Upslope gliding Chin hold Patient supine

Assume somatic dysfunction (A-R-T-T) is identified and you wish to use an upward and forward gliding thrust, parallel to the apophysial joint plane, to produce cavitation at C4-5 on the right (Figs BL5.2, B2.5.2)

Fig. B1.5.1
Fig. B1.5.2

1 Contact point

2 Applicator

3 Patient positioning

4 Operator stance

5 Palpation of contact point

6 Fixation of contact point

7 Chin hold

8 Vertex contact

9 Positioning for thrust

Posterolateral aspect of right C4 articular pillar.

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 you 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. Rotate the head to the left, taking its weight in your left hand. Remove your right hand from the occiput and palpate the right articular pillar of C4 with the tip of your index or middle finger. Slowly but firmly slide your right index finger downwards (towards the couch) along the articular pillar 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 thereby lock 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.

Keeping your right hand in position, slide the left hand slowly and carefully forwards until the fingers lightly clasp the chin. Ensure that your left forearm is over or slightly anterior to the ear. Placing the forearm on or behind the ear puts the neck into too much flexion. The head is now controlled by balancing forces between the right palm and left forearm. Maintain the applicator in position.

Move your body forward slightly so that your chest is in contact with the vertex of the patient's head. The head is now securely cradled between your left forearm, the flexed left elbow, the right palm and your chest. Vertex contact is often useful in a heavy, stiff or difficult case but can, on occasions, be omitted.

Step to the right and stand across the right corner of the couch, keeping the hands firmly in position and taking care not to lose pressure on the contact point. Straighten the right wrist so that the radius and first metacarpal are in line. Maintaining applicator pressure, allow the right index finger to roll slightly on the contact point to align your right wrist and forearm with the thrust plane, which is upwards and towards the midline in the direction of the patient's left eye. Keep the right elbow close to the couch in order to maintain the contact point on the posterolateral aspect of the articular pillar.

(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 (Fig. Bl.5.3). Do not lose firm pressure at the contact point. A common mistake is to use insufficient primary leverage of head and neck rotation.

Fig. B1.5.3

(b) Secondary leverage. Add a very small degree of sidebending to the right, down to and including C4. The operator pivoting slightly, via the legs and trunk, introduces the right sidebending, so that the trunk and upper body rotate to the left, enabling the hands and arms to remain in position (Fig. Bl.5.4). Do not attempt to introduce sidebending by moving the hands or arms as this will lead to loss of contact and inaccurate technique.

Fig. B1.5.4

10 Adjustments to achieve appropriate pre-thrust tension

11 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. The patient should not be aware of any pain or discomfort. You make these final adjustments by slight movements of your ankles, knees, hips and trunk, not by altering the position of the hands or arms.

Relax and adjust your balance as necessary. Keep your head up; looking down impedes the thrust and can cause embarrassing proximity to the patient. 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.

12. Delivering the thrust

Apply a HVLA thrust to the right articular pillar of C4. The thrust is upwards and towards the midline in the direction of the patient's left eye, parallel to the apophysial joint plane. Simultaneously, apply a slight, rapid increase of rotation of the head and neck to the left but do not increase the sidebending leverage (Fig. Bl.5.5). The increase of rotation to the left is accomplished by slight supination of the left wrist and forearm. The thrust is induced by a very rapid contraction of the flexors and adductors of the right shoulder, and, if necessary, trunk and lower limb movement.

Fig. B1.5.5

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

Up-slope gliding Chin hold Patient supine

♦ Contact point. Posterolateral aspect of right C4 articular pillar.

♦ 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.

♦ Chin hold. Ensure your left forearm is over or slightly anterior to the ear.

♦ Vertex contact. Optional.

♦ Positioning for thrust. Step to the right and stand across the right corner of the couch. Introduce primary leverage of rotation left (Fig.

B 1.5.3) and a small degree of secondary leverage of sidebending right. Keep the right elbow close to the couch in order to maintain the contact point on the posterolateral aspect of the C4 articular pillar (Fig. B 1.5.4).

♦ Adjustments to achieve appropriate pre-thrust tension.

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

♦ Delivering the thrust. The thrust is directed towards the patient's left eye. Simultaneously, apply a slight, rapid increase of rotation of the head and neck to the left with no increase of sidebending to the right

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