Assume somatic dysfunction (A-R-T-T) is identified and you wish to use an upward and forward thrust, parallel to the apophysial joint plane, to produce joint cavitation at C4-5 on the left (see below)
1 Contact point
3 Patient positioning
4 Operator stance
Posterolateral aspect of the left articular pillar of C4.
Palmar aspect, proximal or middle phalanx of operator's right index or middle finger.
Sitting with the neck in a neutral relaxed position. The neck should not be in any significant amount of flexion or extension.
Stand in front and to the right of the patient, 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 (Fig. B1.8.1).
5 Palpation of Place the fingers and palm of your left hand against the patient's right contact point occiput and neck, gently covering the patient's right ear. Use the index or middle finger of your right hand to palpate the patient's left articular pillar of C4. Slowly but firmly slide your applicator along the articular pillar of C4 until it approximates the proximal or middle phalanx (Fig. Bl.S.2). Several sliding pressures may be necessary to establish close approximation to the contact point.
6 Fixation of Keep your right index or middle finger firmly pressed upon the contact point contact point while you spread the other fingers and thumb of the right hand to securely support the head, mandible and neck, thereby locking the applicator in position. You must now keep the applicator on the contact point until the technique is complete. The weight of the head and neck is now balanced between your left and right hands, with the cervical spine positioning controlled by the converging pressures of your two hands.
7 Positioning The elbows are held close to or only slightly away from your sides.
(a) Primary leverage. Ensure that the patient's head is securely supported between your two hands. Maintaining all holds and contact points, rotate the head and neck to the right until tension is palpated at the contact point (Fig. B1.8.3). Do not lose contact between your applicator and the articular pillar of C4. Do not force rotation; take it up fully but carefully. A common mistake is to use insufficient primary leverage of head and neck rotation.
(b) Secondary leverage. Add a very small degree of sidebending to the left, down to and including C4. Note: strong sidebending will lock the neck. Slight movements of the operator's forearms, shoulders and trunk introduce the sidebending.
8 Adjustments to Ensure your patient remains relaxed. It is important to keep your achieve elbows close to your sides. Maintaining all holds, make any necessary appropriate changes in flexion, extension, sidebending or rotation until you can pre-thrust tension 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 legs and trunk, not by altering the position of the hands or arms.
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 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 to the left articular pillar of C4. The thrust is upwards and towards the midline in the direction of the patient's right eye, parallel to the apophysial joint plane (Fig. B1.8.4). Simultaneously, apply a slight, rapid increase of rotation to the right, but do not increase sidebending leverages. This is a HVLA 'flick' type thrust. Coordination between the left and right hands and arms 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.
Up-slope gliding Patient sitting Operator standing in front
♦ Contact point. Posterolateral aspect of the left C4 articular pillar.
♦ Applicator. Palmar aspect, proximal or middle phalanx.
♦ Patient positioning. Sitting with the neck in a neutral relaxed position.
♦ Operator stance. In front and to the right of the patient, feet spread slightly (Fig. B 1.8.1).
♦ Palpation of contact point.
♦ Fixation of contact point. Keep your right index or middle finger firmly pressed upon the contact point while you spread the other fingers and thumb of the right hand to securely support the head, mandible and neck (Fig. B 1.8.2).
♦ Positioning for thrust. Stand upright with the elbows held close to or only slightly away from your sides. Introduce primary leverage of rotation to the right (Fig. B 1.8.3) and a small degree of secondary leverage of sidebending left. 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 right eye. Simultaneously, apply a slight, rapid increase of rotation of the head and neck to the right with no increase of sidebending to the left
(Fig. B 1.8.4). Coordination between both hands and arms is critical.
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