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Back Pain Breakthrough

Natural Ways to Treat Lower Back Pain

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Lumbar spine L1-5

Neutral positioning Patient sitting

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 left (see below)

1 Patient positioning

2 Operator stance

Sitting on the treatment couch with the arms folded. The patient should be encouraged to maintain an erect posture.

Stand behind and slightly to the right of the patient with your feet spread. Pass your right arm across the front of the patient's chest to lightly grip the patient's left thorax (Fig. B3.5.1).

3 Positioning for Place your left hypothenar eminence to the right side of the spinous thrust process of L3 and introduce right sidebending to the patient's thoracic and upper lumbar spine (Fig. B3.5.2). The thoracic and upper lumbar spine is now rotated to the right to lock the spine down to but not including L3. The operator maintains as erect a posture as possible. Keep your left hypothenar eminence firmly applied to the spinous process of L3 with your left arm held close to your body.

LUMBAR SPINE L1-5 NEUTRAL POSITIONING; PATIENT SIDING ♦

Fig. B3.5.2

4 Adjustments to achieve appropriate pre-thrust tension

5 Immediately pre-thrust

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.

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.

6 Delivering the A degree of momentum in necessary to achieve a successful cavitation. thrust It is desirable for the momentum component of the thrust to be restricted to one plane of motion and this should be rotation. Rock the patient into and out of rotation while maintaining the sidebending and flexion/ extension positioning. When close to full rotation, you will sense a state of appropriate tension and leverage at the L3--4 segment, at which point you apply a HVLA thrust against the spinous process of L3. The thrust is directed to the spinous process of L3 and accompanied by a slight exaggeration of right rotation (Fig. B3.5.3).

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 NEUTRAL POSITIONING; PATIENT SITTING ♦

Lumbar spine L1-5

Neutral positioning Patient sitting Rotation gliding thrust

Patient positioning. Sitting erect.

Operator stance. Behind and slightly to the right of the patient with your right arm across the front of the patient's chest (Fig. B3.5.1).

Positioning for thrust. Place your left hypothenar eminence to the right side of the spinous process of L3 and introduce right sidebending to the patient's thoracic and upper lumbar spine (Fig. B3.5.2). The thoracic and upper lumbar spine is now rotated to the right to lock the spine down to but not including L3.

Adjustments to achieve appropriate pre-thrust tension.

Immediately pre-thrust. Relax and adjust your balance.

Delivering the thrust. The thrust is directed to the spinous process of L3 and accompanied by exaggeration of right rotation (Fig. B3.5.3). A degree of momentum is necessary to achieve a successful cavitation. The momentum component of the thrust should be in the direction of rotation.

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Lumbosacral joint (L5-S1)

Patient side-lying

Thrust direction is dependent upon apophysial joint plane*

Assume somatic dysfunction (A-R-T-T) is identified and you wish to use a gliding thrust to produce cavitation at L5-51 on the right (Figs B3.6.1, B3.6.2)

*The condition where joints are asymmetrically orientated is referred to as articular tropism. The lumbosacral zygapophysial joints would normally be orientated at approximately 45° with respect to the sagittal plane. There is considerable individual variation and you will encounter patients with lumbosacral apophysial joint planes that range between sagittal and coronal orientation. The variation in apophysial joint plane means that considerable palpatory skill is required to accurately localize forces at the lumbosacral joint and determine the most suitable direction of thrust.

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

positioning

Lower body. Straighten the patient's lower (left) leg at the knee joint while placing the left hip in approximately 20° of flexion. Flex the patient's upper knee and place the patient's right foot behind the left lower leg (Fig. B3.6.3). 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 L5-Sl interspinous space, introduce right rotation of the patient's upper body down to the L5-Sl 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. Be careful not to introduce any flexion to the spine during this movement. Right rotation is continued until your palpating hand at the L5-S1 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 thrust

4 Adjustments to achieve appropriate pre-thrust tension

5 Immediately pre-thrust

6 Delivering the thrust

Apply your left forearm to the region between gluteus medius and maximus. Your left forearm now controls lower body rotation. Your right hand rests on the patient's right axillary area. This will control upper body rotation. Firstly apply pressure to the patient's pelvis until motion is palpated at the L5-S1 segment. Rotate the patient's upper body away from you using your right arm until a sense of tension is palpated at the L5-S1 segment. Finally, roll the patient about 10-15° towards you while maintaining the build-up of leverages at the L5-S1segment.

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 L5-S1 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.

Your right arm against the patient's axillary region does not apply a thrust but acts as a stabilizer only (Fig. B3.6.4). 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 thrust is variable depending on the apophysial joint plane. Commonly the direction of thrust approximates to a line along the long axis of the patient's right femur (Fig. B3.6.5).

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.

SUMMARY

Lumbosacral Joint (L5-S1)

Side-lying

Thrust direction is dependent upon apophysial joint plane

• Patient positioning. Left side-lying.

Lower body. Left hip in approximately 20° of flexion with knee extended. Right hip and knee flexed (Fig. B3.6.3).

Upper body. Introduce right rotation of the patient's upper body until your palpating hand at the L5-S1 segment 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.

• Positioning for thrust. Place your left forearm in the region between gluteus medius and maximus. Apply pressure to the patient's pelvis until motion is palpated at the L5-S1 segment. Rotate the patient's upper body away from you until a sense of tension is palpated at the L5-S1 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. Your right arm against the patient's axillary region does not apply a thrust but acts as a stabilizer only (Fig. B3.6.4). The direction of thrust is variable depending on the apophysial joint plane. Commonly the thrust is along the long axis of the patient's right femur (Fig. B3.6.5).

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HVLA thrust techniques - pelvis

CONTENTS

1 Sacroiliac joint: left innominate posterior; patient prone

2 Sacroiliac joint: right innominate posterior; patient side-lying

3 Sacroiliac joint: left innominate anterior; patient supine

4 Sacroiliac joint: sacral base anterior; patient side-lying

5 Sacrococcygeal joint: coccyx anterior; patient side-lying References

Introduction

The sacroiliac joint as a source of pain and dysfunction is a subject of controversy.1-4 Many authors implicate the sacroiliac joint as a possible cause of low back pain,5-13 but there is disagreement as to the exact prevalence of sacroiliac joint pain within the low back pain population. While many practitioners believe the sacroiliac joint is a source of pain and dysfunction and treat perceived sacroiliac lesions, there is no general agreement concerning the different diagnostic tests and their validity in determining somatic dysfunction of the pelvis.^9

Various models of sacroiliac motion have been proposed and there have been a number of studies relating to mobility in the sacroiliac joint,20-22 but the precise nature of normal motion remains unclear.1-4-23 There is significant variation in sacroiliac joint movement between individuals and within individuals when mobility of one sacroiliac joint is compared with the other side. Mobility alters with age and can increase during pregnancy.

A number of manual medicine texts24-31 refer to the use of highvelocity low-amplitude (HVLA) thrust techniques to the joints of the pelvis, but there is little evidence that cavitation is uniformly associated with these procedures. When an audible release does occur, its site of origin remains open to speculation. Studies undertaken to measure the effects of manipulation upon the sacroiliac joints provide contradictory findings. Alteration in pelvic tilt was identified post-manipulation in one study of patients with low back pain,32 while roentgen stereophotogrammetric analysis was unable to detect altered position of the sacroiliac joint post-manipulation despite normalization of different types of clinical tests.33

Many practitioners believe that HVLA techniques applied to the sacroiliac joint can be associated with good clinical outcomes. As a result, many clinicians continue to use HVLA techniques to treat somatic dysfunction of the joints of the pelvis.

Somatic dysfunction is identified by the A-R-T-T of diagnosis:

• T - relates to tissue texture changes

• T - relates to tissue tenderness.

Part C describes in detail five high-velocity low-amplitude techniques for the pelvis. All techniques are described using a variable height manipulation couch.

After making a diagnosis of somatic dysfunction and prior to proceeding with a thrust, it is recommended the following checklist be used for each of the techniques described in this section:

• Have I excluded all contraindications?

• Have I explained to the patient what I am going to do?

• Do I have informed consent?

• Is the patient well positioned and comfortable?

• Am I in a comfortable and balanced position?

• Do I need to modify any pre-thrust physical or biomechanical factors?

• Have I achieved appropriate pre-thrust tissue tension?

• Am I relaxed and confident to proceed?

• Is the patient relaxed and willing for me to proceed?

1 Contact points

2 Applicators

3 Patient positioning

4 Operator stance

5 Palpation of contact points

6 Positioning for thrust

Sacroiliac joint

Left innominate posterior Patient prone

Assume somatic dysfunction (A-R-T-T) is identified and you wish to thrust the left innominate anteriorly

(a) Left posterior superior iliac spine (PSIS)

(b) Anterior aspect of left lower thigh.

(a) Hypothenar eminence of right hand

(b) Palmar aspect of left hand.

Patient lying prone in a comfortable position.

Stand at the right 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.

Place the hypothenar eminence of your right hand against the inferior aspect of the left PSIS. Ensure that you have good contact and will not slip across the skin or superficial musculature. Place the palmar aspect of your left hand gently under the anterior aspect of the left thigh just proximal to the knee.

Lift the patient's left leg into extension and slight adduction (Fig. C1.I). Avoid introducing extension into the lumbar spine. Apply a force directed downwards towards the couch and slightly cephalad to fix your right hand against the inferior aspect of the PSIS.

Move your centre of gravity over the patient by leaning your body weight forwards onto your right arm and hypothenar eminence. Shifting your centre of gravity forwards assists firm contact point pressure on the PSIS.

Fig. C.1.1

7 Adjustments to achieve appropriate pre-thrust tension

Immediately pre-thrust

Ensure your patient remains relaxed. Maintaining all holds, make any necessary changes in hip extension, adduction and rotation. Simultaneously, adjust the direction of pressure applied to the PSIS until applicator forces are balanced and you sense a state of appropriate tension and leverage at the left sacroiliac joint. 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 and 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.

SACROILIAC JOINT LEFT INNOMINATE POSTERIOR; PATIENT PRONE ♦

9 Delivering the Apply a HVLA thrust with your right hand directed against the PSIS thrust in a curved plane towards the couch. Simultaneously, apply slight exaggeration of hip extension with your left hand (Fig. Cl.2). It is important that you do not overemphasize hip extension at the time of thrust. The aim of this technique is to achieve anterior rotation of the left innominate and movement at the left sacroiliac joint. The direction of thrust will alter between patients as a result of the wide variation in sacroiliac anatomy and biomechanics.

The thrust, although very rapid, must never be excessively forcible. The aim should be to use the absolute minimum of force necessary.

SUMMARY

Left innominate posterior Patient prone Thrust anteriorly

— Left posterior superior iliac spine (PSIS)

— Anterior aspect of left lower thigh.

— Hypothenar eminence of right hand

— Palmar aspect of left hand.

• Patient positioning. Prone in a comfortable position.

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

• Palpation of contact points. Place the hypothenar eminence of your right hand against the inferior aspect of the left PSIS. Place the palmar aspect of your left hand under the anterior aspect of the left thigh proximal to the knee.

• Positioning for thrust. Lift left leg into extension and slight adduction (Fig. C1.1). Avoid introducing extension into the lumbar spine. Apply a force directed downwards towards the couch and slightly cephalad to fix your right hand against the inferior aspect of the PSIS.

• Adjustments to achieve appropriate pre-thrust tension. Make any necessary changes in hip extension, adduction and rotation. Simultaneously, adjust the direction of pressure applied to the PSIS.

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

• Delivering the thrust. The thrust against the PSIS is in a curved plane towards the couch and accompanied by slight exaggeration of hip extension (Fig. C1.2).

1 Patient positioning

2 Operator stance

Sacroiliac joint

Right innominate posterior Patient side-lying

Assume somatic dysfunction (A-R-T-T) is identified and you wish to thrust the right innominate anteriorly

Lying on the left side with a pillow to support the head and neck. The upper portion of the couch is raised 30-35° to introduce right sidebending in the lower thoracic and upper lumbar spine.

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 to approximately 90°. Flex the patient's upper knee and place the heel of the foot just anterior to the knee of 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 L5-S1 interspinous space, introduce right rotation of the patient's trunk, down to and including the L5-S1 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. Be careful not to introduce any flexion to the spine during this movement. Now modify the pectoral hold by positioning the patient's upper arm behind the thorax.

Stand close to the couch with your feet spread and one leg behind the other. Ensure that the patient's upper knee is placed between your legs. This will enable you to make the necessary adjustments to achieve the appropriate pre-thrust tension (Fig. C.2.1). Maintain an upright posture, facing in the direction of the patient's upper body.

Fig. C.2.1

Positioning for thrust

4 Adjustments to achieve appropriate pre-thrust tension

5 Immediately pre-thrust

Apply the heel of your left hand to the inferior aspect of the posterior superior iliac spine (PSIS). Your right hand should be resting against the patient's upper pectoral and rib cage region. Gently rotate the patient's trunk away from you using your right hand until you achieve spinal locking. Avoid applying direct pressure to the glenohumeral joint. Finally, roll the patient about 10-15° towards you while maintaining the build-up of leverages.

Ensure your patient remains relaxed. Maintaining all holds, make any necessary changes in hip flexion and adduction. Simultaneously, adjust the direction of pressure applied to the PSIS until the forces are balanced and you sense a state of appropriate tension and leverage at the right sacroiliac joint. 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 and ensure 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.

SACROILIAC JOINT

RIGHT INNOMINATE POSTERIOR; PATIENT SIDE-LYING ♦

6 Delivering the Apply a HVLA thrust with the heel of your left hand directed against thrust the PSIS in a curved plane towards you (Fig. C.2.2). Your right arm against the patient's pectoral region does not apply a thrust but acts as a stabilizer only. The aim of this technique is to achieve anterior rotation of the right innominate and movement at the right sacroiliac joint. The direction of thrust will alter between patients as a result of the wide variation in sacroiliac anatomy and biomechanics.

The thrust, although very rapid, must never be excessively forcible. The aim should be to use the absolute minimum of force necessary.

SUMMARY

Right innominate posterior Patient side-lying Thrust anteriorly

• Patient positioning. Left side-lying with the upper portion of the couch raised 30-35° to introduce right sidebending in the lower thoracic and upper lumbar spine.

Lower body. Left leg and spine in a straight line. Right hip flexed to approximately 90°. Right knee flexed and heel of right foot placed just anterior to knee of lower leg.

Upper body. Introduce right rotation of the patient's upper body down to and including L5-S1. Do not introduce any flexion to the spine during this movement. Modify the pectoral hold by positioning the patient's upper arm behind the thorax.

• Operator stance. Stand close to the couch, feet spread and one leg behind the other. Ensure that the patient's upper knee is placed between your legs (Fig. C.2.1). Maintain an upright posture facing in the direction of the patient's upper body.

• Positioning for thrust. Apply the heel of your left hand to the inferior aspect of the PSIS. Rotate the patient's upper body away from you until spinal locking is achieved. Roll the patient about 10-15° towards you.

• Adjustments to achieve appropriate pre-thrust tension. Make any necessary changes in hip flexion and adduction. Simultaneously, adjust direction of pressure applied to the PSIS.

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

• Delivering the thrust. The thrust against the PSIS is in a curved plane towards you (Fig. C.2.2). Your right arm against the patient's pectoral region does not apply a thrust but acts as a stabilizer only.

Sacroiliac joint

Left innominate anterior Patient supine

Assume somatic dysfunction (A-R-T-T) is identified and you wish to thrust the left innominate posteriorly

1 Contact points

2 Applicators

3 Patient positioning

(a) Left anterior superior iliac spine (ASIS)

(b) Posterior aspect of left shoulder girdle.

(a) Palm of right hand

(b) Palmar aspect of left hand and wrist.

Patient lying supine in a comfortable position. Move the patient's pelvis towards their right. Move the feet and shoulders in the opposite direction to introduce left sidebending of the trunk. Place the patient's left foot and ankle on top of the right ankle. Ask the patient to clasp their fingers behind the neck (Fig. C.3.1).

Fig. C.3.1

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

5 Palpation of contact points

Positioning for thrust

Place the palm of your right hand over the ASIS. Ensure that you have good contact and will not slip across the skin or superficial musculature. Place the palmar aspect of your left hand and wrist gently over the posterior aspect of the left shoulder girdle.

Rotate the patient's trunk to the right and towards you. It is critical to maintain the left trunk sidebending introduced during initial positioning. Apply a force directed downwards towards the couch and slightly cephalad to fix your right hand against the inferior aspect of the ASIS (Fig. C.3.2).

Fig. C.3.2

7 Adjustments to achieve appropriate pre-thrust tension

Immediately pre-thrust

Move your centre of gravity over the patient by leaning your body weight forwards onto your right arm and hand. Shifting your centre of gravity forwards assists firm contact point pressure on the ASIS.

Ensure your patient remains relaxed. Maintaining all holds, make any necessary changes in trunk rotation, flexion and sidebending. Simultaneously, adjust the direction of pressure applied to the ASIS until applicator forces are balanced and you sense a state of appropriate tension and leverage. 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 and 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.

SACROILIAC JOINT LEFT INNOMINATE ANTERIOR; PATIENT SUPINE ♦

9 Delivering the Apply a HVLA thrust with your right hand directed against the ASIS thrust in a curved plane towards the couch (Fig. C.3.3). Your left forearm, wrist and hand over the patient's shoulder girdle do not apply a thrust but act as stabilizers only. The aim of this technique is to achieve posterior rotation of the left innominate and movement at the left sacroiliac joint. The direction of thrust will alter between patients as a result of the wide variation in sacroiliac anatomy and biomechanics.

The thrust, although very rapid, must never be excessively forcible. The aim should be to use the absolute minimum of force necessary.

SUMMARY

Left innominate anterior Patient supine Thrust posteriorly

— Left anterior superior iliac spine (ASIS)

— Posterior aspect of left shoulder girdle.

— Palmar aspect of left hand and wrist.

• Patient positioning. Supine. Move patient's pelvis towards the right. Move feet and shoulders in the opposite direction to introduce left sidebending of the trunk. Place the patient's left foot and ankle on top of the right ankle. Ask the patient to clasp fingers behind the neck (Fig. C3.1).

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

• Palpation of contact points. Place the palm of your right hand over the ASIS. Place the palmar aspect of your left hand and wrist over the posterior aspect of the left shoulder girdle.

• Positioning for thrust. Rotate the patient's trunk to the right. Maintain left trunk sidebending. Apply a force directed downwards towards the couch and slightly cephalad to fix your right hand against the inferior aspect of the ASIS (Fig. C3.2).

• Adjustments to achieve appropriate pre-thrust tension. Make any necessary changes in trunk rotation, flexion and sidebending. Simultaneously, adjust direction of pressure applied to the ASIS.

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

• Delivering the thrust. The thrust against the ASIS is in a curved plane towards the couch (Fig. C3.3). Your left forearm, wrist and hand over the patient's shoulder girdle do not apply a thrust but act as stabilizers only.

1 Patient positioning

2 Operator stance

3 Positioning for thrust

Sacroiliac joint

Sacral base anterior Patient side-lying

Assume somatic dysfunction (A-R-T-T) is identified and you wish to thrust the apex of the sacrum anteriorly

Lying on the right side with a pillow to support the head and neck.

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 left forearm on the lower ribs. Using your right hand to palpate the L5-S1 interspinous space, introduce left rotation of the patient's trunk down to and including the L5-S1 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. Take up the axillary hold. This arm controls and maintains trunk rotation.

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.

Apply the palmar aspect of your right forearm to the apex of the sacrum. Ensure that contact is below the second sacral segment. Your left forearm should be resting against the patient's upper pectoral and rib cage region and will control and maintain trunk rotation. Gently rotate the patient's trunk away from you using your left forearm until you achieve spinal locking. 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.

4 Adjustments to achieve appropriate pre-thrust tension

5 Immediately pre-thrust

Delivering the thrust

Ensure your patient remains relaxed. Maintaining all holds, make any necessary changes in flexion, extension, sidebending or rotation until you are confident that full spinal locking is achieved. The patient should not be aware of any pain or discomfort. Make these final adjustments by slight movements of your shoulders, trunk, ankles, knees and hips.

Relax and adjust your balance as necessary. Keep your head up and ensure contacts are firm. 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 with your right forearm against the apex of the sacrum in a curved plane towards you (Fig. C.4.l). Your left arm against the patient's pectoral region does not apply a thrust but acts as a stabilizer only. The aim of this technique is to achieve a counter-nutation movement of the sacrum.

Fig. C.4.1

The thrust, although very rapid, must never be excessively forcible. The aim should be to use the absolute minimum of force necessary.

SACROILIAC JOINT SACRAL BASE ANTERIOR; PATIENT SIDE-LYING ♦

SUMMARY

Sacroiliac joint

Sacral base anterior Patient side-lying Thrust apex anteriorly

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 trunk down to and including the L5-S1 segment. 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.

• Positioning for thrust. Apply the palmar aspect of your right forearm to the apex of the sacrum. Ensure that contact is below the second sacral segment. Your left forearm should be resting against the patient's upper pectoral and rib cage region. Rotate the patient's trunk away from you using your left forearm until you achieve spinal locking. 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 thrust against the apex of the sacrum is in a curved plane towards you (Fig. C.4.1). Your left arm against the patient's pectoral region does not apply a thrust but acts as a stabilizer only.

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Sacrococcygeal joint

Coccyx anterior Patient side-lying

Assume somatic dysfunction (A-R-T-T) is identified and you wish to thrust the coccyx posteriorly

The operator must exercise care and attention to ensure that the patient is fully informed as to the nature of this procedure. This technique involves both assessment and treatment via a rectal approach. It is assumed that the operator will examine the anal and rectal region to determine if there are any contraindications to performing this procedure. This technique can be used either as a means of gently articulating the sacrococcygeal joint or applying a HVLA thrust to the coccyx. Coccydynia can be severe and the choice of technique depends as much upon patient comfort as perceived efficacy of approach. Practitioners should become familiar with articulating the sacrococcygeal joint before attempting a thrust to the coccyx.

1 Contact points (a) Anterior aspect of the coccyx through the posterior wall of the rectum (b) Posterior aspect of the coccyx.

(a) Lubricated index finger of operator's gloved right hand

(b) Thumb of operator's gloved right hand.

Lying in the left lateral position with the maximal amount of flexion of the hips, knees and spine consistent with patient comfort. The patient should be fully undressed so that access to the anal canal is possible. The buttocks should be at the edge of the couch.

4 Operator stance Stand behind the patient, approximately at the level of the patient's hip joints, facing the couch and patient's back.

2 Applicators

3 Patient positioning

5 Palpation of contact points

The operator should be wearing a pair of suitable gloves with lubricant smeared over the right index finger. The patient must be informed that a finger within the rectum will cause a sensation similar to that of opening the bowels. Ask the patient to relax and place the index finger of your right hand against the anal margin (Fig. C.5.IA). With steady pressure, insert your right index finger into the patient's anal canal in a cephalic and slightly anterior direction (Fig. C5.1B). The finger will pass through the anal sphincter and into the rectum. If the patient has difficulty relaxing, ask him/her to bear down as if opening the bowels and gently slip your finger past the anal sphincter and into the rectum. Once through the anal sphincter, the direction of the rectum is cephalic and posteriorly along the curve of the coccyx and sacrum. At this stage an examination of the rectum should be undertaken. For male patients this would include examination of the prostate gland.

Fig. C.S.1 Sacrococcygeal joint. A: The index finger is placed against the anal margin. B: The finger is inserted as shown. C: After examination of the rectum, the coccyx is held between the index finger internally and the thumb externally.

The palpating right index finger identifies the sacrum and coccyx through the posterior wall of the rectum. Place the distal phalanx of the right index finger against the anterior surface of the coccyx immediately below the sacrococcygeal joint. Use the thumb of your right hand externally to identify the posterior aspect of the coccyx between the buttocks. The coccyx is now gently held between your index finger internally and thumb externally (Fig. C.5.1C). Gentle pressure is applied in a number of directions to determine undue tenderness or any reproduction of the patient's familiar symptoms. The mobility and position of the coccyx relative to the sacrum is also noted.

SACROCOCCYGEAL JOINT COCCYX ANTERIOR; PATIENT SIDE-LYING ♦

6 Fixation of contact points

7 Adjustments to achieve appropriate pre-thrust tension

8 Immediately pre-thrust

9 Delivering the

Keep your right index finger on the anterior aspect of the coccyx while applying pressure against the posterior aspect of the coccyx with your right thumb. The fixation is gentle but firm with less pressure against the anterior surface of the coccyx.

The operator should be in a position to move the coccyx through a range of motion and in different planes. Ensure your patient remains relaxed. Maintaining all holds, make any necessary changes in flexion, extension, sidebending and rotation of the coccyx until you sense a state of appropriate tension and leverage at the sacrococcygeal joint.

Relax and adjust your balance as necessary. 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.

Apply a HVLA thrust towards you in a curved plane (Fig. C.5.2).

The thrust, although very rapid, must never be excessively forcible. The aim should be to use the absolute minimum of force necessary.

thrust

SUMMARY

Coccyx anterior Patient side-lying Thrust posteriorly

— Anterior aspect of the coccyx

— Posterior aspect of the coccyx.

— Lubricated index finger of operator's gloved right hand

— Thumb of operator's gloved right hand.

• Patient positioning. Left lateral position with flexion of the hips, knees and spine.

• Operator stance. Behind the patient.

• Palpation of contact points. Place the index finger of right hand against the anal margin (Fig. C.5.1 A). Insert your right index finger into the anal canal in a cephalic and anterior direction (Fig C.5.1 B). The palpating index finger identifies the sacrum and coccyx through the posterior wall of the rectum. Place the distal phalanx of the right index finger against the anterior surface of the coccyx. Identify the posterior aspect of the coccyx between the buttocks. The coccyx is now gently held between your right index finger internally and thumb externally (Fig C.5.1C).

• Fixation of contact points. Keep right index finger on the anterior aspect of the coccyx while applying pressure against the posterior aspect of the coccyx with your right thumb.

• Adjustments to achieve appropriate pre-thrust tension.

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

• Delivering the thrust. The direction of thrust is towards you in a curved plane (Fig C.5.2).

REFERENCES

1 Alderink G J 1991 The sacroiliac joint: review of anatomy, mechanics, and function. Journal of Orthopaedic and Sports Physical Therapy 13: 71-84

2 Bernard T N, Cassidy J D 1991 The sacroiliac joint syndrome - pathophysiology, diagnosis and management. In: Frymoyer J W (ed) The adult spine: principles and practice. Raven Press, New York, p 2107-2130

3 Walker J M 1992 The sacroiliac joint: a critical review. Physical Therapy 72: 903-916

4 Dreyfuss P, Cole A J, Pauza K 1995 Sacroiliac joint injection techniques. Physical Medicine and Rehabilitation Clinics of North America 6(4): 785-813

5 Grieve G 1976 The sacroiliac joint. Physiotherapy 62: 384-400

6 Weismantel A 1978 Evaluation and treatment of sacroiliac joint problems. Journal of the American Physical Therapy Association 3(1): 1-9

7 Mitchell F L, Moran P S, Pruzzo N A 1979 An evaluation and treatment manual of osteopathic muscle energy techniques. Mitchell, Moran, and Pruzzo Associates, Valley Park

8 DonTigny R L 1985 Function and pathomechanics of the sacroiliac joint. Physical Therapy 65: 35-43

9 Bernard T N, Kirkaldy-Willis W H 1987 Recognizing specific characteristics of nonspecific low back pain. Clinical Orthopaedics 217: 266-280

10 Bourdillon J F, Day E A, Boohhout M R 1995 Spinal manipulation, 5th edn. Bath Press, Avon

11 Shaw J L 1992 The role of the sacroiliac joint as a cause of low back pain and dysfunction. In: First Interdisciplinary World Congress on Low Back Pain and its Relation to the Sacroiliac Joint. Rotterdam ECO (ISBN 90-9005121)

12 Schwarzer A C, Aprill C N, Bogduk N 1995 The sacroiliac joint in chronic low back pain. Spine 20: 31-37

13 Maigne J Y, Aivaliklis A, Pfefer F 1996 Results of sacroiliac joint double block and value of sacroiliac pain provocation tests in 54 patients with low back pain. Spine 21: 1889-1892

14 Carmichael J P 1987 Inter and intra-examiner reliability of palpation for sacroiliac joint dysfunction. Journal of Manipulative and Physiological Therapeutics 10: 164-171

15 Dreyfuss P, Dreyer S, Griffin J, Hoffman J, Walsh N 1994 Positive sacroiliac screening tests in asymptomatic adults. Spine 19: 1138-1143

16 Dreyfuss P, Michaelsen M, Pauza K, McLarty J, Bogduk N 1996 The value of medical history and physical examination in diagnosing sacroiliac joint pain. Spine 21: 2594-2602

17 Herzog W, Read L, Conway P, Shaw L, McEwen M 1988 Reliability of motion palpation procedures to detect sacro-iliac joint fixations. Journal of Manipulative and Physiological Therapeutics 11: 151-157

18 Laslett M, Williams M 1994 The reliability of selected pain provocation tests for sacroiliac joint pathology. Spine 19: 1243-1249

19 Van Deursen L L J M, Patijn J, Ockhuysen A L, Vortman B J 1990 The value of some clinical tests of the sacro-iliac joint. Manual Medicine 5: 96-99

20 Colachis S C, Worden R E, Brechtol C O, Strohm B R 1963 Movement of the sacroiliac joint in the adult male: a preliminary report. Archives of Physical Medicine and Rehabilitation 44: 490-498

21 Egund N, Olsson T H, Schmid H, Selvik G 1978 Movements in the sacroiliac joints demonstrated with roentgen stereophotogrammetry. Acta Radiologica Diagnostica 19: 833-846

22 Sturesson B, Selvik G, Uden A 1989 Movements of the sacroiliac joints. A roentgen stereophotogrammetric analysis. Spine 14: 162-165

23 Beal M C 1982 The sacroilac problem: review of anatomy, mechanics, and diagnosis. Journal of the American Osteopathic Association 81: 667-679

24 Stoddard A 1972 Manual of osteopathic technique, 2nd edn. Hutchinson Medical, London

25 Walton W J 1972 Textbook of osteopathic diagnosis and technique procedures, 2nd edn. Matthews, St Louis

26 Kimberly P E 1980 Outline of osteopathic manipulative procedures, 2nd edn. Kirksville College of Osteopathic Medicine, Kirksville

27 Downing H D 1981 Principles and practice of osteopathy. Tamor Pierston, London

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29 Hartman L 1997 Handbook of osteopathic technique, 3rd edn. Chapman and Hall, London

30 Greenman P E 1996 Principles of manual medicine, 2nd edn. Williams and Wilkins, Baltimore

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32 Cibulka M T, Delitto A, Koldehoff R M 1988 Changes in innominate tilt after manipulation of the sacroiliac joint in patients with low back pain. Physical Therapy 68(9): 1359-1363

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PART

Technique failure

D

and analysis

Techniques in this manual have been described in a structured format. This format allows flexibility so that each technique can be modified to suit both the patient and practitioner.

Competence and expertise in the use of HVLA techniques increase with practice and experience. Development of a high level of skill in the use of HVLA techniques is predicated upon critical reflection of performance. When a HVLA technique does not produce cavitation with minimal force, the practitioner should reflect upon how the technique might have been modified and improved. Even the experienced practitioner should review each HVLA technique to identify factors that might improve technique delivery.

Inability to achieve cavitation with minimal force may arise for a number of reasons and can be reviewed under three broad headings:

General technique analysis

— Incorrect selection of technique

— Inadequate localization of forces

— Ineffective thrust

Practitioner and patient variables

— Patient comfort and cooperation

— Patient positioning

— Practitioner comfort and confidence

— Practitioner posture

Physical and biomechanical modifying factors

— Primary leverage

— Secondary leverages

— Contact point pressure

— Identification of appropriate pre-thrust tension

— Direction of thrust

— Velocity of thrust

— Amplitude of thrust

— Arrest of technique.

General technique analysis Box D.1

Practitioner and patient variables Box D.2

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