate the patient's upper body away from you using your right arm until a sense of tension is palpated at the L3-4 segment. Be careful to avoid undue pressure in the axilla. Finally roll the patient about 10-15° towards you while maintaining the build-up of leverages at the L3-4 segment.

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 at the L3-4 segment. The patient should not be aware of any pain or discomfort. Make these final adjustments by slight movements of the shoulders, trunk, ankles, knees and hips.

4 Adjustments to achieve appropriate pre-thrust tension

Immediately Relax and adjust your balance as necessary. Keep your head up;

pre-thrust looking down impedes the thrust. 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.

Delivering the thrust

Your right arm against the patient's pectoral region does not apply a thrust but acts as a stabilizer only. Keep the thrusting (left) arm as close to your body as possible. Apply a HVLA thrust with your left forearm against the patient's buttock. The direction of force is down towards the couch accompanied by a slight exaggeration of pelvic rotation towards the operator (Fig. B3.4.3).

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.

SUMMARY

LUMBAR SPINE L1-5 FLEXION POSITIONING; PATIENT SIDE-LYING ♦

Lumbar spine L1-5

Flexion positioning Patient side-lying Rotation gliding thrust

• Patient positioning. Left side-lying with a small pillow or rolled towel placed under the patient's waist to introduce left sidebending in the lumbar spine.

Lower body. Left hip flexed with knee extended. Right hip and knee flexed with the patient's right foot behind the left calf.

Upper body. Introduce right rotation of the patient's upper body until your palpating hand at L3-4 begins to sense motion. Introduce flexion to the spine during this movement (Fig. B3.4.1). Take up the axillary hold.

• Operator stance. Stand close to the couch, feet spread and one leg behind the other. Maintain an upright posture, facing slightly in the direction of the patient's upper body (Fig. B3.4.2).

• Positioning for thrust. Place your left forearm in the region between gluteus medius and maximus. Rotate the patient's pelvis and lumbar spine towards you until motion is palpated at the L3-4 segment. Rotate the patient's upper body away from you until a sense of tension is palpated at the L3-4 segment. Roll the patient about 10-15° towards you.

• Adjustments to achieve appropriate pre-thrust tension.

• Immediately pre-thrust. Relax and adjust your balance.

• Delivering the thrust. The direction of thrust is down towards the couch accompanied by exaggeration of pelvic rotation towards the operator (Fig. B3.4.3). Your right arm against the patient's axillary region does not apply a thrust but acts as a stabilizer only.

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