Assume somatic dysfunction (A-R-T-T) is identified and you wish to use a thrust in the plane of the atlantoaxial (Cl-2) apophysial joint to produce cavitation on the right (see below)
1 Contact point
3 Patient positioning
4 Operator stance
5 Palpation of contact point
6 Fixation of contact point
7 Cradle hold
8 Vertex contact
9 Positioning for thrust
Right posterior arch of atlas.
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 the operator 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. Lift the head slightly and gently rotate it to the left, taking the weight of the head in your left hand. Remove your right hand from the occiput and palpate the region of the right posterior arch of the atlas with the tip of your index or middle finger. Slowly but firmly slide your right index finger downwards (towards the couch) along the posterior arch of the atlas 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 occiput, thereby locking 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.
Keep your left hand under the head and spread the fingers out for maximum contact. Keep the patient's ear resting in the palm of the your left hand. Flex the left wrist, allowing you to cradle the patient's head in your palm, flexed wrist and anterior aspect of forearm. Keep your right index finger firmly on the contact point and press the right palm against the occiput. The weight of the patient's head and neck is now balanced between your left and right hands with the cervical positioning controlled by the converging pressures of your two hands and arms.
The elbows are held close to or only slightly away from your sides. This is an essential feature of the cradle hold method. Stand easily upright at the head of the couch and do not step to the right as in the chin hold method.
(a) Primary leverage of rotation. Maintaining all holds and contact points, complete the rotation of the head and neck to the left until tension is palpated at the contact point. Supination of the left wrist and forearm and simultaneous pronation of the right wrist and forearm achieve the rotation movement (Fig. B1.4.1). Do not lose firm pressure on the contact point. Do not force rotation; take it up fully but carefully. A common mistake is to use insufficient primary leverage of head and neck rotation.
10 Adjustments to achieve appropriate pre-thrust tension
(b) Secondary leverage. This technique uses minimal secondary leverage.
This is almost a pure rotation thrust, but the appropriate tension can be achieved by adjusting flexion, extension and sidebending. The patient should not be aware of any pain or discomfort. The operator makes final minor adjustments by introducing any sidebending, flexion or extension with slight movements of the wrists, arms and shoulders.
11 Immediately Relax and adjust your balance as necessary. Keep your head up;
pre-thrust looking down impedes the thrust and can cause embarrassing proximity to the patient. 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 to the posterior arch of the atlas directed towards the corner of the patient's mouth. This thrust is generated by rapid pronation of your right forearm. Simultaneously, apply a rapid low-amplitude increase of head rotation to the left by supinating the left forearm (Fig. B1.4.2). This rotation movement of the head is very small but of high velocity. This ensures that the occiput and atlas move as one unit during the thrust. The atlas rotates about the odontoid peg of the axis and cavitation occurs at the right Cl-2 articulation. This is a HVLA 'flick' type thrust. Coordination between the left and right hands and forearms is critical.
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.
Patient supine ■ Rotation thrust
♦ Contact point. Right posterior arch of atlas.
♦ Applicator. Lateral border, proximal or middle phalanx.
♦ Patient positioning. Supine with the neck in a neutral relaxed position.
♦ Operator stance. Head of couch, feet spread slightly.
♦ Palpation of contact point.
♦ Fixation of contact point.
♦ Cradle hold. The weight of the patient's head and neck is balanced between your left and right hands with cervical positioning controlled by the converging pressures.
♦ Positioning for thrust. Stand upright at the head of the couch. The elbows are held close to or only slightly away from your sides. Use primary leverage of rotation with minimal secondary leverage. Your direction of thrust is towards the patient's mouth and into rotation (Fig.
♦ Adjustments to achieve appropriate pre-thrust tension.
♦ Immediately pre-thrust. Relax and adjust your balance.
♦ Delivering the thrust. The thrust is directed towards the corner of the patient's mouth. Simultaneously, apply a rapid low-amplitude increase of head rotation to the left. The occiput and atlas move as one unit during the thrust (Fig. B1.4.2).
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Cervical spine C2-7
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