Upslope gliding Cradle hold Patient supine Reversed primary and secondary leverage

In certain circumstances the operator might wish to perform an up-slope gliding thrust but minimize the extent of head and neck rotation 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 (see below)

1 Contact point

2 Applicator

3 Patient positioning

4 Operator stance

5 Palpation of contact point

6 Fixation of contact point

7 Cradle hold

Posterolateral aspect of the right articular pillar of C4.

Lateral border, proximal or middle phalanx of operator's right index finger.

Supine with the neck in a neutral relaxed position. If necessary, remove or adjust pillow height. The technique should not normally be executed in any significant degree 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. Lift the head to throw the articular pillars into prominence. Rotate the head slightly 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 right index finger. Slowly but firmly slide your right forefinger 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.

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. When treating the lower cervical segments, the middle or distal phalanx may be used as the applicator.

8 Vertex contact

None in this technique.

Positioning The intent with this technique is to perform an up-slope gliding thrust for thrust but to limit the amount of head and neck rotation. This modification requires a greater emphasis upon the use of sidebending to achieve joint locking. It is critical that the direction of thrust be parallel to the apophysial joint plane in an up-slope direction. There should be no exaggeration of the sidebending leverage.

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 sidebending. Maintaining all holds and contact points, gently introduce sidebending of the head and neck to the right until tension is palpated at the contact point (Fig. B1.7.1). To introduce the right sidebending, the operator pivots slightly via the legs and trunk so that the trunk and upper body rotate to the left, enabling the hands and arms to remain in position. Do not lose firm contact with your contact point on the articular pillar of C4. A common mistake is to use insufficient primary leverage of head and neck sidebending.

(b) Secondary leverage. Add a little rotation to the left, down to and including C4 (Fig. B1.7.2). This requires extensive practice before one develops a refined 'tension sense'. Movement of your hands and forearms introduces the rotation.

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 (Fig. B1.7.3). This thrust is generated by rapid pronation of your right forearm. Simultaneously, apply a slight rapid increase of rotation of the head and neck to the left. A key element in this technique is to avoid exaggeration of the primary leverage of sidebending when the thrust is applied. The increase of rotation to the left is accomplished by slight supination of left wrist and forearm and coordinated to match the thrust upon the contact point. This is a HVLA 'flick' type thrust. Coordination between the left and right hands and forearms is critical.

It must be appreciated that the use of sidebending as a primary leverage is predicated upon the operator's desire to limit the amount of head and neck rotation. Generally, when sidebending is used as a primary leverage, the aim will be to thrust in a down-slope direction. Exaggeration of the sidebending leverage in this technique must be avoided. Sidebending enhances locking but does not assist with an up-slope gliding thrust. The thrust in this technique is accompanied by slight exaggeration of the secondary leverage of rotation and is directed towards the patient's opposite eye.

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 Cradle hold

Patient supine Reversed primary and secondary leverage

• Contact point. Posterolateral aspect of the 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.

• Cradle hold. The weight of the patient's head and neck is now 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. Introduce primary leverage of sidebending to the right (Fig. B1.7.1) and a small degree of secondary leverage of rotation left (Fig. B1.7.2). Maintain the contact point on the posterolateral aspect of the C4 articular pillar.

• 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 (Fig. B1.7.3). A key element in this technique is to avoid exaggeration of the primary leverage of sidebending when the thrust is applied. The use of sidebending as a primary leverage is predicated upon the operator's desire to limit the amount of head and neck rotation.

Cervical spine C2-7

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