Assume somatic dysfunction (A-R-T-T) is identified and you wish to use a flexion gliding thrust, parallel to the apophysial joint plane, to produce joint cavitation at T5-6 (see below)
1 Contact points
3 Patient positioning
(a) Transverse processes of T6
(b) Patient's elbows.
(a) Palm of the operator's right hand, held in a clenched position
(b) Operator's lower sternum or upper abdomen.
Supine with the arms crossed over the chest and hands passed around the shoulders. The arms should be firmly clasped round the body as far as the patient can comfortably reach (Fig. B2.2.1).
4 Operator stance Stand on the right side of the patient, facing the head of the couch.
Reach over the patient with your left hand to take hold of the left shoulder and gently pull it towards you. With your right hand, locate the transverse processes of T6. Now place the clenched palm of your right hand against the transverse processes of T6 (Fig. B2.2.2).
Keeping the right hand pressed against the transverse processes of T6, roll the patient back to the supine position. As the patient approaches the supine position, transfer your left hand and forearm to support the patient's head, neck and upper thoracic spine (Fig. B2.2.3).
7 Immediately pre-thrust
Adjustments to achieve appropriate pre-thrust tension
Allow the patient to roll fully into the supine position. Flex the patient's head, neck and upper thoracic spine until tension is localized to the T5-6 segment. Lean over the patient and rest your lower sternum or upper abdomen on the patient's elbows. Initially, a slow but firm pressure is applied with your lower sternum or upper abdomen downward towards the couch. Maintaining this downward leverage, introduce a force in line with the patient's upper arms. By balancing these different leverages, tension can be localized to the T5-6 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 T5-6 segment. The patient should not be aware of any pain or discomfort. Make these final adjustments by slight movements of ankles, knees, hips and trunk. A common mistake is to lose the chest compression during the final adjustments.
Relax and adjust your balance as necessary. Ensure that your contacts are firm and the patient's head, neck and upper thoracic spine are well controlled. 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.
Delivering the thrust
The shoulder girdles and thorax of the patient are now a solid mass against which a thrust may be applied. Apply a HVLA thrust downwards towards the couch and in a cephalad direction via your lower sternum or upper abdomen. Simultaneously, apply a HVLA thrust with your right hand against the transverse processes in an upward and caudad direction (Fig. B2.2.4).
A common fault is to emphasize the thrust via the patient's shoulder girdles at the expense of the thrust against the transverse processes. The hand contacting the transverse processes of T6 must actively participate in the generation of thrust forces.
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.
This technique has many modifications:
• Different shoulder girdle holds can be used.
• Different applicators can be used.
• Respiration can be used to make the technique more effective.
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