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Ribs R4-10

1 Contact points

2 Applicators

3 Patient positioning

Patient prone

Gliding thrust

Assume somatic dysfunction (A-R-T-T) is identified and you wish to produce cavitation at the costotransverse joint of the sixth rib on the left (see below)

Angle of left sixth rib (right applicator). Right transverse process of T6 (left applicator).

Hypothenar eminence of left and right hands.

Patient lying prone with the head and neck in a comfortable position and the arms hanging over the edge of the couch.

4 Operator stance Stand at the left side of the patient, feet spread slightly and facing the patient. Stand as erect as possible and avoid crouching as this will limit the technique and restrict delivery of the thrust.

5 Palpation of There are many different ways to perform this technique. This is one contact points approach. Locate the transverse processes of T6. Place the hypothenar eminence of your right hand against the angle of the patient's left sixth rib and establish a firm contact (Fig. B2.7.1). Place the hypothenar eminence of your left hand against the right transverse process of T6 (Fig. B2.7.2). Ensure that you have good contact and will not slip across the skin or superficial musculature.

Fig. B2.7.2

6 Positioning for This is a short lever technique and as a consequence the velocity of the thrust thrust is critical. Move your centre of gravity over the patient by leaning your body weight forwards onto your arms and hypothenar eminences (Fig. B2.7.3). Shifting your centre of gravity forwards will direct a downward pressure on both the transverse process of T6 and the sixth rib. You must apply an additional force directed cephalad with the right hand against the angle of the sixth rib. The final direction of thrust is influenced by the degree of thoracic kyphosis and any pre-existing scoliosis.

7 Adjustments to Ensure your patient remains relaxed. Maintaining all holds, make any achieve necessary changes in extension, sidebending and rotation until you appropriate sense a state of appropriate tension and leverage at the pre-thrust tension costotransverse joint of the sixth rib. The patient should not be aware of any pain or discomfort.

8 Immediately Relax and adjust your balance as necessary. Keep your head up and pre-thrust ensure that your contacts are firm. 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.

9 Delivering the Apply a HVLA thrust directed in a downward and cephalad direction thrust against the angle of the sixth rib. It is important to achieve fixation of

T6 by maintaining a firm downward pressure against the transverse process of T6 on the right. The thrust is generated by your right hand in contact with the sixth rib (Fig. B2.7.4).

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

Patient prone Gliding thrust

• Contact points. Angle of left sixth rib (right applicator). Right transverse process of T6 (left applicator).

• Applicators. Hypothenar eminence of left and right hands.

• Patient positioning. Prone with arms hanging over the edge of the couch.

• Operator stance. To the left side of the patient, facing the couch.

• Palpation of contact points. Place the hypothenar eminence of your right hand against the angle of the patient's left sixth rib and establish a firm contact (Fig. B2.7.1). Place the hypothenar eminence of left hand against the right transverse process of T6 (Fig. B2.7.2).

• Positioning for thrust. This is a short lever technique and the velocity of the thrust is critical. Move your centre of gravity over the patient by leaning your body weight forwards onto your arms and hypothenar eminences (Fig. B2.7.3). Apply an additional force directed cephalad with the right hand against the angle of the sixth rib.

• Adjustments to achieve appropriate pre-thrust tension.

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

• Delivering the thrust. The direction of thrust is in a downward and cephalad direction against the angle of the sixth rib. It is important to achieve fixation of T6 by maintaining a firm downward pressure against the transverse process of T6 on the right. The thrust is generated by your right hand in contact with the sixth rib (Fig. B2.7.4).

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Ribs R4-10

1 Contact point

2 Applicator

3 Patient positioning

Patient sitting

Gliding thrust

Assume somatic dysfunction (A-R-T-T) is identified and you wish to produce cavitation at the costotransverse joint of the right sixth rib (Fig. B2.8.V

Angle of right sixth rib. Hypothenar eminence of right hand.

Sitting astride the treatment couch with the arms crossed over the chest and the hands passed around the shoulders. The arms should be firmly clasped around the body as far as the patient can comfortably reach.

4 Operator stance Stand behind and slightly to the left of the patient with your feet spread. Pass your left arm across the front of the patient's chest to lightly grip over the patient's right shoulder region (Fig. B2.8.2).

5 Positioning for Translate the patient's trunk to the right and away from you. This thrust opens up the intercostal space between the sixth and seventh ribs

(Fig. B2.8.3) and allows better access to the inferior aspect of the sixth rib. Place your right hypothenar eminence on the inferior surface of the angle of the sixth rib. The thorax is now rotated to the left (Fig. B2.8.4). Sidebending to the right is introduced to lock the spine down to T6. The operator maintains as erect a posture as possible. Keep your right hypothenar eminence firmly applied to the sixth rib with your right elbow held close to your body (Fig. B2.8.5).

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 costotransverse joint of the sixth rib on the right. 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. 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.

A degree of momentum is necessary to achieve a successful cavitation. Rock the patient into and out of rotation whilst maintaining the other leverages. When you sense a state of appropriate tension and leverage at the sixth rib, apply a HVLA thrust against the inferior aspect of the angle of the rib in a cephalad and anterior direction. Simultaneously, apply slight exaggeration of left trunk rotation (Fig. B2.8.6).

6 Adjustments to achieve appropriate pre-thrust tension

7 Immediately pre-thrust

8 Delivering the thrust

Fig. B2.8.6

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

Patient sitting Gliding thrust

♦ Contact point. Angle of right sixth rib.

♦ Applicator. Hypothenar eminence of right hand.

♦ Patient positioning. Sitting astride the couch with the arms crossed over the chest and the hands passed around the shoulders.

♦ Operator stance. Behind and slightly to the left of the patient with the feet spread. Pass your left arm across the front of the patient's chest to lightly grip over the patient's right shoulder region (Fig. B2.8.2).

♦ Positioning for thrust. Translate the patient's trunk to the right and away from you (Fig. B2.8.3). Place your right hypothenar eminence on the inferior surface of the angle of the sixth rib. The thorax is now rotated to the left (Fig. B2.8.4). Sidebending to the right is introduced to lock the spine down to T6. The operator maintains as erect a posture as possible. Keep your right hypothenar eminence firmly applied to the sixth rib with your right elbow held close to your body (Fig. B2.8.s).

♦ Adjustments to achieve appropriate pre-thrust tension.

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

♦ Delivering the thrust. A degree of momentum is necessary to achieve a successful cavitation. The direction of thrust is in a cephalad and anterior direction against the inferior aspect of the angle of the rib. Simultaneously, apply slight exaggeration of left trunk rotation

Section 3

Lumbar and thoracolumbar spine

UPPER BODY HOLDS FOR SIDE-LYING TECHNIQUES

All techniques in this manual are described with the operator taking up the axillary hold (Fig. B3.O.1). 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 high-velocity low-amplitude (HVLA) force in a controlled manner. Patient comfort must be a major consideration in selecting the most appropriate hold.

Fig. B3.0.1

Three alternative upper body holds are available:

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