Rotation gliding Patient prone Short lever technique

Assume somatic dysfunction (A-R-T-T) is identified and you wish to use a rotation gliding thrust, parallel to the apophysial joint plane, to produce joint cavitation at T5-6 (see below)

1 Contact points

2 Applicators

3 Patient positioning

Transverse processes of T5 (right applicator) and T6 (left applicator). Hypothenar eminence of left and right hands.

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

4 Operator stance

5 Palpation of contact points

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.

There are many different ways to perform this technique. This is one approach. Locate the transverse processes of T5 and T6. Place the hypothenar eminence of your right hand against the left transverse process of T5 and establish a firm contact (Fig. B2.4.1). Place the hypothenar eminence of your left hand against the right transverse process of T6 (Fig. B2.4.2). Ensure that you have good contact and will not slip across the skin or superficial musculature when you apply downward and caudad or cephalad forces against the transverse processes. Maintain these contact points.

Fig. B2.4.2

6 Positioning for This is a short lever technique and the velocity of the thrust is critical. thrust Move your centre of gravity over the patient by leaning your body weight forwards onto your arms and hypothenar eminences (Fig. B2.4.3). Shifting your centre of gravity forwards will direct a downward pressure on the transverse processes. You must apply an additional force directed caudad with the left hand and cephalad with the right hand. The final direction of thrust is influenced by the degree of thoracic kyphosis and any pre-existing scoliosis.

Fig. B2.4.3

7 Adjustments to Ensure your patient remains relaxed. Maintaining all holds and achieve pressure upon the transverse processes, make any necessary changes appropriate by introducing very slight components of extension, sidebending and pre-thrust tension rotation until you sense a state of appropriate tension and leverage at the TS-6 segment. 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.

Delivering the Apply a HVLA thrust directed in a downward and cephalad direction thrust against the transverse process of T5 while simultaneously applying a thrust downwards and in a caudad direction against the transverse process of T6 (Fig. B2.4.4).

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

Thoracic spine T4-9

Rotation gliding Patient prone Short lever technique

♦ Contact points. Transverse processes of T5 (right applicator) and 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 left transverse process of T5 and establish a firm contact (Fig. B2.4.1). Place the hypothenar eminence of your left hand against the right transverse process of T6 (Fig. B2.4.2).

♦ 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. B2.4.3). Apply an additional force directed caudad with the left hand and cephalad with the right hand.

♦ 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 transverse process of T5 while simultaneously applying a thrust downwards and in a caudad direction against the transverse process of T6 (Fig. B2.4.4).

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Ribs R1-3

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 second rib on the right (Figs B2.5.1, B2.5.2)

Fig. B2.5.2

1 Contact point

2 Applicator

3 Patient positioning

Angle of the second rib on the right. Hypothenar eminence of the right hand.

Patient prone with the point of the chin resting on the couch and the arms hanging over the edge of the couch. Introduce a small amount of sidebending to the left by gently lifting and moving the chin to the patient's left (Fig. B2.5.3). Do not introduce too much sidebending.

4 Operator stance

5 Palpation of contact point

6 Positioning for thrust

Head of the couch, feet spread slightly. Stand as erect as possible and avoid crouching over the patient as this will limit the technique and restrict delivery of the thrust.

Locate the angle of the second rib on the right. Place the hypothenar eminence of your right hand gently, but firmly, against the rib angle. Ensure that you have good contact and will not slip across the skin or superficial musculature when you apply a caudad and downward force towards the couch against the angle of the second rib. Maintain this contact point.

Keeping your position at the head of the couch, gently place your left hand against the right side of the patient's head and neck. While maintaining the left sidebending, introduce rotation to the right, in the cervical and upper thoracic spine, by applying gentle pressure to the right side of the patient's head and neck with your left hand (Fig. B2.5.4). Maintaining all holds and pressures, complete the rotation of the patient's head and neck until a sense of tension is palpated at your right hypothenar eminence. Keep firm pressure against the contact point.

Fig. B2.5.4

7 Adjustments to achieve appropriate pre-thrust tension

Immediately pre-thrust

Ensure the patient remains relaxed. Maintaining all holds, make any necessary changes in extension, sidebending or rotation until you can sense a state of appropriate tension and leverage. The patient should not be aware of any pain or discomfort. You make these final adjustments by altering the pressure and direction of forces between the left hand against the patient's head and neck and your right hypothenar eminence against the contact point.

Relax and adjust your balance as necessary. Keep your head up and ensure that your contacts are firm and your body position is 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.

9 Delivering the thrust

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.

Apply a HVLA thrust to the angle of the second rib on the right directed downwards towards the couch and also in a caudad direction towards the patient's right iliac crest. Simultaneously, apply a slight, rapid increase of head and neck rotation to the right with your left hand (Fig. B2.S.S). You must not overemphasize the thrust with the left hand against the patient's head and neck. Your left hand stabilizes the leverages and maintains the position of the head and cervical spine against the thrust imposed upon the contact point. The thrust is induced by a very rapid contraction of the triceps, shoulder adductors and internal rotators.

SUMMARY

Patient prone Gliding thrust

♦ Contact point. Angle of the right second rib.

♦ Applicator. Hypothenar eminence.

♦ Patient positioning. Patient prone with the chin resting on the couch and arms hanging over the edge of the couch. Introduce sidebending to the left (Fig. B2.5.3). Do not introduce too much sidebending.

♦ Operator stance. Head of the couch, feet spread slightly.

♦ Palpation of contact point. Place your hypothenar eminence against the angle of the second rib on the right. Ensure that you have good contact and will not slip across the skin or superficial musculature when you apply a caudad and downward force towards the couch against the angle of the second rib.

♦ Positioning for thrust. Place your left hand against the right side of the patient's head and neck. Rotate the cervical and upper thoracic spine to the right, by applying pressure to the right side of the patient's head and neck with your left hand until a sense of tension is palpated at the contact point (Fig. B2.5.4).

♦ Adjustments to achieve appropriate pre-thrust tension.

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

♦ Delivering the thrust. The thrust to the angle of the second rib on the right is directed downwards towards the couch and also in a caudad direction towards the patient's right iliac crest. Simultaneously, apply a slight, rapid increase of head and neck rotation to the right with your left hand (Fig. B2.5.5). You must not overemphasize the thrust with the left hand against the patient's head and neck.

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Ribs R4-10

Patient supine

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 (Fig. B2.6.1)

Fig. B2.6.1

1 Contact points

2 Applicators

3 Patient positioning

(a) Sixth rib on the left, just lateral to the transverse process of T6

(b) Patient's elbows and left forearm.

(a) Hypothenar eminence of the operator's right hand

(b) Operator's lower sternum or upper abdomen.

Supine with the arms crossed over the chest and the hands passed around the shoulders. The left arm is placed over the right arm. The arms should be firmly clasped around the body as far as the patient can comfortably reach.

4 Operator stance Stand on the right side of the patient, facing the couch.

5 Positioning for thrust

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 sixth rib on the left. Now place the hypothenar eminence of your right hand against the rib just lateral to the transverse process of T6 (Fig. B2.6.2).

Keeping contact with the rib, begin rolling the patient back to the supine position (Fig. B2.6.3). Continue until the patient's elbows are directly over your hypothenar eminence. This introduces additional rotation, which is a critical element in the technique.

Rest your lower sternum or upper abdomen on the patient's elbows and left forearm. Initially, a slow but firm pressure is applied with your lower sternum or upper abdomen downward towards the couch. Maintaining this downward leverage, introduce left rotation of the patient's upper thorax by directing forces towards the patient's left shoulder along the line of the patient's left upper arm. By balancing these different leverages, tension can be localized to the costotransverse joint of the sixth rib.

6 Adjustments to Ensure your patient remains relaxed. Maintaining all holds, make any achieve necessary changes in flexion, extension, sidebending and rotation until appropriate you can 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. Make these final adjustments by slight movements of the ankles, knees, hips and trunk. A common mistake is to lose the chest compression during the final adjustments.

7 Immediately Relax and adjust your balance as necessary. Keep your head up and pre-thrust ensure that your contacts are firm and the patient's body weight is 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.

8 Delivering the The shoulder girdles and thorax of the patient are now a solid mass thrust against which a thrust may be applied. Apply a HVLA thrust downward towards the couch and in the line of the patient's left upper arm via your lower sternum or upper abdomen. Simultaneously, apply a HVLA thrust with your right hypothenar eminence upward against the sixth rib (Fig. B2.6.4). The force is produced by rapid supination of your right forearm.

A common fault is to emphasize the thrust via the patient's shoulder girdles at the expense of the thrust against the sixth rib. The hand contacting the rib 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.

Ribs R4-10

Patient supine Gliding thrust

— Sixth rib on the left, lateral to the transverse process

— Patient's elbows and left forearm.

— Hypothenar eminence of the operator's right hand

— Operator's lower sternum or upper abdomen.

• Patient positioning. Supine with arms crossed over the chest.

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

• Positioning for thrust. Take hold of the patient's left shoulder and pull it towards you. Place the hypothenar eminence of your right hand against the rib just lateral to the left transverse process of T6 (Fig. B2.6.2). Roll the patient back to the supine position (Fig. B2.6.3). Continue until the patient's elbows are directly over your hypothenar eminence. This is a critical element in the technique. Rest your lower sternum or upper abdomen on the patient's elbows and left forearm. Apply a slow firm pressure with your lower sternum or upper abdomen downward towards the couch. Maintaining this downward leverage, introduce left rotation of the patient's upper thorax by directing forces towards the patient's left shoulder along the line of the patient's left upper arm.

• Adjustments to achieve appropriate pre-thrust tension.

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

• Delivering the thrust. The direction of thrust is downward towards the couch and in the line of the patient's left upper arm via your lower sternum or upper abdomen. Simultaneously, apply a thrust with your right hypothenar eminence upward against the sixth rib (Fig. B2.6.4). The force is produced by rapid supination of your right forearm. The hand contacting the rib must actively participate in the generation of thrust forces.

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