Companion DVD Included
Translato ri c Spinal Manipulatio n™ ISBN 978-1-59975-1 95 -5 Written by - John R. Krauss PhD, PT, OCS, FAAOMPT, Ol af Evj enth , PT, OMT and Do ug C reighto n OPT, OCS , FAAOMPT Illustrated By - John R. Krauss A Lakeview Medi a L. L.C . Publi cati o n This labo ratory guide is intended to be used by licensed phys ica l therapi sts or phys ica l therapi st students studyi ng under the su perv ision of an instructo r sk ill ed in th e appli cati o n of TS M. O ther Ka ltenborn- Evjenth based instructional materia ls are ava ilabl e thro ugh O PTP at www.o ptp.com. These inc lude: Manua l Mobili zati on of the Jo ints Volume I: The Extremiti es 6th Editio n by Freddy M. Ka ltenbo rn ISBN 82-7054-043 -3. Manua l Mobili zati on of the Jo ints Volume II : The Spine 4th Edition by Freddy M. Kaltenborn IS B 82-7054-069-2. Evjenth , O. an d Hamberg, J. Muscle Stretching in Manua l Therapy: A Clini ca l Manual, Volume I. Alfla Rehab Forlag : Alfta , Sweden, 1998 . ISB : 9 1-85934-02-X. Evjenth , O. and Hamberg, J. Muscle Stretchin g in Manua l Therapy: A Clini ca l Manua l, Volume 2. A lfta Rehab Fo rl ag : Alfta , Sweden, 1998. IS BN: 9 1-85934-03-8. Evjenth, O. and Hamberg, J. Auto Stretchin g. A lfta Rehab Forl ag: A lfta, Sweden, 1997. IS BN : 9 1-85934-05-4.
Copyright 2006 - rev 1.3 Th is manual is the copyright pro perty of John R. Krauss. Thi s manual is di stributed by O PTP. 800-367-7393 www.optp.com
Ackn owledgements The develo pment of thi s book was an eno rmo us undertaking, taking over three years to compl ete. We would like to thank the indi viduals li sted be low fo r volunteering their time as models, techni ca l consultants and ed itors. Thi s proj ect could not have been compl eted witho ut all of your generous assistance. Dawn Gilbert, PT, OMPT Jill Marian, PT, O MPT C hri stina Michajl yszyn, PT, O MPT Jess ica Wetzel, PT, O MPT Me lodi e Kondratek, DSc, PT, O MPT Marie- Eve Pepin, MS , PT, OMPT Derek C han, PT, O MPT James Wold, MS , PT, OMPT
Dedication For our wives, Jennifer, Grella and Kristin our ch ildren, David, Kri stin , Ane, Karleigh, Katie and Cam and our grandchildren, Oli via and Vendela Thanks for your love and support ...
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Contents - An Overview Chapter 1 - Introducing TSM - 3-6 Chapter 2 - Applying TSM - 7-24 Chapter 3 - Cervical Spine - 25-73 Chapter 4 - Thoracic Spine - 75-95 Chapter 5 - Lumbar Spine - 97-122 Chapter 6 - The SI Joint - 123-133
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Contents - In Detail Acknowl edgements Dedicat ion - iii
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Introducing TSM Background - 3 Joint moti on - 3 Indications and contraindications for TSM Goa ls ofTSM - 4 Resea rch in TSM - 5 Mechan ics ofTSM techniques - 5 Features of thi s text - 6
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Applying TSM Patient & therapist pos iti onin g for TSM 8 Locali zati on of the treatment segment - 8 Locking: an introducti on - 9 Locking the segment(s) above the treatment segment or joint (lockin g above) - 10 Locking the segment(s) below the treatment segment or joint (lockin g below) - 10 Testin g pri or to using locking during manipulation - \I The amplitude of the translatoric mobili zati on & impulse - \I Generatin g speed during high ve locity translatoric manipulation - II Us ing enough fo rce with TSM : "As little as necessary, as much as needed" - 12 Integrating TSM into clinical practi ce - 12 Supporti ve and correcti ve interventi on techniques used in conjunction with TSM - 13 Clini ca l conditi ons, examinati on findin gs and common sequencing ofTSM techniques Deve loping skill with TS M - 24
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Cervical Spine The Upper Cervical Spine - 26 Osseous anatoniy - 26 Upper cervical arti cul ations - 26 Li gamentous anatomy - 27 Vasc ul ar anatomy - 27 Kinemati cs - 28 Translatori c manipul ation of the upper cervica l Spine Selectin g a contact for OA traction - 30 OA-Tracti on Side-lying - 3 1 OA-Traction Supine - 32 OA-Traction Seated - 33 OA glide techniques - 34 Occiput- Dorsa l - 35 Atl as-Ventra l - 36 Al ias-Dorsa l - 37 Selecting a contact for AA traction 38 Frequency of AA manipul ation - 38
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Translatoric Spinal Manipulation
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AA-Traction Side-lying - 39 AA -Traction Supi ne - 40 The Lower Cervical Spine - 41 Osseous anatomy - 41 Lower cervica l articulations - 42 Ligamentous anatomy - 43 Kinematics - 43 Bi omec hanics of Lower Cervica l TSM C2-7-Disc Traction Supine - 47 C2-Disc Traction Side-lying - 48 C2- Di sc Traction Supine - 49 C2-7-Disc Traction Seated - 50 C3-6-D isc Traction Side-lying - 51 C3-6-Disc Traction Supine - 52 C2-7-Facet Distraction Supine - 53 C2-6-Facet Distraction Seated - 54 C2-6-Facet Distraction Seated - 55 C2-6-Facet Distraction Supine - 56 C2-6-Facet G lide Supine - 57 C2-6-Facet Glide Seated - 58 C7-Disc Traction Side- lyin g - 59 C7-Facet G lide Supine - 60 C7-Facet G lide Side-lying - 61 C7-Facet G lide Supine - 62-65 C7-Facet G lide Prone - 66-68 C7-Facet G lide Seated - 69-70 C7-Facet Distraction - 71-73
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Thoracic Spine The Thoracic Spine - 76 The stable thoracic segments - 76 Osteo logical features of the thoracic spine - 76 Thoracic facet join ts - 76 Biomechanics ofThoraciG Spine TSM - 78 Thoracic-Disc Traction Supine - 79 Thoracic-Facet Traction Bilateral Supine - 80-82 Thoracic- Facet Traction Unilatera l Supine - 83-84 Thoracic-Facet Traction Bilateral Prone - 85 Thoracic-Facet Traction Unilateral Prone - 86 Thoracic ribs - 87 First Rib-Distraction Supine - 89 First Rib-Distraction Seated Locking Above - 90 First Rib-Distraction Seated Locking Below - 91 .Ribs2-12-Distraction Supine - 92 Rib 2-12-Distraction Prone with Manual Stabilization Ribs2-12-Distraction Prone with Locking Above - 94 Ribs2-12-Distraction Seated - 95
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Lumbar Spine The Lumbar Spine - 98 Osseous anatomy - 98 Ligamentous anatomy - 99 The intervertebral disc (lVD) - 99 Vascular anatomy - 99 Biomechanics of Lumbar Spine TSM 101 Lumbar-Traction Side-lying - 106-107 Lumbar-Traction Seated - 108-109 LI-4-Side Bending in Ventral Flexion - 110-112 LS-Side Bending in Ventral Flexion - 113 L 1-4-Side Bending in Dorsal Flexion - 114-116 LS-Side Bending in Dorsal Flexion - 117 L I-S-Facet Distraction Bilateral Prone - 118 L1-5-Facet Distraction Unilateral Prone - 119 L I-S-Facet Glide to Improve Dorsal Flexion Prone - 120 L1-S-Facet Glide Bilateral to Improve Ventral Flexion Prone - 121 LI-5-Facet Glide Unilateral to Improve Ventral Flexion Prone - 122
The SI Joint SI Joint - 124 Osseous anatomy - 124 Ligamentous anatomy - 124 Muscular support of the SI joint - 12S Kinematics of the SI Joint - 12S The symphysis pubis - 125 Biomechanics ofSI joint TSM - 127 Sacrum Cranial Prone - 129 IIlium Caudal Prone - 130 Sacrum Cranial Side-lying - 131 IIlium Ventral Prone - 132 IIlium Dorsal Supine - 133 References -
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TranslalOl'ic Spinal Manipulation
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TSM
Introducing TSM
I: Forwa rd Th e fo ll ow ing tex t is intended to be used by physica l the rap ists and physica ll herapist students inte res ted in deve lo pin g the ir thco rCli ca lundcrstanding and phys ical sk ill leve l in the ~lpp li ca t io n of tra nslatoric sp in al ma ni pul ation (TSM). In keeping
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consislenl wilh Ihc slandard of praclice defi ned by Ihe American Physical Therapy Associal ion. Ihe aUlhors ha l e adopled Ihe fo llow ing de fin iti o n of manipul ati on: '"A man ual th erapy tec hniq ue comp ri sed of a conti nu um of ski ll ed passive moveme nt s to the j o int and/or re lated so il tissue th at arc app lied at vary in g speeds a nd a mp lit udes. in cluding a s mall amp litudclhigh veloci ty th erape uti c 1110 \ cme nt '".
Wilhin Ihis lexl. bOlh high (HV) and low velocilY (LV) Iranslatoric manipulalions arc presenled. some of which are appropriale for enl ry- Iel el (E L) physica l lherapisl educat ion and olhers Ihal are more appropriale fo r posl-professional ( PP) ph ys ica llh crapis l ed uca ti o n. This is due in part lO the ent ry- leve l stude nt 's lac k o f expe ri ence in eva luatin g, mnnag ing and ph ys icall y handling patie nt s who are ex peri enc ing spina lm ovc mc nt impa innents. This does not impl y th at post-profess io na l students do no t lack si milar skill s. howeve r. they a re no t faced wi th the daunting tas k o f lea rnin g the w ide range o f sk ills necessary to become tI lice nsed physical the rapi st in additi o n to th e hi ghe r leve l cogniti ve and psyc ho mo lor s kill s necessa ry to deve lop a hi g h leve l o f profi c iency in a ll o f th e techniques presented w ithin th is tex t. To identify w heth er o r not the a utho rs fee l a g i\ cn tec hniqu e is a pp ropriate for an ent ry- leve l or post-pro fess io na l student and w hether hi gh or low ve loc it y is recomme nded, each tec hnique page incl udes two boxes in th e upper ri g ht corne r.
nexllo Ihe lechnique lille (sec Ihe illuslra lion below for fun her delai l). Exa mples
Key
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EL = Entry-level PP = Post-professional
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HV = This technique is appropriate for high velocity LV = This technique is appropriate for low velocity 12' = This technique is not recommended for this student group/population
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I Chapter I : Inlroducing T5M
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Background TranslalOric Spinal Manipulation (TSM) consists of a series of high and low velocity manipulative spina l techniques do, eloped by Olar Evjenth PT, OMT in collaboration wi th Freddy Kaltenborn PT, OMT or No rway, Each or their careers has spanned over 50 years or clinical practice, Early in their careers as educators and clinicians, Mr, Evjenth and Dr. Kaltenborn realized that there were controversia l issues regarding the safety of certain spinal manipulative techniques. They also noted Ihal many commonly applied manipulati,e techniques failed to consistently decrease pain and restore motion in hYPolllobile spina l segments. Following years of st udy and critica l eva lualioll oftcc hniqu cs used by osteopaths, chiropracto rs and physical therapists they concluded that thesc issues and problems stemmed rrom the lack or spccific app lication of rorces to \ ertebra l segments and from the reliance on large r. angular and principally rotational forces during manipulation. With these issues in mind. they endeavored to develop a method of manipulation that more specifica ll y isolates motion to a single spi nal segment. What they developed is now called '"Translatoric Spinal Manipulation" (TSM) and consists ofa system of manipulative tec hniques which emphasize the use of small amp litude and straight line (Iranslatoric) traction or gl iding impu lses de livered parallel or at a righ t angle LO an individua l vertebral joint or movement segment . To further localize the effects of these lranslatoric techniques. TSM emphasizes the use of either direclmanual stabili za tion or the usc of spinal pre-positioning to restrict the amount or motion occurring al adjace nt spinal segments during the translatoric impulse. Deli\ erillg translatoric impulses (in the foml of disc traction. disc glides, facct traction and facet gl iding) to an individual joilll or spi nal motion segment while using stabiliLation provides th e malllial therapist with a manipulative tool that has a predictable c lrcct in terms of symptom reduction and motion rcstoration with minimal potcntial risk o r patient inj ury.
Joint motion All joint motion is comprised of two types of arthrokinematic motion. joint rolling and glidi ng (aka translation). The dircction and amount of joint rol ling and gliding differs with in and bet\\een joints depending on the specific functional requirements and osseo us configuration of the joint. Changes in the normal proportion of rolling and gliding in the joint due to pathological or age related changes in the joint and its surrounding sofl tissues may lead to excessive ro lling or gliding between joint surraees. Excessive joint gliding is defined as h.lper/llobilil)' and decreased joint gliding is defined as hypomobili~r. I-Iypennobility is managed through phy ical therapy inten entions that assist in restricting motion. such as stabilization exercises, mQ\cmcnt re-education techniques. cervical collars. lum bar braces corsets and taping. Hypo mobility is managed throu gh phys ica l therapy interventions such as manual muscle stretching. fl.lllclionalmassage and low and hi gh velocity TSM.
Table I - R'llin gs of joint motion. th eral)ist I)Crcept ions Ratin g of Joint Motion (6 point sca le)
~lnd
joint end feels
Resista nce Perceived During Testing
Endfeel
6 ~ Unstable
Little force required to move segment. little resistance to movement perceived.
5 = Moderately increased Illotion
Moderately decreased resistancc to spinal Illotion
Least firm, if non-guarded Finn. if significant guard ing present Less firm. soficr and later endrecl
4 = Mildly increased motion
Mildly decreased resistance to passive spinal motion.
Firm and later end feel
3 - Normal Motion
Anticipated resistance. similar in quality LO adjaccnt spina l segment (assuming no regional hype rm obil ity) Mildly increased resistance to spinal Illo tion. Increased force required to move spina l segment
Firm
2 ~ Mildly decreased motion
I - Moderately decreased motion
Moderately increased resistance to spinal mot ion. Moderate force rcquired to move spinal segment
0 - No perccivable motion
Segment resistant to mOlion. even when significant force is used
Firm. endreel pcrccived mildl y earlier in range of motion Finllcr cndfeel percci\ cd modcrntel y earlier in the rangc of motion l'lard endreel perceived immediately upon initiation of passive motion
Translaloric Spinal Manipulation
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I: The di agnos is o f segm ental o r reg io na l s pinal hype r o r hYPOln o bility is deteml ined th roug h the ca re ful ana lys is o f the patient hi story. o bse rva tion of ac ti ve mo ti o ns and passive angul ar and translato ri c motion testing. Fo r exampl e. if a patien t/client: ( I) repo rts that he/she feels wo rse w iLh stati c posi ti o ning o f hi s/her lumba r spine a nd bctter during and fo ll o wing movcment , (2 ) demo nstrates earl y excessi ve mo ti on in the lumbar s pine upon bac kwa rd bending, (3) demo nstrates increa sed lum bar spinal motion upon passive segmental motion testin g and (4) repo rts tenderness upon pa lpation o f the interspino us space at the corres po ndin g s pinal segment(s) th en he/she wo uld be cat ego ri zed as hypennobile in the involved lumbar spinal segmenl (s). T he amo unt o f spinal moti on can be categori zed by the therapi st by using a six point sca le (see Table I). When perfo rming pass ive segme nta l moti o n testing, the therapist will percei ve less res istance to move me nt and a large r range o f avail able motio n in hypermobile spina l segments (assumin g there is no muscle g uarding due to segmenta l irritability). Conversel y, the therapist will percei ve inc reased resistance to movement a nd a dec reased range o f avail able mo tion in hypo mobil c spina l segm ents (i.e. an earl y endfee l). Lastl y, th e therapist may perceive a differe nce in the resistance rell at th e end o r pass ive mo ti on testin g. Abn ormal/ pathological endl'eels ma y be perccived as e ither ( I) less finn , as may be th e case wi th hypermo bil ity, (2) more firm as may be the case w ith hypomo bility o r (3) mo re firm o ve r a regio n o f spina l segments wh en th e patient is using hi s/her mu scles to res ist movement due to pa in o r apprehen sio n.
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Indications and contraindications for TSM In simple and brief temls, TS M is indicated when pati ent/c li ents are di agnosed w ith decreased joint moti o n. T hi s co rrespo nds w ith th e mo ti on ratings of grade 2 and g rade I listed in Table I. Typically. patients ex perienc ing mo ti on res tricti o ns o r a g rad e 2 will de mo nstrate th e qui ckest and best respo nse to TSM . Patients with g rade I moti o n restri cti ons Illa y sti ll respond to tra cti o n TSM s, however, improveme nt in segmental ran ge of moti on typicall y requires a longer time period and lower velocity TSMs in additi o n to mallualmuscle sLretchin g procedures. Factors that the autho rs have found to be associated w ith good manipUl ati ve o ut co mes include: ( I) recent onset o r impaired moti o n. (2) lowe r level o r j oint o r segmenta l irritati on. (3) e ndle els th at are firm a nd a rri ve sli g htl y ea rl y in the passive ran ge o r mo ti on, (4) good pati ent a nd th era pist rappo rt and (5) good co mpli ance w ith selrmanage me nt programs. Facto rs that the auth ors have found to be associated wi th poor manipul ative outcomes inc lude: ( I) co nstant unremittin g pa in, (2) pain that is pulsa tile and wavel ike in q ua lity. (3) pa in that awa ken s th c pati ent from s leep and is unrelated to pos itio n o r changcs in pos ition . (4) pain and assoc iated se nsory di sturban ccs that are ex pe ri enced mo re peripherally than centrall y. (5) pa in that is provo ked by a ll spina l movements, (6) signifi cant ske leta l de ro rmity. (7) poo r response to prior s pinal manipUlati ve interventio n, (8) patients wh o are apprehensive abo ut mov in g th e ir spi ne a nd (9) patient s who a re unwilling! unable to relax e nough during TS M. Additi o na l facto rs assoc iated with poor o utco mes fro m TSM are listed in Table 2.
Table 2 - Reaso ns for poor outcomes with TSM
C Re ~l so n s
Pathological and Structural Related Rea so ns
Therapist Re lated Reasons
Patie nt Related
Inadequate dia gnosti c skill s
Emo ti o na l li abi lity
Connec tive ti ss ue laxity/wea kness
Inadequate experience recogni zi ng and managing s pina l path ology
Psychologica l in vo lvement
Wo rsening o f an inflamm ato ry episode
Re liance o n a positio na l vs. movement re lated diagnos is
Too mu ch pai n in too many d irecti o ns.
Multiple medica l co mo rbidities (e.g. c ircul atory compromise)
In adequate manipul ati ve skill s
Sig nifi ca nt jo int restri cti o n
Sig nifi cant osteophytos is
Casua l use o f manipulation without adequat e phys ical exa minati o n
1-1 istory of Illulti ple manipu lati o ns w ith o nl y transient be nefit.
Centra l cord sig ns Lo ng track signs
Goa ls ofTSM T he ove rall goa l or TSM is the resto rati on o r mo ti on in hypomobi le spina l segments and the reducti on orpai n in symptomati c spina l segments. The exact mec hani sms behind th c e ffect of a ll s pinallllanipulati o n techniques. in cluding TS M. have been di scllssed a mo ngst practiti o ners fo r many yea rs. Pro posed mec han isms include: ( I) mec ha ni cal. (2) ncurolog ic. (3) hydrauli c. (4) c irculalOry and (5) psyc hologiGal. Mechanical e nects inc lude th e breaking o f connective ti ss ue adh es io ns. stretching o f li ga ments a nd joi nt ca psul es and resto rati o n of gliding w ithin fasc ial planes. In additi on. intra-art ic ula r menisco ids that a re trapped or impinged betwee n joint surfaces may be freed. Neuro logical e ffects in clude those e ffects ge nerated by stimul ati o n of the mechano receptor system and inc lude c hanges in resting musc le to ne and pain pe rception. Hyd ra uli c e fTec ts incl ude c hanges in synov ia l fluid distri butio n within the joint as well as synov ia l flu id viscos ity. Circul atory elfec ts in c lud e a reducti o n o f c ircul atory congestion and are postul ated to occ ur second ary to reducti o n in prcssure in the intervert ebral fo ramen and mu scle ti ssues. Psyc hologica l. e ffec ts include th ose that res ult rrom thc pa tient's belief that manipulatio n w ill be e ffecti ve, the ir tru st in th e ph ys ica lthcrapist's compctence and the be nefits associated with human to uch. Whil e th e autho rs do not cla im to have any parti cul arl y un ique insig ht into th e s pec ific mcc hani sm(s) be hind 4
I Chapter I : tntroducing T5M
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the effect of manipu lation. we ha ve see n benefits from TSM that would likely indicate that more than one o f the above mechanism are involved. For example, changes in quality and quantity of overall spinal motion and specific segmenta l function have been seen with TSM s delivered using Kalte nborn 's grade II and II I at both hi gh and low ve locity. For a review
of these grades, see Table 3 below. Logica lly, these movement changes would seem to be related to non-mechanica l effects. While scic ntific theory regarding the proposed efTec ts of manipulation remai n important, our focu s over the past few years has shifted to outcome analysis ofTS M. The author 's pos ition rega rding this researc h is di sc ussed below.
Research in TSM The authors strongly encourage further resea rch into the effectiveness of TSM . A number of case studies a nd case seri es performed at Oakland Uni\ ersily are in various stages of publication. It is the hope of the authors that these studies will providc a fo undation for continued development o f co ntrolled case series and randomi zed controlled tria ls in order to assess the efficacy of TSM in terms o f moti on restora tion and symptom reduction . The authors also recommend that studies in spina l manipulative therapy should not just address manipu lati ng through the sy mptoma tic segment but should also assess the outcomes of joint manipulation of hypo mobile segments that are adjacent to symptomatic hypermobi le segments. Table 3
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Ka ltcnborn 's three trea tm ent gr ades
Defin ed
Grade I
Grade II
Trentm ent Use
A very small traction force used to nullify the normal co mpress ive lorces acting in a joint. No appreciable joint eparation or movement occ urs. No ti ss ue resistance is perceived by the
therapist.
Grade I and II are used to reduce
Movement from grade I to the end o rthe slac k in ti sslles surrounding the joint. Little resistance is percei ved in the beginning of grade II while a great deal of resistance is
pain/sy mptoms and restore qua lity o f motion within the joint.
relt at the end or grade II . A greater amount of motion is relt by the therapist.
Grade II I
Stretching of the ti ssue surroundin g the joint occurs. Little to 110 movement is felt by the practitioner, howeve r a great deal of resistance is perceived.
Grade II I is used to stretch tight structures crossing the joint.
Mechanics ofTSM techniques There are three primary types o fTSM techniques: di sc traction. facet di stra cti on and face t gliding. Disc tractions are app lied at a ri ght ang le to the SU rf~lCC orthe di sc joinl and are intended La un load/decompress the di sc and intervertebral foram en. During disc trac ti on tec hniques, the patient is positioned in his/her actual resting position (the position of greatest co mfort or ymptol11 relief). Irthe patient is mosl comfortabl e with his/her spine in a mid-position, then care is taken to assure the patient's spine ends in a midline position during the TSM . If the th erapist is usi ng a bilateral contact and force 10 ge nerate the spinal traction. the n the patient may start in a mid-posi tion. If
Cervical disc traction example
a unilateral force or contact is being used. the patient will be placed in slight side bending towa rd s th e side o rthe impulse prior to the manipulation. The resultant manipulative fo rce ge nerated during the tec hni que wili return the spinal segment to a mid-position. Facet jo int di strac ti ons are ge nerall y performed with the spinal segment posi ti oned in side bending and rotati on in opposi te directions. These techniques use facet joint co mpression on one side of th e spinal segment to create face t joint distraction on th e other. While the patient's spinal segment is only placed in thi s position for a short time, two factors should be considered. One. th e articulations undergo ing compress ion must tolerate the compressive lorces and two. the position and movement used durin g facet di straction may cause narrowing to occur in the intervertebral lora men.
TrclI1slalOric Spinal Maniplllalion
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Facet joint glide techniques a rc pcrfonncd w ith the sp ina l segment in a coupled position (see Chap ter 2 for a
description of cou pled patterns in the various spinal regions). The TSM impulse is directed parallel to the articular surface durin g facet gliding techn iq ues. Stabilization of adjace nt spinal segments is ac hieved through direct manual contact or through spinal locking (see Chapter 2 for further details).
Cervical facet distraction example
Cervical facet glide example
Ventrally. medially and
A ventral cranial
. . . . . .' V caudally directed impulse
directed impulse on the left.
A dorsal caudal directed impulse on the right
Caudal stabilization
Features of this tex t The technique pages of thi s tex t have been designed to reduce the I11cntalload imposed on th e learne r when studying TSM. The author's recommendation regarding how to best approach the study of these materials is described below. The authors do not recommend that first time learners attempt to read and process all infomlation on each page at the same time. Rather we recommend that the technique and its description boxes be studied first. followed by the other sections as appropriate.
C 2-7-Disc Traction Indication : To improve movement in all directio ns Position: Supine
Start by reading and studying the technique illustration thoroughly. The details needed to understand and perform the technique are integrated into the illustration to eliminate the need for student integration of separate pictures and technique descriptors.
The next section , titled "troubleshooting your technique~, provides the author's insight into common mistakes made by the learner when learning TSM . It is intended to serve as a guide to instructors who are trying to determine the source of a student's error and for students • Ir. . ___ ol ... ...,..,...._ ....... - . . - . _ . . . , . ... ......, ...·~·----,~lF~--~ ~~~~
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I Chapter I : tntroduclng TSM
The last section includes clinical and practical insights of the authors regarding a given technique .
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TSM
Applying TSM
Translatoric thrust tec hnique consists of a series of manipulati ve maneu vers which arc quite complex and prese nt a learning c hallenge to even the Illost experienced c linic ian. The following secti on provides a de tailed description of tec hlliquc parameters such as patient and therapi st positioning. loca li za ti o n of movcmcnt within the s pine and the gene rati o n of speed,
force and appropriate amplitude ofmovcmcnt when performing TSM . Finally, suggestions regarding training arc discussed.
Patient & therapist positioning for TSM As with a ll ph ys ica l examinati o n and trea tment techniques, proper pos itioni ng is essential for bo th the patient and
therapist. When positioning a patient for translatoric manipulation, it is cnlc iai that he/she is comfo rtabl e and able to relax hi s/ her whole body, espec ially the region of the body that wi ll be treated. In addition to selecting a pos ition that pro motes patie nt relaxation, the th erapi st must also consider patient posi ti o ns where th ey are most effective in achieving a s uccess fu l manipU lation. This text inc ludes a number of different pos itio ns the therapist may use to ac hieve the sa me manipulati ve effect. T herapists studying these various positional options are encouraged to practice a ll va riations to ach ieve the sa me cflectiveness regard less of patient position. The therap ist
should always position themselves with : ( I) a stable (wide) base of support, (2) good spinal alignment/position and (3) a relaxed upper body. This will ass ist in the process of correct patient positioning and promote more precise control of the patient's body part during the
Therapist & patient positioning i
i
with his/her spine in good alignment avoiding excessive ventral. dorsal and lateral flexion. To achieve this the patient is positioned dose to the edge of the table, the table is adjusted to an appropriate height and the therapist uses a wide base of support.
manipulative technique.
c c c c c c
c c c
c: c: c
c: c
Finally, the skillful app lication ofTSM requires thc therapist to be in close proxi mity to his!her patient. Regarding th is, the therapist should be aware of all physica l contacts that occur when positioning the patient. These con tacts. in addition to the specific pre-posi tioning, manual sta bilizati o n a nd pre-stressing ofa ve rtebral segment , sho uld at the minimum, be no n-painful and shou ld
c:
also allow the pat iel1l to relax. Patient relaxation is facilitated by providing adequate and skillfu l suppon of all body pans supponed
K:
by th e therapist 's hands. In add ition, th e movement used to posi ti on the pati ent for the translato ri c thrust technique should be preCise and purpose/ul. Therapists should avo id repetitive pre-positioning. The consideratio n of o ur phys ical presence and th e use of precise and purposeful movement enhances patient co nfidence in Ollr ab il iti es as experienced and professional practitioners of manual therapy. Ultimatel y, bo th patient re laxa tion and patient confide nce in o ur abilities will furth er impro ve the o utcome ofTSM.
c: c: Localization of the treatment segment
K: I: C
Localization of the treatm ent segment
G
TSM emphasizes the localized app lication of joint specific and segme nt s pecific manipulat ion. This is achi eved by manua l contacts directly on the joint or segment to be moved. The use of stabi li zat ion techniques such as locking or direct manual stabilizati on of th e adjacent vertebra further enhances treatment specificity. This is in contrast to so me co mm o nl y applied methods of manipulative treatment that lISC contacts w hi ch may be far away from th e intended
I&:
I:
G
treatment segment, such as the pelvis or the head. Typically, these
I&:
techniques are combined w ith larger rotational moti ons th at move mUltiple s pinal segments. These no nspecific rotational techniques not only prod uce multiple cavitati ons in an unpredictable pallem bUlmay also unnecessarily stress weakened and sensit ive oft tissue structures includin g th e facet j oi nt capsules, the intervertcbral di sc and o th er
c: ~
supporti ve segmental liga mentous structures. This is panicularly pro blemati c whcn applied over dege nerative hypermobile segments. Even manipulative tec hniques which use manual co ntacts on adjacent spino us processes but still incorporate the rib cage and pe lvis into th e manipulati ve movemcnt are nOltrul y specifi c techniques and ha ve the po tential to irritate hypcnnobil c spinal segments. For reade rs who are 8
I Chapter 2 : Apptying TSM
L____________~====:::!J
unl.1nu
"lth the con\..
oft
mg r for th'" reader \\ ho \\ Ishes to
fe\
ie\\ the concept. please read the fo llowing section .
Locking: an introduction Locking is a technique used to re (riel intersegmental moti on for the purpose of stabili zing/co nstraining the 110nmampulated \ enebra in the spinal motion segment. The underl ying principle behind locking is that the spinal motion :tegment ha!t a finite amOllnt or motion. \Vhe n Illotion ill one plane is taken up, less mOLi on will be available for movement in the remaining planes. To illustrate this point, try the following: I) With yo ur cervical spine in a mid-positi on, rotate your Comparison of right rotation in neck ( 0 the right being careful not to dorsal or ventral neutral and left side bending flex or sidebend your neck at the sa me time. Note how far yo u can move and how easy it is to move into righ t rotation. 2) Return yo ur neck to the mid-position. 3) Next, s ide bend your neck all the way to th e len. At th e end of your available range of cervical side bending to the len. add rotati on lO the right. No te how far you can
Compare how it feels to rotate from a mid cervical position , to easy it is to rotate from
rotate and how difficult it is to rotate from this s ide bent a left side bent position. position compared to when YOLI started in mid-position. It is much harder to rotate from a full y side bent position then it is from a non-side bent position. This simple example can be tried with a number of combinations of movement. For each combination. th e first cardin al plane motion will decrease when additiona l cardinal plane motions are added prior to performin g the pri ma ry motion. In addit ion to changes in the range of movement available wi th th ese various combinations of movcment, there will also be changes in the ease in which the end of motion is reached by the patient and th e sensc ofstiflness perceived at the end of motion . This endfeel wi ll typically vary from a morc clastic/musc ular end feel to a fiml er or more articular endfcel. How quickly the moti on in the segment will re~l c h its end range and the endfeel pcrceived by the patient and therapist at the end range of move men1 will vary, dependin g on how many and in what ord er planes of motion are combined inlhe movemen t segment. Exam ples of two and three plane movement combinations and their typica l endfeels are prov ided in the tab les below. C2- T3 Move ment Side bending and rotati on op posi te Side bending and rotation same Ventral flexion, side bending and rotation oppos ite Ventral fl ex ion. side bending and rotation same Dorsa l flexion , side bending and rotation opposite Dorsal fl ex ion, side bending and rotation same
End ree l Finn Elasti c Firm Elastic Firm Elastic
Move ment C lass ifica ti on Noncou pled Co upled Noncou pled Co upl ed Noncoupled Co upl ed
Move ment Ventral fl exio n. side bendin g and rotation oppos ite Ventral fl ex ion. side bendin g and rotation same Dorsal fl exion, side bending and rotation opposite
Endreol Firm Elastic Elastic Fiml
Move ment CI1Issification Noncou pled Coupl ed Coupl ed
T3-L5
Dorsal fl ex ion. side bending and rotation same
Noncou pled
Translatoric Spinal Manipulation
I
9
c It is impo rtant to remember tha t these movements and spina l coupling patterns are dependent 0 11 the specific anatomical and biomcchanica l characteristics orlhe indi\ idua l spinal mot ion segme nts. Because the a natomy orlile vertebrae (specifica ll y the facet joints) may \ ary between and \\ ithin spinal levels. it is necessary to pay c lose atlen tion to the end feels pcrcci\cd with these dilTerent mo\ement combinations during the pa tient examination. When variations are round. the subseq uent mm'cmenl used to constrain 1110tion must also be modified in order to lock or constrain motion al the segmc nt(s) adjacent to where the TSM will be app lied. For the purposes of this text. movement patterns that produce finn endleels arc c lassified as l1ol1collpled molions. MO\cmcnt pa tt erns \\ hich produce morc clastic endfeels are classified as coupled mOlionf. The finnness or the endfccl associated \\ ith no ncoupled motions is attributed to the interaction of the facet joints and the interconnecti ng ligamentous tissues. Conversely. the e lastic nature or coupled mOl ions is attributed to the lengthening of muscular tissues. Because the combination of spinal segmcnt mO\cments that may be used during locking is extensive. noncouplcd positions. as identified in the table abo\'e. are uscd to illustrate locking in association with TSM \\ ithin this text. Howevcr, il is important to remember Ihat locking can be achic\ed through a numbcr of combinations ofsevcral planes ormation. When using TSM to restore segmental motion. the therapist may either mobilile the cranial or caudal \crtebra. When mobili7ing the caudal \ ertebra. locking may be used to constrain and protect the vertebral segments cranial to the segment or joint being manipulated. This is called locking above. When mobilizing the cranial vcrtebra, locking is used to stabi li ze/constrai n and protect thc vcrtcbra l segments caudal to the segment or joint being manipulated. This is ca ll ed locking belo\\ and is described in further detail in the following two scctions.
Locking th e seg ment(s) above the treatment segment or joint (locking above) When locking is llsed to stabilize, constrain and protecl the \crtebra l segments cranial to lhc segment or joint being ma nipulated it is called locking abo\ e. An example of the use o r locking abo\ e is trans lato ric C5 cen ical facet Joinl traction manipulation. During this technique. in order to traction the right facct joint at lhe CS spinal segment, the supra-adjacent spinal segmen ts. including the C5 spinal segment. are Side bent lell and rotated righ t in cnect locking thcm against lcn rotation. The therapist Ihen applics a translatoric \entral. mcdial and caudal fo rce on the right lamina and superior articular proccss ofC6 c reating a sligh l lell rotation ofC6. In Ihis example. C5 and the scgments above arc restrai ned from turning 10 the left with C6 by their pre-positioning in lell side bending and right rotation. The segments 010\ ing caudal to C6 \\ ill follo\\ into slight len rota tion \\ hi le a lready pre-positioned in lell side bending. This combin ation of len side be nd ing and len ro ta tio n is a co uplcd mo tion. In this situa ti on. segments that end in a coupled position or scgments that are mmed into or tm-.ard a coupled position are refe rred to as III1/ocked.
Locking above (see page 54 for fu rther detai ls rega rding this technique)
c
c r: c I:
I:: I:
r: I::
r: r:
r: r: r:
r: I: Ie
C Ie Ie
Loc kin g the segment(s) below the treatment segme nt or joint (loc king below)
~
When locki ng is used to stabi lize, co nstrai n and protect th e vertebral segments ca uda l to the segmcnt or joint bci ng manipul ated il is call ed locki ng belo \\ . A good exa mple of
IIC
locki ng belm\ is the translatoric C:? facet glide man ipulation. Duri ng thi s tec hn ique. in o rde r to treat the rig ht lacet joi nt at the C2 spinal segment wilh a ventral-crani a l trans lato ric gl ide, th e infra-adjacent spi na l segments a re side ben t righ t and rota ted lell. By ri g ht side bend in g prio r to le n rotaling w hen pos itioning th e loc k, the th era pist compresses the right racet joints and takes lip li gamento us a nd mllsc ular slac k in th e sidebc nt po rti on of lhe spine. This in turn restricts the amount of avai lab le left rotation in the loc ked po rti on or the spine. ex t, the therap i t pass i\ e ly and specificall y side bends the C2 seg ment to the le n to unl ock o nly that segment (C2/3). At thi s pO int. \\ he n C213 is placed in a coupl ed pos itio n (unl oc ked). a sho rt q uick tra nslato ric move me nt is perfo ml ed in H ve ntra l and c rani al directi o n on th e ri g ht lamin a and inferi or art icular process ofC2. 10
I
Chapter 2 : Apply ing T5M
Locking below (see page 57 for further details regarding this technique)
C
c:
Placi ng th e C2 segment, or any ot her spinal segment. in a coupled pos ition (in thi s case len side bending and left rotation) facilitates greater ease of movcment for the scgmcnt during the tran slatoric g liding manipulation . Therefore, segmcntal mo \ ement ofC2 during the impulsc will ge nerate the most effective stretchin g of interseg mental connective tissues while minimi zing articular co mpressio n at the segment.
Testing prior to using lockin g durin g manipulation \Vhile locking may prO\ idc g reate r stabili zat ion than direct manua l stabili zati o n during TSM, there arc timcs when the pre-pos itio ning used durin g a locking maneuver may still cause too much stress across an irritable or hypennobile s pinal segment. To best determine if lockin g \\ ill provoke sig ns and sympto ms in a patient . the therapi st mu st first perform a co mpreh cnsi\c ~I ctive and passive movement examination o n the sec tion of the s pine which w ill be placed in a locked position . Afier the movemc nt examination ha s becn performed and hypermobility ha s not been identified , the therap ist should then pass ively move the section of tile spine to bc locked into a locked position and apply a small amount of overpress ure to determine if the segments are still nonreactive. An example orlhis is when the therapi st is performing a ve ntral crania l glide ofC]: on the ri g ht and they want to usc lock ing belo\\. Ancr the acthe and pass ive movement examination has bee n perfo rmed and hypc rm obilit y ha s no t been identified, the therapi st will co ntact C3 and pass ively position C3 and belo\\ into a locked pos itio n. Thc therap ist monitors the patient's rea cti on to the lockin g through bo th \erba l responses from the patient regarding th e posi ti o nin g and through nonverbal rcsponses s uch as facia l g rimac ing and muscular guarding of the cervical para spinals during the passive pos itioning. Ifhypermobi lity is identified during the move ment exa minati o n or if the patient to lerance to the locking is poor, the therapist shou ld e ither aba ndo n the usc ofl oc king or su pplement the locki ng \\ ith manual stabi li za ti o n. To determine \\ het her the locki ng sho uld be abandoned all together, the therapist must decide if plac ing the segments to\\ ards a locked position \\ ill prevent Ihem from mO\ ing into a position that is further irritating. An exa mple of this is \\ hen a therapist wan ts to imprO\ e ven tral cranial glid ing at C1 and the patienl does nOltoleratc len rotatio n at CS. By posi ti oning C5 i11l0 right ide bending but not rotati ng C5 to the left. the segment is in elTec t partially stabili zed aga inst len rotation bccause movement has been taken up at the scgmcnt. This position is then flu1hcr re inforced through manual stabili /a ti on. When applying a manual stabi liLa ti o n procedure, th e ph ys ica l therapist must co ntinu ously monitor the amount of co ntact pressure he/shc is applying to a patient 's vertebral segment and rel ated soft ti ss ll es. The pressure mu st be e fTecti ve in restrai ning mo vemen t and tolerable lor th c patie nt. Thc the rapi st may use a broader co nt ac t such as the pad o f the thumb as opposed to the tip ofth c thumb to enh ance patient tol era nce. In addi tion. o tht: r port ions of hi s/her hand may be used sim ultaneous ly to further minimi ze cont act pressure points and stabili ze the no n-manipul ated \ ert ebra. Furthennore, the sta bi li L.ation pressure shou ld be app li ed in a graded manner with a li ght relaxed grir> initially. building to a mo re secur~ stabi lization as the slack in the segmen t is taken up. and then reducing back to a light re laxed g rip follo\\ in g the translatoric th rust technique.
T he a mplitude of t he tra nslatol'ic mobiliza tion & impu lse When lIsing 10\\ \ elocity translatoric manipulation. the therapist may usc grade I. 1: or 3 mo\'ements from Kaltenbom's scale. Gradcs I and 1: translatoric movcments are used to relie\ e pain. rcduce joint and neural swelling. reduce muscle gua rd ing and imprO\e the qua lity of 1110\ Cl11c nt in a spinal motion segmc nt or region of motion segments. Grade 3 translatoric motion is used to stretch the intersegmental ti ss ues restricting spi nal segmcnta lmotion. Thcse ti ssues ma y include segmental musclc(s). facet joint caps ular ti ssue and discal ti ss llc. For a more detailed re\ ic\\ o f the three gra des of move ment advocated by the Ka ltenbo rn-E\jenth conce pt, please co nsu lt Kaltenborn's Manu al Mobilization o f the Joi nts Vo lume I or II. In genera l term s. \vheJ1l1sing hi g h ve locity movement th e translatoric impulsc sho uld bc as sho rt as possible. Thc translatoric impulse shou ld be de l i\l,~rcd at the end o r Kaltenborn's grade 2 (whcre the final stop occ urs). In o rder to ge nerate a joint Cin itation and therapeutically streIch joint related restricti ons. the impulse must cross th e final stop. In o rdcr fo r thi s to occ ur. the amplitude ofa TSM may \ary sl igh tl y dependent upon the tec hnique in qucstion. Ot her factors that w ill also play a role in determining th e amplitude ora TSM are dependent on: ( I ) the area of the body being manipulated (e.g. C2 \ entml cran ia l glide \'s. lumbar disc traction \\ ith a bod) drop), (2) the physical allributes (size, strength and body weight) or the therapist and (3) the motor skills (experience and quickness) of the therapist.
Ge nerating speed durin g high veloc ity tra nsla toric ma nipulati on When performing high \elocity TSM. the therapist uses an impulse o r quick. high speed move mcnt to di stract o r glide th e IVD o r facet joints. One challenge encountered by c linicians lea rning this type o f movement intcr.ention is the tendency to gcnera te hi gher amplitude mo \ cments w hen trying to generate a hi g her \elocity movement. To properly protect the joints and seg ments undergoi ng manipulation durin g thi s learning phase. the cl inic ian should reduce the amplitude and at times the fo rce. T hat said. the practi tioner o fTSM must always bear in mind that when s peed and force arc increased the am plitudc of the movemen t must always rcmai n sma ll.
Trans latoric Spinal Manipulation
I 11
There will be so me natural va riations in how s peed is ge nerated when performing TSM to different parts of the sp ine dependent on the T S M technique used. For examp le, when
Generating speed during TSM
a cervical facci traction or glide is performed the impu lse is ge nerated by the shoulder and s ho ulde r gi rdle. In contrast. when
pcrfom1ing a TSM lumbar disc traction technique the impulse may be ge nerated lIsing a body drop. To ge nerate a high s peed move ment , the manipulator must determine how they ca n prepare themselves to move quickly. This is no t an easy task. As mentio ned pre vious ly. a ll ph ys ica l interfaces (manual co ntacts) w ith a patient must convey a se nse
of confidence and relaxation. At the same time. the muscles which will ultimately be used to move the therapist"s hand/arm must be ill a "ready state ." This ready state ca n be best described as an ""active tens io n" in the musc le groups that wi ll power the manipulating han d/a rm . This active tension is an athletic co ncept that a lso needs to be app li ed to the th erapist's lowe r ex trem ities and spi nal alignm ent. Grea ter neuromuscular enort is required to reach a ready state in individuals who have a tend ency towards lower mo lor to ne. poor hand/eye coordinati on and poo r postural sense. Conve rsely. for indi vidua ls with higher motor to ne and better athletic ab ilities it is equally important to relax thei r neuromuscular system prior to delivering a translatoric impulse. Ski llful application ofTSM ca n only be learned through repeated practice and g uidan ce from an ex pe ri e nced and s kill ed TSM practiti o ner. A therapi st interes tcd in deve lo pin g a n advanced leve l of ski ll in the app licati o n of these techniques should creative ly find ways to practice improvi ng the ir motor sk ills in the area of s peed generati on. The therapi st should cont inue to train the mse lves to ge nem te as hig h a ve loci ty move me nt as possible us in g all of the techniques illustratcd w ithin this text.
c: c Lumbar disc traction TSM
Using enough force with TSM: " As little as necessa ry, as much as needed" The force applied during TSM is dependent o n the treatment grade desired (Kaltenborn's grades 1-3) and the deg ree of stiffn ess present within the spina l segment. It is not uncommon to find g reater degrees of joint restriction in cases of adva nced segmenta l degeneration and afler prolonged periods ofsegrne ntalmovement restriction. In these clinica l si tuati o ns, g rea ter fo rce is ty pica ll y req uired to resto re 1110ti o n us ing T S M . If too much fo rce is required , then high veloc it y TSM is not indicated. Rather, low velocity TSM whi ch is under vo liti o nal control orthe patient is used to redu ce th e st iffness to th e po int where a h igh ve locity TSM can be eflect ive. If performing a grade 3 high o r low ve loc ity techn ique. enoug h force mu st be lI sed to crea te joint separa ti o n/tracti on o r g liding. This app lied fo rce ma y vary based upon th e length of time the motion segment has been res tricted, the s tage of degenerative change and resultant co nnec ti ve tissue changes and the physical s ize of th e patient (i.e. more force is typically required to move larger pati ents).
Integratin g TSM into clinical practice As c linicians put these new ly Icamed techniques int o prac tice we would ca uti o n individua ls to pay ca refu l attention to technique se lect ion and the tcrnpora l proximity of the use ofTS M to o ther interventions. Specifically. if the manipulative interventio n is used in combinat ion wi th other tec hn iq ues it may be diffi cult (if not imposs ibl e) to son o ut the specific effects of TSM . Regarding thi s, a clinician will never develop a sense of whi ch TSM technique appears best s uited for certa in cl ini ca l presentations. On the ot her hand , wi th prope r ment ori ng from an experienced TSM practitioner and with increased expe ri ence usi ng the techniques it is possible for the novice to effecti ve ly integra te TSM w ith other therapeutic interventions to o ptimi ze patie nt o utco me from trea tment.
12
I Chapter 2 : Apptying TSM
= = = = = = c: = = E: = c
Prior to appl ying TSM , the clinician may wa nt to use isolated short arc acti ve spi nal movements, hold/relax manua l musc le stretchin g. conve nt ional son tiss ue massage and functi onal massage to reduce muscle tension. TSM should also be fo llowed by movement reeduca tion aimed at co nt ro lling movement at adjacent sympt omati c hype rm obile spinal segme nts a nd encouragi ng isola ted moveme nt at hypomobilc segments that we re recentl y mmlipulated. This general practice ph ilosophy prov ides not onl y good immed ia te results ror pat ients, but is also crucial ror the long term management or ymptomatic hypermobi le segme nts that are adjace nt to hypomobile spinal segment(s). For exa mp le, TS M may be used to improve move ment at th e C7rrl motion segment when there is sympto mati c hypenn obili ty at the CS/C6 and/or C6/C7 spi nal segment s. With improved move ment at C7rr 1 segment (a fter TS M). th e pat ient will potent ially recruit moti on th rough the ce rvicoth oracic j unction and into the upper thoracic region more efTecti ve ly. This will reduce move ment stress at the sym ptomatic hypermobile segments. The pa ti ent wi ll then be instructed in specifi c selr-mobiliza ti on M the C7ff l segment, and the upper thorac ic segments and also instructed in movement reed uca ti on tec hni ques th at Ini nil11i ze moti on through the mi d-cervical region. This comprehensive pla n of ca re is based upon sound orthopedi c biomec hani cs and should serve as a plan for long itudinal management o f sy mptomati c spinal dege nerative c hange or inj ury. Aft er yea rs of clinica l prac ti ce, th e a uthors have obse rved trend s in segmental movement patt erns. These trends include redu ced Illoti on (hYPoI11 obili ty) or illcreased 1110ti on (hyperm obility) in both symptomati c and pre-symptomat ic spinal segme nts. Some or th ese trends a re as ro ll olVs: ( I) dec reased movement at 011, C2/3, C7ff I. TI -8 and L 1-3 and (2) incrcased move mcnt at C4/5. C516, C617, T I2/ L I. L4/5 and L5/S I. Fail ure to recognize and acknow ledge these co mmon motion tendencies leads to ma nipulat ive tec hn iques and spinal exercise programs that are mult i-segmental in nature. These non-specific management stra tegies may inadvertent ly lead to furt her degenera ti ve cha nges in spinal moti on segments th at a re hyperm obile. Because or th is commonl y observed tende ncy, a thorough interventi on plan must include both the identi fication and ma nagement of the pri mary spinallevel(s) in vo lved. as we ll as a care ful exa minati on o f and intervent ion fo r th e surrounding regions of the spi ne that may contribute to sympto ms and im paircd functi on at the primary spinal level(s).
Supportive a nd corrective inter vention techniqu es used in conjunction with TSM Additiona l As pects of Interve ntion: Implementati on of intervclltion for a patie nt with orthoped ic spinal pathology and assoc iated move me nt impairments requ ires a comprehensive exa mination and on en a multi-faceted plan fo r inte rvention. Typica ll y, th e auth ors blend man y d iffere nt fo rms o f interventi on. In additi on to TS M tec hniques, our approac h will consist o f: S uppo r ti ve biomechanical ~,d v i ce regardin g: Moti on segment(s) protecti on through movement reeducation techniques includin g co rrect use o f spinal moti on cou pl ing and restri cted or substitute forms of joint movement in ord er to minimi ze 1110ti on th rough symptomati c hy pennobi Ie segments. Contro ll ing vert ica l loading th rough sy mptomatic load sensiti ve moti on segme nts th ro ugh th e instruction of variolls and multi ple fonns of spinal self- traction. Instructio n in spin al muscle trainin g exercises: Postura l and movement patt ern instructi on that emph asizes correct use or the deep cervical ve ntra l Hexor muscles and pelvic/hip pos itioning and moveme nt pa tte rns that fac ilitate th e co rrec t use o f the deep lumbar ex te nsor muscles and abdominal muscles. Spinal iso met ri c and spinal sho rt arc iso toni c move me nt panern s that trai n the deep spi na l stabi lizer musc les without ca using signifi ca nt or pat hologica l segmental translation. Spinal stabili zat ion training that inco rpora tes the use of equipment th at support s th e trun k, unloads th e trunk a nd trai ns pati ents in non-sy mptomati c spina l positions. Self LV TSM exercises : A combi nati on of specific active a nd passive segmental movement exe rcise presc ribed to ma intai n a nd e nh am:c segme ntal mot ion after a sessio n of manua l interve nt ion.
Soft t issue interve nti on: Functi onal massage tech ni ques whi ch incorporate ge ntl e repetiti ve and pa in free pass ive or acti ve assisted spinal moti on whil e at the sa me tim e providi ng a co mfortab le massagi ng of the spinal muscle . Hold-re lax spi na lmusde stretching whic h provides a means to relax, wa rm up , stretch and train spinal muscles.
Translatoric Spinal Manipulation
I 13
C linical conditions, ex amin ation findin gs a nd co mm on sequ encing of TSM techniq ues The following sectio n inc ludes several brief but comlllon case scenarios illustra ting the selection and sequencing
or low velocity (LV) and high velocity (HV) TSM techniques. This section will on ly include TSM intervention recol11mendations. The techniques are listed with the 111 0St cranial segmcnt(s) listed at the top oreach table progressi ng to the most caudal spinal segment(s) listed at the bottom. This is not intended to imply an order in which the techniques shou ld be perfo rmed, rather it is seq uenced to faci lit ate the reade r in tracking and comparing the tec hniques listed und er the intervention tab le and lh e reassessment tabl e. The tec hniques listed are intended to serve onl y as exam ples.
110 t
as a prescription for the
practice or TSM . Th e dosi ng ora ny physical therapy intervention, includ ing TSM , requires careful consideration of the benefits and ri sks assoc iated wi th the intervention. The benefits of adept app lica tio n ofTSM include th e immediate improvement of segmental movement and reduction of sy mptoms fo r the patient. The risks of improper or overly aggressive applications of TSM incl ude worse ning o f th e patient's sym pto ms and reduct io n of segmenta l movement fo llow ing its application. Because
TSM techniques are short and quick linear passive movements, they arc extremely sare whe n app lied skiII rully to a spina l joint or motion segment and rarely result in exacerbation of symptoms. That said, even the most skilled a nd experienced practitiOller of these techniq ues ca nn ot completely guara ntee that certa in patients wil l not experience minor or brief flares of his/her sy mpto ms. Regarding this, there a re historical fea tures and examina tion findings that can assist a c linician in detcmlining who
mayor may not react favorably to HV TSM. These historical rcatures and examination findings include: (I) the historical time line or the patient's condition. (1) the reactivity or the patient's symptoms to movement and loading. (3) the degree ofstifTness and the e ndfce l present in the restricted segments and (4) any comorbidi ti es thaI may slow recovery or may be exacerbated by certain treatment selections and dosages. This infonnation is then e\aluated in order to estimate the changeability of the patient's condition. The changeabi lit y or lack thereof is factored into the formation ofshon and long term goa ls and the selection of intervention s trategies for th e patient. While th ere are no hard and last rules for th e opt ima l nlll11ber oftota ltcchnique app li cat io ns and the optimal num ber of techniques used per treatment session the authors ha\ c observed the following. Patients who have impainncnts that are more resistant to change require morc technique variations and oftcn repeated app lication of 'a rio us LV and HV TSM tcchniques in order to receive optima l benefit. In many cases, multiplc repetitions of the same TSM technique may be applied within the same treatment session \\ ithoUI negative erTect. Patient s who experience first time Illotion rcstrictions may show significant improvcment with only a single application ofTSM.
To determine the elTect or both LV and HV TSM intel"\ention, the therapist should frequently retest movement
==
=
= = = = ;; = = ;: =
= = =
;:
&:;
quantity and passive segmcn ta lmotion. T he movements used to retest movement after the application ofTSM are identical
C
to the motions used during TSM, varying only in the speed in which they arc appl ied (lor further detail consult Kaltenborn's A1cmual A10bili=aliol1 oflhe JOiI1IS. Volume II. The Spine). When improvement with one TSM technique diminishes. or if the
C
therapist wa nts to stretc h a dilTcrent joint or tissue within the same segment, the therapist may change TSM techniques and wo rk o n ot her pa ilS of the struClU res potentially restricting motion. During thi s multi-grade, multi-speed and multi-technique treatment session. the therapist shou ld dialogue with the patient to determine the location and intensity of the stretching sensa tion he or she feels. Occasionally. a patient \\ ill experience soft tissue discomfon during the application of prolonged
grade III LV TSM. Often, this is the same patient
\I
ho will respond belter to I-IV TSM. With HV techniques. there is no
prolonged soli tissue contacL. So reness that lasts morc th an a le\\ minutes following stre tchi ng may indicate that too much stretching has been performed. Practitioncrs ofTSM should engage his/her patient in an honest. opcn discussion regarding their physical therapy diagnosis and prognosis fo ll owing the physical examination. The therapist should discuss the intcrvclllion options available and the course or action the therapist feels would be the most beneficial. Fina ll y. lhe therapist and patient should arri\c at a mutual decision regarding the course of action or intef\ention "hich will be taken within physical therap). While thc therapist may not be able to predict with 100% accuracy how an indi\ idual patient ma) respond to a gi\'cn intcn ention. by using co ntinuolls exp loratio n of the techniques and technique parameters pro\ idcd within this text it is possible to build a
knowledge base orhow patients genera ll y respond to TSM. This knowledge may then be used as a starting point lor the application ofTSM and may be adjusted as necessary to match the needs or indi, idua l patients. Lastly. therapists should a\oid making any unrealistic claims regarding the \alue or any ghen intervcntion technique(s) and shou ld especia ll y avoid any "fix it" language. This is especially true when providing manual imen-enllon for comll1o n degenerative orthopedic spinal conditions. In thesc cases and e\en in cases where th ere is no significant radiological evidence of degcnerative spinal disease. the best therapeutic management requires thc establishment of long tenn
relationship between the patient and an orthopedic manual physical therapist. Thi not only benefits the patient who can call upon " hi s/her thera pist'· when he/s h ~ experiences a sy mpto mat ic Illoti o n loss in the ce rvica l. thoracic or lumba r sp ine but the therapi st benefits by seeing how s pinal motion and certain s pinal co nditi ons tend to c ha nge ove r th e years.
14
I Chapter 2 : Apptylng TSM
&:;
I:: I:: ~
I:: I:: ~
C
II: ~
Case I C6 nerve root irritation with segmental hypomobility (Grade 2) at C2/3 and C7rrl. Sequeuciug o/TSMtecimique(sl Grade
Tl!chnlque
I.
2.
3.
Bt Bt et
Facet distraction
III
Veloclly
Treatmen t Segment(s)
LV ipsilateral progressing to II V
C2/3 segment
contralateral gapping
Disc traction
II
LV
C5/6 segme nt
Ventral icranial
III
LV progressing to HV
C7ffl segment
dorsal 'c3udal facet glide
Sele!'1 examination techniques applied 10 C!1'a/llale ,he reslIll.\' q(rSA J il11en'elllioH Spinal Lc\ci(s)
Examination Tcchlliquc(s)
I.
C2/3
Passi \ c facet distraction testing
")
CS,6
"Doorbell and specific Spurling's test applied to reassess th e irritubility or the C6 ne"e roo\.
3.
C7ffl
Ventral cranial (VC)/dorsal caudal (DC) facet g lide testin g
ote(s)
• The Doorbell test is an examination procedure \\ here palpatory pressure is applied to the ventral primary ramus as it lies in the cen ieal nene root g utter. The specific Spu rlin g's test inco rporales the passive tra nslation ora s uperi or facet in the movement segme nt into th e cen ical inten c rt ebra l forame n. Both examination procedures are used to assess the provocability of the s pinal nerve undergo in g co mpress io n.
Translatoric Spinal Maniplllation
I 15
Ie Case 2 C4/5 and C5/6 symptomatic segmental hypermobility (Grade 5) with segmental hypomobility (Grade 2) at CO/ I, C2/3 and TI-T4.
Ie
Sequencing oj TSM reclmique(s)
Ie
Technique
I.
2.
, Et
3. ~
Traction
Grade
Velocity
Trea tment Segment(s)
III
LV progressing to HV
COli
Ie
Ie Ie
I: IC Facet distraction
III
LV ipsilateral progressing to HV co ntralateral gapp ing
C213 segment
I:
I: I: Ie Bilateral fa ce t distraction
III
LV progressing to HV
T 1-4 segments
~
I: I: I:
4.
Ce rvical move ment reeducat ion and stabilizati on trainin g for C4/S, CS/6.
I: I:
Select examination techniques applied to evaluate the results oj TSM imen'el1liOI1
I:
Spina l Level(s)
Exa minati on Techni quc(s)
I.
COi l
Joint play and pass ive coupled rotation testing
I:
2.
C2/3
Passive facet distraction testing
I:
3.
C4-C6
Joint play testing and re-examinati on of symptom localization· testing for these spinal levels.
I:
4.
TI-4
Joint play testing
s:
I: Note(s) • Symptom localizati on testing is a comprehensive series of clinica l examination movements used to difTcrcntiate whether symptoms are originating from different regions, segments or structures in the spine. For further details consu lt Evjenth and Gloeck 's The Symptom Locali:atiol1 in the Spine and the Extremity JoilJl available from OPTP at www.OPTP.com.
I:
s:
Ie IC
11=
16
I Chapter 2 : Apptying T5M
Case 3 Generalized grade I hypo mobility at all cervical motion segments Sequencing o/TSM lechniqlle(s)
Grade Velocity
Treatment Segment(s)
Traction & disc traction
III
LV progressing to I-I V
COli, C2/3, C3/4 and C7IT I segments
Ventral/cranial dorsa llcaudal facet glide
III
LV progressing to HV
COli. C2/3. C3/4 and C7fT l segments
Facel di straction
III
LV progressing to HV
COli, C2/3. C3/4 and C7fT I segments
Technique I.
2.
3.
~
et Et
Select exomil1C1liol1lecilniqlles applied fO el'o/ual e the results oj TSM inlen'el1liol1 Spi nal Lc\cl(s)
I.
2.
011
C2/3, C3/4,
71T1 3.
Cervica l Spine
EX3mi naiion Tcchnique(s) Traction joint play testing and passive coupled Illation testing Translatoric joint play testing, passive segmental side bending testing, passive segmental coupled motion testi ng and passive segmenta l facet distraction testing CROM measurements pre- and
POSI
intervention
Note(s)
I. 2. 3. 4.
For further info mlation regarding passhe moti on testin g in th e cervical spine consult Kaltenborn's flvfclI1l1ol Alfobili:alion of lite ) oil1ls. Volume II. The Spine. In the case of grade I restrictions. facet distraction and gl iding LV TSMs are often performed with the patient in a seated position to allow the therapist's chest and lower extremities to con tribute to the manipulating force . Facet distraction is app lied unilaterall y in the cervical spine. Irboth sides are restricted the technique is app lied to both sides. one at a time. Grade I restrictions are tre.:1ted with LV TSMs until move ment is improved to a grade 2 and then HV TSMs may be used to further restore motion.
Translatoric Spinal Manipulation
I 17
I: Case 4 A painful block of left cervical rotation with a recent onset.
I:
Seqllencing ojTSM tec!l/Jiqlle(s)
C
Technique I.
2.
3.
Bt st et
Disc Traction
Grade Velocity II -III !-IV
Treatment Segment(s)
I: C
r:: Facet distracti on
III
LV progressing to !-IV
Involved segment(s)
I: C
r: C Ventral/ cran ial
III
LV progressing to !-IV
Involved segment(s)
dorsal/caudal facet glide
Select eramil1nfiol1 techniques applied 10 eva/lillIe (he reslIlls a/T5M il1len'ellliol1 I.
I:
Involved segmcnt (s)
Spina l Le, el(s)
Exam ination Tcchniquc(s)
Involved spinal segments
Joint play testing and fe-examination ofsymptorn loca lizati on· testin g for these spinal levels prc- and post treatment.
c r:
c c Ii: C
C 2.
Cervica l Spine
CROM measurements taken pre- and post intervention
Nole(s) 1.
Left rotation can be limited due to either restri cted ventral cranial gliding or the ri ght facet of restricted dorsa l caudal
2.
gliding of the len facel. If the motion is limited due to restricted do rsal ca udal gliding of the len lacet it may be treated wih face t joint distraction !-IV TSM with the ccrvica l spine placcd in ri ght side bending and slight left rotation. If le ft rotation is still lacking and the patient 's cervical spi ne shows no sign of increased irritation. then ventral/cranial facet joint glide HV TSM can be
applicd to the caudal vertebra of the involved segment with the cervica l spine placed in dorsal flexion, left side bending and len ro tation. Applying a ventral cranial glide to the superior art icular surface of th e caudal vertebra while stabili zing th e cranial vertebra generates a relati ve dorsa l cauda l glide of the len facet in th e treatment segment .
r:
c c r: r::
c Ii: C C ~
i:I ~
~ 18
I
Chapler 2: Apptying TSM
&;:
Case 5 Right sided upper cer vical pain with referral of discomfort to th e right posterior aspect of the head and grade 2 motion restriction at COI l and C 2/3. Sequencing oj'TSM feclll1ique(s)
Grade
Ve locity
Treatment Segment(s)
Traction
III
HV
COi l
Ve ntral/cra nia l dorsal/ca uda l face t glide
III
1-1 V
C2/3 segment
Technique
I.
2.
, et
Select eraminCllion leclmiqlles applied 10 eva/lime lite results ofTSM inten'enliOI1 Spinal LeI el(s)
Examination Tcchnique(s)
I.
COli
Traction joint play testi ng, passhc coupled motion tes ting and rec heck of symptom loca li zati on testing for COli
2.
C2/3
Tra nslato ri c joint play testin g. pass ive segmcma l side bend in g testing, pass ive segmental coup led moti o n testin g and pass ive segment al face t di stracti o n testin g and rechec k o f sympt om loca li:U1ti on tes ting for C2/3
'ote(,) 1. Pass ive upper cervical ro tation testing invo lves manu al stab il ization of th e ca udal vertebra o rth e seg ment being tested, e ither COi l or C 1/2. T he exa mincr genera tes passive rotati on with sidebc nd ing in the opposite dircction. Q uantity o f move ment. qu alit y of move ment and endfeel are evaluated. 2. Pass ive upper ce rvica l coupl ed rotation testing and symp tom loca lizati on testing may a lso be performed at C I /2 th ough th is segmcnt is rarely restric ted give n its inherent ca psular an d ostcological fea tu res.
Translaloric Spinal Manip ulation
I 19
C ase 6 Mid-thoracic pain, decreased active ROM and grade I hypomobility at the T4-8 spi nal segments. Seqllencing o/ TSM lecllll iqlle(s) Technique
I.
~ ~
2.
Disc tractio n
Grade
Velocity
Treatment Segment(s)
III
LV progress ing to HV
T4-8 seg ment s
2.
I: Bilatera l facet di straction
II osc ill ati o ns, p rogressi ng to susta in ed g rade II, progressing to sustained g rade III
LV progress ing to HV
T4-8 segments
Exami nation Techniquc(s)
T4-8
Trans lato ri c j o int pl ay testing. pass ive segmenta l ex tens ion testing and rec heck o f sy mpto m loca li zati o n testing fo r T4-8
Mo vement quantifi catio n us ing tape mea sure tec hniques or doubl e inc linom eters (universal goni o mcters) be lo re and at the co nclus io n o f eac h intervention.
Nole(s) I.
C C
C C
Spinal Leve l(s)
Th o rac ic Spine
c c c C
Select examination techniques applied 10 eva/uol e the results ofTSM intervention I.
r::: r:::
The autho rs co mmo nl y tes t pass ive segmenta l ex tension in the tho racic spine w ith the pati ent pos iti oned in sidc ly ing. For funh cr deta i Is co nsult Kaltenbo rn 's Mallllal Mobili=alion o/Ihe Joinls, Volllllle II, The Spine.
C
C C C
-=C C
-=I: I:
c:
I:
20
I
Chapter 2 :
Applying TSM
Case 7 Mid-thoracic pain that wraps around th e rib cage with loss of segmental motion at the same level(s) as the referred pain pattern . Sequencing oj TSM teclll1ique(s) Grade
VeiocilY
Disc traction
III
LV progressing
10
HV
Involved segmenl (s)
Bilaleral facel
II osci ll ati ons progressing to grade III
LV progressing
10
HV
Involved segmenl(s)
II osci ll ations progressing to grade III
LV
Techniqu e
I.
2.
.Ii.".
3.
distraction
Costotransverse
rr::
distracti on
Treatment Segment(s)
Invo lved segmenl(s)
SeleCI examination techniques applied 10 evaluate the resulls ojTSM il1len'entiol1 Spinal Leve l(s)
Examinalion Technique(s)
I.
Mid-I horacic (in vo lved segmenls)
Mid-t horacic joint play tesling. manual co mpression and lraclion tesling. recheck o f symptom loca liza ti on testing for mid-tho rac ic.
2.
Rib joints adjacent to invo lved spinal
Rib distra cti o n joint pla y testin g and sy mpto m loca li zation testing or the rib joints.
regIon
Note(s) I. Rib di s tracti on jo int play tes tin g ca n be performed in a number of examination pos itions. For fu rth er deta ils cons ult Kaltenbom's Manllal Mobili:otion ojthe )oil1ls. Volullle II. The Spine. 2. For details regarding sympto m localiza ti o n for the rib arti culat ions, refe r to Symptom Locali::atiol1 il1 the Spine and £rtl'emity Joil1ls by Evje nth a nd Gloeck.
Trallslatoric Spinal Manipulation
I 21
Case 8 Lower lumbar ner ve irritation with segmental motion restrictions from L 1-3_ Seql/ellcillg of TSM techniql/e(s)
Technique I.
2.
Grade
Ve locity
Treatment Segmcnt(s)
~
Side bending
III
HV
L 1-3 segments
~
Disc traction
II
LV progress in g to HV
L4/5 & L5/S 1 segments
Select examination techniques applied (a evaluate (he results ofTSM il11er vel1li0l1 Spinal Level(s)
Examination Technique(s)
I.
LI-3
Translatoric joint play testing and segmenta l side bendin g testing.
2.
L4-5
Translatoric joint play testing and sciatic nerve tension testing and bowstring testing to monitor th e results of LV and HV tracti on TSM.
No te(s) I. Lumbar disc traction LV TS M applied to the L4/5 L5/S I segments if nerve bowstrin g testin g is consis tent with a very irritated nerve root. Progression to HV lumbar di sc tracti on T SM ifn erve bowstring signs show mild irritation. Self
2.
22
management with lumbar disc self traction techniques. Lumbar joint play and pass ive side bending is often exa min ed wi th the patient in a side-ly ing pos ition. Fo r fu rt her deta ils consult Ka ltenbom 's Malll/al Mobilizatioll of the Joillts. Voll/Ille II. The Spille.
I Chapter 2 " Apptying 15M
Case 9 Sy mptomatic grade 4 hypermobility at L4/S with concurrent grade 2 hypomobility at LS/Sl. Sequencing of TSM rec/lI1iql/e(s) Technique l.
l3
2.
3.
~
Grade
Veloci ty
Trea tm ent Segment(s)
Bilateral facet distraction
III
LV
L5/S I segment '
Ventral cranial and dorsal caudal facet g lides
III
LV
L5/S I segmen t"
LUlTIbo-pclvic move ment reeducation and stabil iza tion training.
SeleCI e raminotiolilechlliques applied 10 e\'o/UGle the results oj TSM inlerl'el1fion l.
Spinal Level(s)
Exami nation Technique(s)
L5/S 1
Translatoric j oint play testing and passive segmental flexion and ex tension testing.
Note(s)
* To protect the L4/5 hypermobility. a firm lowe I ro ll or cufTweight is placed anterior 10 the L3-5 ve rtebrae. th en a wedge is used to press the sacrum ventrally. " VC gliding of the L5 segment ca n be achieved by ha\ ing th e L5 vertebra positioned at the edge of th e table and the pel vis and legs dangling. ex t, the sacrum is manipulated in a caudal and slightly ventral direction . During dorsal caudal gliding of the L5 segment, a cufTweight is placed anterior to th e L3-5 ve rtebrae and the base of the sacrum is manipulated in a ven tral crania l direction .
Translatoric Spinal Manipulation
I 23
Case 10 Acute onset of right lumbo-sacral pain with a slight antalgic posture (left lateral list). Sequencing of TS M rechniql/e(s)
Grade
Ve loc ity
Treatment Segment(s)
~
Disc tracti on
II
HV
Involved segment(s)*
~
Side bending
II progressing to grade III
LV
Involved segment(s)*
Technique I.
2.
Selecl examination techniques applied 10 eWlluate the results ofTSM intervention I.
Spi nal Level(s)
Exa mination Tcchniquc(s)
L5/S 1
Le ft sciatic bowstring test monitored while in right side lying and L5/S I joint play assessed preand post HV TSM. Antalgie posture re-evaluated rollowing BV TSM
Notc(s)
* During these techniques the patient is placed in ri ght side-lying with the len latera l list supported (i.e. patie nt in hislher actual resting posit ion). •• In cases ofac ul c lum bo-sacral pa in. it is onen be neficial to combine ho ld-relax a nd func ti o nal massage w ith TSM.
Developing skill with T SM Developing a high level orsk ill in the app lication orTSM req uires detailed and accurate instruction. continua l feed back, years of psychomotor refi nement and a refl ecti ve prac tice pattern. Th is tex t and companion DVD are designed to act as instructional/learn ing aids to facilitate in this developmenl. Ifyo ll are interested in learnin g more abou t TSM. th e author's encourage yo u to contact o ne of four estab lished U.S. res idency/ fe ll ows hip programs whi ch s pec ia li ze in th e instructio n of TS M: Oak land Uni vers ity in Roc hester, Michiga n, T he Institute of Manual T herJpy in Boston. Massach usclIs.
Folsom Physical Thera py and Training Center in Folsom. Ca li ro rn ia and The Inst itute or Re hab il itation and Tra ini ng in Pra ttville. Alabama. Non-US res idents may contact Lasse Thlle, the presiden t or K-E International, at lasse-th@:onl ine. no ror inrormation regarding TSM based courses olre red worl dwide.
24
I
Chapter 2 :
Applying TSM
Cervical Spine u@©lffi D1J 0C9J (ill@
The Upper Cervical Spine The upper cervical spine (consisting of the Occipital-Atlantal (OA) and Atlanto-Axial (AA) joints) presents with unique anatomical and biomechanical characteristics that require additional consideration for the manual therapist. In addition to their unique joint structure and lack of intervertebral discs, these segments also encompass the spinal cord, brain stem, meninges and vertebral arteries. The particularly large amount of rotation available at the AAjoint in combination with the angular path of the vertebral arteries between occiput-atlas-axis places additional stress on these important vascular structures at end-range upper cervical rotation. The following section will present a concise review of upper cervical anatomical and biomechanical characteristics followed by a detailed explanation of the translatoric thrust techniques used in the management of upper cervical movement impairments.
Articular surfaces of the upper cervical spine
Osseous anatomy The occipital bone (occiput) is the inferior portion of the skull. The occiput articulates with the first cervical vertebra through two condyles located on either side of the foramen magnum (a large opening in the base ofthe occiput through which the medulla oblongata, spinal cord, vertebral arteries and meninges pass). The occipital condyles are convex in all directions, face inferiorly and laterally and converge anteriorly. The atlas (CI) is a ring shaped vertebra that unlike typical vertebrae has no vertebral body, spinous process or intervertebral disc. Two lateral masses constitute the principal bony structure on the anterolateral aspects of C I. On each side of C 1, the lateral mass gives rise to the superior and inferior articular facets. The superior facets typically present as a concave elongated oval. They are longer in an anterior-posterior direction and their direction of orientation is superior and medial. The inferior facets are oriented in an inferior and medial direction. Typically, and based on cartilaginous thickness, these facets will be slightly convex. The axis (C2) is a unique vertebra in several regards. First, it presents with a large superior projection from its vertebral body called the odontoid or dens process. This process acts as the vertebral body for C 1. Second, the superior articular facets of C2 have the more typical upper cervical orientation whereas the inferior articular facets of C2 show a typical lower cervical facet joint orientation. Similar to the remaining lower cervical vertebrae, C2 also possesses a spinous process. The C2 spinous process is large, projects straight backward and is in line with the lamina and inferior articular facet.
Upper cervical articulations The OAjoint is the articulation formed between the convex occipital condyles and the superior articular surfaces of atlas. These joints are surrounded by a fairly thick capsule that encloses the synovial membrane for this articulation. OA is a plane synovial joint or enarthrosis with three degrees of freedom. The principal movements are ventral and dorsal flexion with a total range of motion of 13-25°. Smaller amounts of side bending and rotation also occur at this joint. The AAjoint is comprised offour distinct articulations which form a central AAjoint and two lateral AAjoints. The central AAjoint is comprised of two articulations, the atlanto-dental joint and the transversedental joint. The atlanto-dental joint is formed between the posterior aspect of the anterior arch of atlas and the anterior aspect of the dens. The transverse-dental joint is the fibrocartilagenous joint formed between the posterior aspect of the dens and the transverse ligament. The anterior aspect of the dens process has a convex facet that corresponds to an oval 26
I
Chapter 3 :
--= --= --= --= --= --= --= --= --= --= --= C
--=
]I:
11:
s: 11: OA joint articulations
C
s:
s: c
s: s: s:
-= -= -= -=
Cervical Spine Application
•
facet on the posterior aspect of the anterior arch of at las. The posterior aspect o f the dens contains a groove which articu lates with the transverse ligament. The lateral AAj oint comprises the two art icu lations fonned between the infe rior arti cular surfaces of at las and the superi or articular surfaces of axis. The articular sur faces of C I are slightly convex and face inferiorly and medially. The superior artic ular surface ofC2 faces superiorl y and laterally. The capsular liga ments of the two lateral facet joints are thin and loose allowing betwee n 35-45° of transverse plane rotation.
Ligamentous anatomy There are a numbe r of supportive ligaments in the upper cervi cal reg ion, some of which are continuations of their lower ce rvical counterparts. These ligaments include the tectorial membrane, anterior atlanto-occipital membrane, posterior atlanto-occipital me mbrane, anterior atlanta-axial membrane and posteri or atlanto-axial membrane. All assist in conveying a dcgree of stability to this rcgion. Becallse there are no discs at OA and AA, stability of these joints is primaril y supported by ligaments. Criti cal to the maintenance of upper cervica l stability is the transverse portion of the cruciate ligament (transverse ligame nt) and alar li gament. These stabili zing structures are unique to the upper cervical region and will be the focus of th e remainder of this section . The transverse ligament and upper The tran sve rse liga ment is the primary ligamentous cervical flexion constraint to excessive ventral flexion at the at lanto-axial j oint. This li gament is a strong and thi ck band (7-8 mm thick in its central portion). It attaches to the tubercles on the lateral masses of the atlas, articulating with a groove on the posteri or portion of the dens. Togethe r with the anterior arch of at las, the transverse ligament form s an osteoligamentous ring arou nd the dens preventing anterior translation of the atl as on the axis. An intact and healthy transverse ligam ent wi ll a llow less tha n 3 mm of separation between the anterior arch of atlas during ventral fle xion of the neck. In children, 5mm of separation is considered within normal limits. The alar ligament is an important ligamentous connection between C2 and the occiput. It is a strong cord- like ligamentous structure di vided into two bands. These bands run from the superior and posterol ate ral aspect of the dens trave ling in a superior, ve ntral and lateral direction to the ir eventual attachment on the medial aspect of the occipital condyles. In a mid or neutral cervical spine position, thi s li game nt is ta ut. The alar li gaments (I) limit rotation and side bending of the occiput and (2) limit distraction of the OA and AAjo ints. According to White and Panjabi, th ere is a re ported 30% increase in rotation of th e head when the opposite alar li gament has been cut. Clinically. if th ere is greater th an 56° of AA rotati on or greater than go of OA rotation, significant instability of The vertebral artery and upper cervical the upper cervical region should be suspected. Laxi ty in the alar or transverse ligament has important rotation implications for two primary structures, the spinal cord/b rain stem and the vertebral artery. Specifi cally, if the transverse ligament is lax or weakened du e to injury, pathology or other abn ormal physical stresses, the dens may move relati ve ly dorsall y pressing on the spinal cord/brain stem as a result of ventral translation of C I on C2. This may cause serious neurological compromise. This movement abnormality is generally more pronounced with ventral flexion of the upper cervical spine or when lying su pine without support under C2 . As mentioned pre viously, lax ity in the alar ligament may allow excessive rotation between occiput, atl as and ax is which in tum may ca use excessive tensile stress, lumen compromise or intima l wa ll damage to the vertebral artery. To understand this it is important to re vie w the anatomy o f the vertebral artery whi ch will be presented in the next section.
Vascular anatomy The ve rtebral arteries are a maj or source of blood suppl y to the cervical spine and spinal cord. The arteri es arise from the subclavian arteries as the fi rst and largest branches. They enter
Note the acute angulation the right VA during left rotation at the AA joint.
Translatoric Spinal Manipulation
I 27
the transverse foramen of the cervical spine at C6 ascending from transverse foramen to transverse foramen before entering the foramen magnum. At the level ofC2, the vertebral arteries course laterally to enter the transverse foramen ofCl. They then angle posteriorly passing over the posterior arch of atlas , through the posterior atlanto-occiptal membrane and continue
cranially through the foramen magnum where they anastomose forming the basilar artery. Of particular importance regarding the path of the vertebral artery in the upper cervical spine is its lateral angulation/orientation between the transverse foramen of axis and atlas, and its sharp posterior angulation after it exits the transverse foramen of atlas. It is at this third segment of the artery, between atlas and axis , where anatomical injury may occur secondary to excessive rotational cervical movement. Note the illustration on the previous page.
Kinematics The OAjoint
Direction of joint rolling and gliding occuring during OA ventral and dorsal flexion
The osteokinematic movements observable at the OA
joint include ventral and dorsal flexion (nodding ofthe head), small amounts of side bending or tilting of the head and small amounts of rotation. The arthrokinematics of the OAjoint follow
Ventral Flexion
Kaltenborn's convex rule. Accordingly, the occipital condyles
glide posteriorly on the superior facets of C I during ventral flexion and anteriorly during dorsal flexion. During these movements, the
posterior arch of atlas and the occiput will separate during ventral flexion and approximate during dorsal flexion (see illustration at
the right). Side bending at the OAjoint also follow Kaltenborn's convex rule where the occipital condyle will glide in a direction
opposite side bending (e.g. with right side bending the right occipital condyle will glide medially and the left occipital condyle will glide laterally). The instantaneous axis of rotation for lateral flexion of the occiput is 2-3 cm above the apex of the dens process. Small amounts of rotation have been described at the the OA joint which also follow Kaltenbom' s concave-convex rule. During right rotation a small amount of dorsal gliding will occur at the right OAjoint, and a small amount of ventral gliding will occur at the left OAjoint. Rotation at the OAjoint occurs around a vertical axis located in the dens process ofC2 when both joints are gliding
Dorsal Flexion
normally. The AAjoint The greatest observable movement between atlas and axis occurs during rotation (35-45°). This comprises approximately 50% of the rotation occurring in the cervical spine as a whole. In addition to rotation, the atlas also moves into ventral and dorsal
x-ray. A small amount of side bending (2_4°), described as a lateral shift of the atlas on the axis, has been observed by several authors. Some clinicians, including the authors of this text, feel that any amount of "lateral shifting" ofCI on C2 may be indicative ofup-
Upper cervical dorsal and ventral flexion radiograph
-= -= -= -= -= -=
-= -= -= -= -= -=II: -=
-= -=
•
II:
If
arch of atlas slides superiorly and inferiorly respectively along the
I
IE:
II:
and articular function , during rotation the atlas rotates around the dens. During right rotation , the right articular surface glides posteriorly and the left articular surface glides anteriorly. During dorsal and ventral flexion , the posterior surface of the anterior anterior edge of the dens. As discussed in the previous section, the amount of anterior translation of th e articular surfaces of atlas on axis is largely determined and restricted by the transverse ligament. During dorsal flexion at AA, posterior movement of the atlas is blocked by the dens process. During upper cervical dorsal flexion, the amount of superior sliding and perhaps the amount of subtle 28 Chapter 3 : Cervical Spine Application
IE: IE:
II:
distance between the posterior arch of atlas and the spinous process of axis during ventral and dorsal flexion viewed on a lateral
The arthrokinematics of the AAjoint are the most complex of all the spinal segments. Assuming normal joint shape
IE:
-=
flexion (10-20°). This is evident by an increase or decrease in the
per cervical ligament laxity.
-=IE:
Note the change in space between the base of the occiput, the posterior arch of atlas and the spinous process of C2 during upper cervical dorsal and ventral flexion.
•
If
•
ventral or dorsal movement of atlas on axis is in part detennined by the shape (banana vs. straight) and orientation (superiorventral , superior-dorsal or superior) of the dens. During side bending, the degree of side-to-side translation of the atlas on the axis is limited by the shape of the atlas and the fixed connection occurring between the axis and occiput via the alar ligament (sec illustration). The C2-3 vertebral segment While not classically considered a part of the upper cervical spine, movement at the C2-3 segment and below will influence the amount of mati on occurring in the upper cervical spine, particularly in the coupled motions of side bending and rotation. This is due to the alar ligament's attachments between occiput and axis combined with the articulations between occiput-atlas-axis as prev iously described. This connection is readily apparent when passively testing side bending in the upper cervical spine. When the occiput is side bent to the right, immediate movement of the spinous process of axis to the left may be palpated. It is hypothesized that right side bending of the occiput pulls the dens into right rotation (principally via the left alar ligament). If C2 is unable to rotate to the right then side bending orthe occiput to the right will be hindered. Because of this osteoligamentous connection between the C2 movement segment and the occiput, it is important to examine the coupled side bending and rotation movements at the C2/3 segment as well as the coupled side bending and rotation movements at the COi l segment. Restriction of coupled rotation at either of these two segments will cause a resultant motion loss at the other segment. This type (direction) of motion loss can be easily mistaken for rotational motion loss at the C 1/2 segment if clinicians are not fully trained in specific passive motion examination techniques for all three segmental levels.
AA arthrokinematics Right Rotation
Side Bending
During right side bending. the left alar ligament prevents separation of the dens from the occiput. As the atlas translates towards the right its wedge-like shape will allow only a small amount of movement before the atlas is "wedged" between the occiput and axis.
Testing and treatment implications of AA uniarticular restrictions Non-restricted rotation
axis of movement for an unrestricted AA joint runs longitudinally through the dens process of C2. Note the lack of proximity of the dens and the anterior arch of atlas . Also note the space available cord and
Forced rotation and uniarticular restrictions
Wh e n one articulation between atlas and axis is restricted, the axis rotation is displaced to the restricted joint. If the testing or tre atment procedure involve s a forceful ventral force on the side opposite the restriction , greater stress will be placed on the transverse ligament. This may lead to its compromise and subseque ntially may cause compression of the spinal cord and meninges.
Translatoric Spinal Manipulation
I 29
Translatoric manipulation of the upper cervical Spine Because of the intimate relationship between occiput-atlas-axis and the unique neuro logical, arti cular, ligamentous and vascular structu res associated with this region of the spine, only certain short amplitude techn iq ues are recommended. At the OAjoint, low velocity and high velocity manipulations are performed in three translatori c directions: ( I) join t tracti on (separation), (2) OAj oint ventral gliding and (3) OA joint dorsal gliding. At the AAjoint, low velocity mobilizations are only perfo rmed by a dorsal gliding of C I on C2 and rotational manipulatio n is avo ided all together. This is due to the ri sks assoc iated wit h anatomica l injury to the vertebral artery, alar ligament and transverse ligament (see illustration). At the C1I2 level, translatoric traction manipulation is the manual
treatment of choice for the rarely observed AA joint rotational restrictions.
Selecting a contact for OA traction To create a tracti on of one of the OAjoints, a contact point on the occiput must be selected that is both easy to palpate and facilitates controlled movement at the OA joint during the manipulati on. There are two possible contact points on the occiput, the mastoid process laterall y and the base ofthe occiput posteri orly. The posterior contact on the occiput is typica ll y easier to identify and access, while the lateral contact to the mastoid process is more difficult to access. However, it is more difficult to minimize unwanted flex ion occurring from a posterior contact on the occiput, then it is to minimize unwanted side bending that may occur wi th a mastoid contact. Therefore, to generate the purest trac lion between occiput and aUas, the mastoid contact is the contact of choice desc ribed in th is tex t. To counter any unwanted side bending that may occur between occiput and atlas during the manipulation, the OA jo int is positioned in slight side bending towards the mani pulating hand prior to the manipulation (see illustration below). Lastly, the tip of the mastoid process may be sensiti ve to contact during the technique. To minimize any patient discomfort the therapist should refrain from holding Movements that occur at OA based on bony contact his/her manipulating hand too tense against the mastoid process and pull some of the skin and ~ ~ underl ying soft tissues over the mastoid process 1 2 '-----------, Flexion -13-25· ROM Side Bending - 3-S· ROM when positioning the contact hand for the impulse. _ 1... _ _ _ _ _ _ _ _ _ _ _- ' The combination of th ese two measures, in addition to the inherent brevity of an impulse, makes the mastoid process an excellent contact for this technique.
Avoiding excessive side bending at OA
To avoid excessive right side bending when impulsing the left mastoid process, the therapist positions the occiput in slight left side bending prior to the impulse. The impulse will move the occiput towards the midline position while at the same time tractioning the left OA joint. 30
I Chapter 3 : Cervical Spine Application
----=
---= ---= ---= ---=
--= .c -I:
--=
-= --=
.c
-=c c s:
-= -= -= -= -= -= -= -= -= -= -=
~
EL - I2J PP -HV
OA-Traction
Indication: To improve movement in all directions (Right OA Joint) Position: Side-lying
Slack between occiput and is taken up cranially by the i left hand and chest prior to delivering the impulse.
Troubleshooting your technique: One cardinal sign that too much slack is being taken up by the manipulating hand is di scomfort on the masto id process prior to the impulse. Furthermore, taking up too much slack with the manipulating hand may cause increased tension throughout the manipulating upper extremity whi ch can "slow down" the speed of the impulse. If th e amplitude of the impulse is too large, the manipulating hand may slide ove r the mastoid process durin g th e technique resultin g in an ineffecti ve and potentia lly uncomfortable manipu lati on. Fai lure to support the head aga inst the th erapist's chest may result in un wanted flexion of the OA joint during the manipulation.
Note(s) During this manipulation the lower cervical spine remains in a neutral or slightly extended position. The author's have found both th e side-lying and supine OA traction techniques to be helpful in reducing symptoms assoc iated with cervicogenic headache.
Translatoric Spinal Manipulation
I 31
OA-Traction
EL -0 PP -HV
Indication: To improve movement in all directions (Right OA Joint) Position : Supine
;;;;;-~;;; is positioned the patient's head, and right shoulder. therapist's left hand and are positioned behind patient's head and against left side of the patient's
Slack between occiput and atlas is taken up cranially by the therapist's left hand and chest prior to delivering the impulse .
with the index and middle cu pped around the ~ 0,,1;001'< chin .
Troubleshooting your technique: Fai lure to correctl y locate the mastoid process w ith the manipulatin g hand is a COl11mOIl error. Th e manipul atin g hand shou ld be pos iti oned laterall y under the ma stoid (not pos teri o r and medial under the base of the occ iput ). O ne ca rdinal s ign that too much slack is being taken up by the manipulatin g hand is di sco mfort o n the masto id process pri or to the impul se. If the amplitude of the im pul se is too large, the manipulat ing hand m ay s lide over th e masto id process during the technique resultin g in an ineffecti ve and potenti a ll y un co m fortab le manipul at io n. Failure to support the head aga in st th e th erapi st's chest may res ult in excess ive sid e bend ing motion of the OA jo int during the manipulation. Nole(s) In so me cases, the th erapi st mu st s li ghtly fl ex th e patient ' s lowe r ce rvica l spine in orde r to ga in access to the mastoid process pri or to pos iti oning the O A joint for the TSM.
32
I
Chapter 3 :
Cervical Spine Application
• • •
EL--:-[v -
OA-Traction
l
Indication: To improve movement in all directions (Left OA Joint) Position: Seated
The therapist's fight hand holds around the left side of the patient's head with the fifth finger positioned under the occiput. The head is supported against the therapist's chest. After the left and right hands are in contact with the patient, slack is taken up by the thentpist applying (1) a gentle cranial force with their right hand and chest and (2) a caudal and slightly ventral stabilizing force on the posterior arch of atlas with their left hand.
The therapist stands in front of and to the right of the
patient. The therapist's left hand contacts the posterior arch atlas.
Troubleshooting your technique: Fai lure to provide an equal impulse from the chest and hanclmay resu lt in a side bending movemen t at OA during th e manipu la ti on. [fthe am plitude of the impulse is too la rge, motion ma y be felt lower in th e ce rvical spine durin g Ihe manipulation. Discom fort may be felt by the patient if the therapist squeezes the atlas an d/or occ iput w ith too much force during thi s techn ique. Nole(s)
While it is difficult to stabilize the at [as, th e use ofa short amp litude mo ve ment and th e caudal stab ilizing force wil! help to minimi ze the amount of movement occ urr ing at AA and below. In clinical practice, it is common to blend var ious interven tion te ch niques . TSM, translatoric mobilization and fun cti onal massage ca n be read il y applied in the seated position. This is true when treating throughout the ce rvical sp1l1e.
Tt"anslaloric Spinal Manipulation
I 33
I: OA glide techniques While OA tracti on TSMs are exce ll ent treatment techniques, there are times when they are not sufficientl y effective in restoring ventral o r dorsal gliding of the occ iput. In these instances, a more iso lated approach that is directed speci fi ca lly at restoring ventral and dorsal gliding movement may be necessary. When using TSM to restore ventral fle xion, the therapist may e ither perforo, a dorsal g lide of the occiput or a ve ntral glide o f the atlas. Performing a dorsal glide of the occiput in supine is a particularl y good technique because it ca n be easily combined with PN F hold-relax stretching techniques to treat both OA glide restrictions and subocc ipital muscle tightness. The seated technique may be easil y combined w ith functional
massage wh ich may help relax the suboccipitals. In additi on, the seated position is parti cularly useful beca use cervical moti on can be measured usi ng a CROM immediately preceding and following treatment wit hout changing the patient 's position. It is the experience of the authors that the OAjoint is less commonly restricted in dorsal flexion , however, in cases of advanced arthrosis or prolonged immobilization it may be necessary to use TSM to restore this motion. Because it is easier to stab ili ze the occiput, this technique is performed by gliding the atlas dorsally to create a re lative ventra l gl ide of the occiput. To achieve the greatest movement of atlas in a dorsal direction, the therapist must contact the anteri or portion of the transverse process ofatla5. Because there are a number of sensiti ve soft tissue structures located in thi s area, precise in structions o n how best to contact atlas are in clu ded on the technique page.
Direction of gliding used to improve OA vental and dorsal gliding
Dorsal Flexion
Ventral Flexion
34
I
Chapter 3 :
Cervical Spine Application
C
C
EL - LV PP-LV
Occiput-Dorsal
Indication: To improve left rotation and flexion (Left OA Joint) Position: Supine The therapist stands facing the top of the patient's head. Slack between occiput and atlas is taken up in the direction of the sta bilization hand. The left OA joint is mobilized by the combination of a dorsally applied mobilization force applied by the therapist's right shou lder while th e atlas is simultaneously stabilized by the therapist's left __ hand. --L.-
The therapist's right hand is placed posteriorly under the patient's occiput. The therapist's right shoulder is pos itioned anteriorly on the patient's forehead superior to the patient's right
eye.
The patient's occiput is pos itioned in ventral flexion , slight right side bend ing and slight left rotation. The therapist maintains this position by gently pulling cranially on the posterior aspect of the occiput with their right hand while pressing caudally on the forehead shoulder. their i
The therapist's left hand co ntacts the posterior su riace of the left transverse process and posterior arch of atlas with the MCP and radial border of their
The therapist's hand is positioned with the thumb exte nd ed and the fingers "stacked " over each other. This position provides support for the index finger and the hand.
Trou bles hootin g yo u r tec hni q ue: Co mpre ss io n throu gh the top of th e pat ient's head s hou ld be avoid ed during this tec hniqu e. Pressure over th e o rb it, temple o r bridge or the nose shou ld be avoided durin g thi s tec hni que. Fai lure to properly pos it io n the occiput durin g thi s technique may lead to a poo r ly loca lized and pote ntiall y ille fTective tec hn iqu e. Note(s) Th is technique is predo m inantly used as a mobi li zat ion tec hniqu e. W hilc an impu lse is not nccess ari ly contraindi ca ted , it is di ffi c ult to de live r an e ffe cti ve impul se in thi s pos itio n. See the "A tla s vent ra l" tec hniqu e o n th e nex t page fa r a more e Oecti ve manipu lat ive tech niqu e to improve dorsal gl iding o f th e O Ajo int. This tec hniqu e as illustrated is a unilateral technique . It may al so be performed as a bi lateral technique. To perfo rm thi s as a bilateral technique, the sta bi lizati o n hand is moved to the midline poste riorl y, the therap ist' s s ho ulder co ntac t is mo ved to the midd le ort he fore head, th e occipu t is pos itio ned in ventra l fl ex io n (minus the side bendi ng a nd rotati o n) and th e mobil izati o n force is directed purel y pos teriorly.
Translatoric Spinal Manipulation
I 35
Atlas-Ventral
EL - LV __ PP - HV_& LV
Indication: To improve right rotation and flexion (Right OA Joint) Position: Seated
II: II:
.: II: II: II:
After the left forearm and right hand are in contact with the patient. slack is taken up by the therapist applying (1) a gentle dorsal and medial force with their left forearm and (2) a ventral force on the right side of the posterior arch of atlas with their right hand .
II:
The therapist stands behind and to the left of the patient.
II:
The therapist's left forearm is placed against the left side of the
-=
The therapist's left hand rests gently on the patient's head, avoiding any cervical compression.
The therapist contacts the posterior surface of the right transverse process and posterior arch of atlas with the radial border of their right hand's 2nd MCP.
Tro ubl es hooting yo ur tec hnique: T he stab il izing force and impu lse occ ur in an equal and oppos ite d irec tion. Fai lure to provide adequate stab ili zati o n aga inst the mid-portion o rth e face andlor an impulse w ith an amplitud e that is too large may res ult in upper ce rv ical dorsa l fle x ion d ur in g the manipu lat ion. Prcss ure app li ed on the top or lhe head or agai nst the eye may res ult in discomfort for the pat icnt and should be avo ided. Nole(s) Th is tec hniqu e is one n effec ti ve at restori ng co upled rotat ion at the OAjoints. Translatoric mobi lization and fUll cli ona ll11assage are eas ily int egrat ed into a comprehensive sess ion of manua l intervention to th e upper cervical region.
36
I
Chapter 3 :
Cervica l Spine A pp licati on «
EL - 121
Atlas-Dorsal
PP - HV & LV
Indication : To improve right rotation (Left OA Joint) Posit i on: Supine
therapist maintains this position by gently holding the patient's head against the table and between their left hand and right
The therapist stands with their right thigh positioned against the right side of the patient's head. The therapist's right hand presses in the direction of the anterior surface of the transverse process of the patient's atlas.
therapist's left hand is placed against the left
' - _AlIt...--t side of the patient's head above the ear.
Tt'oublesho oti ng yo ur tec hni que: To maximi ze pat ien t comfort durin g thi s technique, the contact on at las should be spread out ove r the therapist 's hypothenar em inence. In add ition , th e hand delivering th e impulse shou ld be re laxed prior to the man ipulati on. If the contact is too firm or the pressure is directed too medial , the pati ent may experience discomfort when the slack is taken up prior to the impulse. To position the righ t ha nd 0 11 the atlas for this tech nique, the therapi st shou ld sta rt wit h their right hand 0 11 the son tissues sligh tly anteri or to the lett transve rse process of atlas . The tissues are then slacke ned by pulling mcdia ll y being ca reful not to slide over the skin. The therapi st th en presses in the directio n of the anterior surlnL'c of th e transverse process of atlas until a firm stop is felt. Failure to slacke n the skin or position th e hand medial enou gh may cause discomfort and may lead to the ha nd sliding off the tra nsve rse process. Note(s)
Positioning the patient's occiput on th e edge of the table and the therapi st's ri ght thigh on th e side ortlle head will provide addi tional stabili zation of the occiput. This is a very specific man ual technique that will ass ist in the restoration of dorsifl ex ion and coupled rotat ion between occiput and alias. The therapist should va ry the direction and amount of side bending and rOlation betwee n occiput and at las when testing and treat ing using this techn ique. When treating a joint with a greater amount of restriction, th e the rapis l should treat in the position where the greatest amount ofmovelllcnl is felt during testing.
Translatoric Spinal Manipulation
I 37
Selecting a contact for AA traction Obtaining a good contact o n Atlas to generate a traction of one of the AAjoints req uires th e therapist to have both
Contacting Atlas
II::
exce llent paJpatory skill s and a sense for fine moveme nt. This is in part why the AA traction techn iq ues are recommended onl y for
I::
th e post-professional stud ent. To contact the atlas , the therapist wi ll sli gh tl y side bend th e AA j o int away from the si de of co ntac t and rotate the atlas towards the manipulating hand. Rotating the atlas towa rds the manipul atin g hand moves the posterior arch of at las dorsa lly allowing th e therapist to ach ie ve a better co ntac t. In addition,
_I::
th e manipulating hand will press the axis slightl y ven tral to maintain atlanta-denta l contact and to provide for co ntact of the manipulatin g hand under the inferior edge of th e posterior arch of atlas. Thi s positioning is performed after the the rapi st has contacted the patient with both hand s and is a very sm all motion.
Frequency ofAA manipulation After many years of treating patient' s w ith upper cerv ical movement impairment s, it is the opinion of the autho rs of this text that the AA joint is less co mmonl y restricted th an Illan y pra ct iti oners of manual th erapy think. We attribute the cont inu ed mobility of the AAjoint to its articular configuration and li gam entous anatomy. If the CI /2 (AA) segmen t is clinica ll y d ia gno sed as hy pomobil e and joint restrictions are also found at COi l e~A) and e2/3, we reco mmend that th e two segments immediately above and below C 112 be loose ned first. As di sc llssed in the opening to thi s chapter, given the li gamentous connection between the occiput and e2, once the COil and/or e2/3 segments are loosened, movement at C I 12 ca n ofte n be felt. If after the cranial and/o r caudal res tri ction s are addressed and the AA joint is still believed to be restri cted, then the traction techniques which follow offer a safe and effecti ve method of restorin g AAjoint moveme nt.
38
I
Chapter 3 .-
Cervical Spine Application
II::
Rotating atlas to the left exposes the poste rior edge of the transverse process and posterior arch of atlas.
AA-Traction
EL-0
PP - HV
Indication : To improve movement in all directions (R i ght AA Joint) Position: Side-ly i ng
The rad ial border of therapist's right index finger contacts the inferior edge of the patient's transverse process and posterior arch of atlas . The dorsal surface of the therapist's right index finger contacts the lamina and transverse process of C2.
Slack between atlas and axis is taken up cranially by the therapist's lett hand and chest prio r to delivering the Im~)UIS,e.
The therapist is positioned behind the patient's head , neck and upper thoracic spine . The therapist's left hand and forearm are positioned under the left side of the patient's head with the index and middle fingers cupped around the ' chin.
Troubles hooting yo u r tec hni que: Ifille amplitude o r lhc im pul se is too large. the manipu lating han d may s lide cranially result ing in di scomfort and/ or a poor ly local ized and less effective impulse. Failure to s uppo rt the hea d against the thera pist's c hest ma y result in a poorl y controlled mo vc me nt of the head during the manipu lat io n. Note(s)
By pos iti o nin g in ri g ht rota ti on, the ri g ht poste rior arch and tran svc rse process o f the Atlas is moved do rsa lly al low ing bettcr contact ro r the manipu la ting hand. The dorsa l s urfa ce of til e index finger o f the manipu lating hand co nta cts the posterio r lateral lam ina o f C2. By press in g s lig htly ve ntra l prior to the manipulation and by directin g the imp ulse cra ni a lly and sl ightl y ve ntrally, the odontoid is pressed agai nst the anterior arch of at las th e reby pro tecting the trans ve rse ligame nt. Using a co upl ed pos it ion at the AA leve l wi ll assi st at taking up the s lac k in the upper cervical reg ion wh il e at the same time placi ng mi nima l tens il e stress 0 11 the upper ce rv ica l ligaments.
Translaloric Spinal Manipulalion
I 39
-= II:
AA-Traction Indication: To improve movement in all directions (Right AA Joint) Position: Supine
II:
II: II:
II:
-=II: The therapist's right hand contacts the inferior edge of the patient's transverse process and posterior
II:
-=II: -= -=
arch of atlas.
~ ~
-=Ie therapist's Jeft hand and are positioned behind patient's head and against left side of the patient's with the index and mi ddle cupped arou nd the l o" tio,n!'s ch in.
Ie Ie Ie Ie
Troubleshoo ting your tec hnique: If th e amp litude orl he impulse is too large, th e ma nip ulating hand may slide crani all y res ultin g in discomlo rt and/ o r a poo rl y loca lized and less effective impu lse. Failure to suppo rt th e hea d agai nst the thera pist 's ches t may res ult in a poorl y co ntro ll ed move ment of the hea d during the manipu lat ion. Note(s) By posi tio ning in right rOlation, th e rig ht poste ri or arc h and tra nsverse process of th e atlas is movcd dorsa ll y all ow ing better co ntact for th e mani pu lat ing hand. T he do rsa l s ur face of the index fin ge r 0 11 the man ipu latin g hand co nt acts the pos terio r latera l lam ina orC2. By press ing sli g ht ly ve ntra l prior to th e manipu lation and by direc tin g th e impulse cran iall y and sli g htl y ve ntra ll y. the odo nto id is pressed aga inst the ant eri or arch of at las th ereby protect ing th e tra nsverse ligamen t. In thi s posi tion to ga in access to the transve rse process and poste rior arc h of atlas. the th erap ist must sli ght ly tlex the patient's lower cervica l spine.
40
I
Chapter 3 :
Cervica l Spine Appli cation
-=
Ie
IC
-=
T he Lower Cer vical Spine The lower cervical (Lie) spine works in conjunction with th e upper cervical (U/C ) spine to pos ition the head in space . Together th e two rotat ional cou pling patterns of th e U/C and LIe spine maintain the eyes on a level plane and allow fo r a field of vision through a range of almost 180 degrees in th e hori zo nta l plane.
Osseous anato my The lower cervical spine in c lude s the C2 throu gh C7 spina l segments. Simi lar to the thorac ic and lumbar region, a lowe r ce rvica l ve rtebra co nsists oftwo fundamenta l parts, an anterio r vertebral bod y a nd a posterior vertebra l arch. The body of a lower ce rvica l vertebra is cy lindrica ll y sha ped, co nvex anteriorly and flatt ened posteriorl y. The superior surface is concave and th e inferior surfa ce is slightl y co ncave in the anteri or-posterio r d irection and slightl y convex tra nsve rsely. One of til e n10s t un ique charac teristics of tb e LlC vertebra l bod y are the uncinate processes. These processes ari se from th e upper posterolateral borde rs of each ve rt ebra l body. The uncinate processes are co ncave transve rse ly and co nvex anteropos teriorl y. Thcy are directed up wa rd towa rd a conca ve groo ve in the lateral marg in o f the inferior surface of the ve nebral body above. At th is int ersecti on, each process or uncus forms ajo int ca lled th e un covc rtebral j oint. Thi sjoint is unique to th e ce rvical
Articular surfaces of the lower cervical spine
SpIllC.
The ve l1ebral arch is form ed by the pedicles and laminae. The pedi cles are two short, th ick processes, which proj ect posterolaterall y and are attached to the superior pal1 of the vertebral bod y on each side. Co ntinuing from each of the pedicles, laminae are angled posteromedi all y to enclose a large tri ang ular ve rtebral foram en. The ve rtebral foramen is bounded by lam inae posteri orl y, th e pedicles la tcrall y and thc ve rteb ra l body anteriorl y. The vertebral foramen is th e largest in the ce rvica l region measuri ng approximately 17 111m in the sagitta l direct ion and 18-20111111 transve rse ly. Coll ec ti ve ly, the ve rtebral foramina form the ve rtebral ca nal wh ich houses the thickest part or the spinal co rd measurin g approximate ly 8- I 0 mm in diamete r. The laminae o f th e ve rtebral arch are broad, fl at plates of bo ne that ex tcnd posteromediall y and slightly interiorl y. La minae ty pica ll y ove rl ap from one leve l to th c nex t and, as mentioned above, form th e posterior wall ort he vertebral foramen. In co mpariso n to th e rest of the ce rvical spine, th e lami nae of' C2 are thicker than at lower levels. The laminae co me together in the midline to form the spinous process. The spinous process is a si ng le process tha t projects posteri orl y and inferi orl y from eac h ve l1ebral arch at the junction of th e laminae. The spinolls processes of C3 to C6 are short and bifid whil e the spinous process of C7 is long and rou nd ed at its end point. The ce rvica l ve rtebral arch has man y projections, including four m1icula r (the superior and interior facets bilaterall y) and th ree non-al1 icul ar processes. The three non-a rti cular processes include th e two transverse processes (TPs) and one spinolls process. The TPs arise from the juncti on of th e ped icles and th e vertebra l body. Together the TPs divide th e arch into an terior and posteri or portions. The TPs of C3-C7 are bifid and proj ec t laterall y and slightl y anteriorly endin g in all anteri or and a posterior tubercle. Together. the anterior and posterior tubercle form th e co ncave spinal nerve sulcus, whi ch provides a "gutter" for the anterior primary ramus. In addit ion, the lo wer ce rvical spine may be distin guished fro m th e lumbar and thoracic spines by th e prese nce or all ova l shaped foramen in eac h of the TPs called the foral11e n tra nsvc rsari ul11 . The fo ramen tra nsve rsariulll is di rected supe riorl y and infe riorl y and ex ists for the ve rtebra l al1eries and veins to co urse throu gh . The vertebra l artery en ters the transverse fo ram en of the sixt h ce rvica l vertebra. These transverse fo ramina are vert icall y al igned from C3 through C7 but are more laterally placed at C I and C2 . Concave shaped sections of bone on the superior and inferior POl1 iOI1 of eac h pedi cle are known as interve rtebral notches. \Vhen the LlC vertebrae are articulated, these two notches (pedicles) form the roof and floor of th e in terve rtebral forame n (I VF) th rough whic h spi na l ncrves and blood vessels co ursc. The IVF is a small ca nal approximately 4 111111 in lengt h that is directed anteriorly and inferiorly. It is ovoid in shape with a ve rti ca l diameter of approx imately 10 Illlll in height and a hori zo ntal diameter ofapproximate[y 5 mill . Adjace nt art icu lar processes, in particular the anteri or aspect of th e superior art icular process, form the postero latera l wa ll of the ce rvical IVF. The posterolateral portion of th e ve rtebral
Translatoric Spinal Manipulation
I 41
bodies and th e un coverteb ra l joi nts rorm the a ntero latera l wa ll of the cerv icall VF. A rthrit ic hypert ro ph y of the structures that co nstit ute the ce rvicall VF playa ro le inlh e deve lopmen t of ne rve root comp ress ioll and irritatioll .
Lower cervical articulations There are five arti culations in the lower cerv ical spine: o ne interve rteb ra l d isc ( IVO)joint , two uncoverteb ral jo ints an d two race t Lower cervical articulations jo ints. In the lower cerv ical sp ine, the re are six IVDs. Duri ng bendin g moveme nt s, the IY O fac ilitates and res tra ins moti on betwee n th e cervica l vertebral segments. Further, th e cervica l IVDs dis tribu te we ig ht over a large r surrace area. In o th er words, wi thout th e IY O, we ig ht wo uld be co ncentrated ecce nt rica ll y on th e vertebral edge, toward th e direct ion th e sp ine is be nt. Thus, th e dcfo rma bility of the cc rvica ll V O all ows distributi o n of forces over a grea ter sur face a rea . The amoun t o r movement poss ible for a parti c ul ar region o r the spi ne is large ly determ ined by the rat io o r disc he ight and th e correspo nding ve rtebra l bodi es of a segment. In th e cerv ical spine, th is ratio o f disc thickness to vert ebra l bod y heigh t is 2 to 5. T he cerv ica ll YDs are approx imate ly 5mm th ick and a re considered to be the th innest of a ll th e in te rverte bral d iscs. The somew hat saddl e-shaped IVOs are res po nsible fo r the cervica l lordos is in that th e ante ri o r as pec t of the ce rvica l I V O is th icker than the posterior aspect. The nu clea r porti on of the ce rvica l disc is pos itio ned more ant eri o rl y than in any other port io n o rthe spine. T he cervica ll VDs are innervated fro m a vari ety of so urce s. Posteriorl y, the IV Os are inn erva ted fro m branches ofa posteri or lo ngitud inal plex us that is deri ved fro m the cervical sinu vertebral ne rves. Ant er iorly, th e IV Ds are in ne rvated by a sim ilar plex us de ri ved l1'o m the ce rvica l sy mpa thet ic trunk s and the verteb ra l nerves. Latera ll y, the discs receive pene trating branches from the vertebra l nerve. Nerve fibers penetrate at least the outer 1/3 and up to th e oute r 1/2 of the an nulu s fib rosus of the cervica l d iscs. The ce rvica l arti cu lar processes ari se from th e j uncti o n of the pedicles and l a mil~ ae .. Tl~ e l.·e are two superior art icula r p ro~esses tl.,at project superio rl y a n~ ve ~l t r~ l1 y a lld two inferi ? r pro cesses th at projec t Il1l en orl y and do rsa ll y. At the end o f" the artlCll1 ar process, a fl at s urface IS formed ca ll ed th e face!. Eac h face t fo rm s a joint wit h an adj ace nt ve rt ebra and is ca ll ed a facet j oi nt o r zygapo physea l j oi nt. These jo ints are class ifi ed as pl anar diarthrodial joints a nd li e in an obl ique fro nta l pl ane at approxi mately 45 degrees to the lo ng ax is of the spine. T he superio r Hlcets of the infra-adj acen t ve rtebra in a segment arc posit ioncd in front of (a nt erior to) the in ferior facet of the supra-adjacent vertebra. T he arti cul ar surface ofa super ior facet faces do rsa ll y an d crania ll y whil e the artic ul ar surface of a n infe ri or facet faces ve nt ra ll y and ca udally. A practi ti o ner of translatoric manipU lat ion !TI ust be ab le to see the se an atomi ca l rclationships in order to ful ly un de rstand the biomecha ni cs oftra nslato ri c facet joi nt glid in g and trac tion tec hniq ues. The facet join t's ca psula r li ga ment s are att ached just beyond th e margi ns of the adj acent a l1i c ular processes of the t~l cet joints. T hese caps ul ar li gament s arc oriented approx i ma te ly perpendi cu lar to th e plane of the face t j oi nts. Studies by Panj abi have fo und that these ligame nt s arc o rie nt ed posteriorly at approx imately 45 degrees to the tra nsverse plane in the lower cerv ica l spi ne. T hey are longe r and less taut in the ce rvica l reg ion as co mpared to the lum bar and thorac ic regio ns. T he capsul a r liga ments provide stab il ity in the lower cerv ical spine during fl ex io n and are onc or the princ ipa l stru ct ures stretched during translato ri c face t joi nt gli di ng and face t join t di strac tion tec hni ques. In additio n to th e facet jo int art ic ulatio ns, each typica l cervica l vertebral body has two uncovc rtebra l joi nt s. A lth o ugh a sy novial me mbrane has bee n fou nd in th e ul1 cove rt ebral jo in t, the re is some deba te regarding the classificat io n of the joint. The presence o f the di sc a nd fi bro us tissue in the joint lead so me anato mists to be lieve that it is fibro us in nature. As menti o ned ea rli er, th e supe ri o r platea u ora LlC vertebra l body is rai sed on each side in th e sagi tta l pla ne form in g the unc inate process. T he ac tua l ca psul e is located medial to the unc in ate process and latera l to th e disc. The un ci nate processes begin to develop at abo ut 8 years of age and do not fu ll y develop un til approximate ly 18 years or age. The average sizes of the unc inate processes have been in vest igated in many anato mi ca l stu dies. In ge nera l, it has bee n shown that the un cinate processes are higher at C4 to C6 levc ls as co mpared to the C3 o r C7 levels. The ro les of the uncoverteb ra l joints arc bo th to guide co upl ed moti o n and to res trict moti ol1 . T he un covertebra l joints he lp prevent poste ri or tra nslati on and postero latera l disc movement , limi t lateral be ndi ng and he lp guide flex io n and ex tensio n. T he unc inate processes th emselves ac t to limi t motion, whe reas the entire jo int func ti ons to all ow moti o n by ass isting coup led movc ment.
42
I
Chapter 3 :
Cervicat Spine Application
«
Ligamentous anatomy Th e ligaments of the lo wer cervical spine have many important rUllctions. First, they allmv appropriate physiologic Illation and fixed postural positions between vertebrae w ith minimal expenditure ofmusclc energy. Secondly, the li gaments protec t th e spinal cord and other structures by restraining motions w ithin we ll -defined limits. What follows is a brief review of the cervical intra-canal ligame nto us structures. The posterior lon gitudinal ligament (PLL) is narrower and slightly weaker than the anterior long itudi nal li gament (ALL). It runs over the posterior surfaces of the vertebral bodies from C2 to C7 within the ve rte bral canal. This ligament has an interwoven connection with the intervertebra l disc. In contr ast to the ALL , the PLL narrows over the cervical vertebral bodies and fans laterally over the discs. On eith er side of the midline of the annu lu s t-ibrosus , the PLL is only weakly distributed. This ligament is broadest in size in the cervica l spine where it supports the posterior aspect orthe intervertebral joint, assisting to prevent posterior displacement of the disc. This ligament tightens in ftexion and slackens in extension . The ligamentum flavum , also known as the "yellow li gament," extends lon gitudinally from the anterior inferior border of the lam inae above, to the posterior superior border of the laminae below. The fi bers of this li gament therefore run in a ventral crania l and dorsal cauda l fashion fl'om C2 to C7. There are two ligaments at eac h vertebra l segme nt, a right and a left, which are separated by a small fissure and merge with the interspinous ligament posteriorly and the facet capsu les anteriorly. Unlike the ALL and PLL, the ligamentum flavum is segmen tal beginning and endi ng at one vertebral segment. The ligamentum ftava are important in controlling and stab ili zing the spine during flexion , a motion that causes the Iigamcnts to stretch. Th ey then regain their original shape when the neck returns to thc neutral position. In extens ion, the ligaments retract and thi cken by volume redistribution and relaxation of their fibers. Finally, being located immediately behind the neural column w ithin the vertebra l canal, the more elastic nature of this li gament may reduce the risk of buckling into the vertebral canal and causing spinal cord compression during lower cerv ical extension .
Kinematics Segmenta l motion in the LlC region follows Kaltenborn's concave rule with regard to movement through th e IVD joint. For example, cervical ven tral flexion is accompanied by a slight rocking of the c ranial vertebrae over the cauda l vertebrae in the segment. Slight translation wi ll occur in a ventral direction (concave rule) and the inferior articular face ts of the cranial ve rtebrae wi ll glide in a ventral and cranial direction. The arthrokinematic movements for cervical dorsal flexion (extension or backward bending) are exact ly opposite. During dorsal flexion , the crania l vertebra rocks in a dorsal direction with sligh t dorsal glid in g through the IVD joint and dorsal and caudal g liding of the inferior facets of the cranial vertebrae. The facet joint, uncovertebral joints and the capsulo l igamentous structures of the LlC spine are respons ibl e for th e coupled movement pattern seen in the Lie region. By definition , a coupled movement is one that is mechanically forced to occur. The LlC segments show a mechanically forced pattern oCside bending and rotation to the same side. For example, rotation and latera l ftexion to the same side accompany each other as a result of the infe rior articular process of the superior vertebra s lidin g down on the superior articular process oftJle inferior vertebra. During this motion, the facets stabi li ze and guide coupled motion whi le helping to absorb the shock of weight bearing.
Direction of joint rolling and gliding during lower cervical coupled sidebending and rotation Left Sidebending and Rotation
Right Sidebending and Rotation
Translalorie Spinal Manipulation
I 43
I:: Direction of joint rolling and gliding occuring during lower cervical ventral and dorsal flexion
I:
I:
I:: Vent ral Flexion
I:: I::
-= -= -= -= -= -= ~
Ie Dorsal Flexion
Ie .I e
Ie Ie Ie Ie
-=Ie Ie IE
IC IE IE
IF III
44
I Chapter 3 :
Cervical Spine Application
Biomechanics of Lower Cervical TSM Disc Traction Lower cervica l disc t racti on T5M t ech niques use a cou pled position of side bending and rota t ion to th e same side and t oward s the th erapist. This position both faci litates contact on the lami na and articular process and insures t hat the spinal segment ends w ith neutra l sidebending w hen performi ng a single handed impulse. Th e impul se is directed cranially with either th e hand on th e concave side of th e spin e or w ith both hand s wh en perfo rming a two handed impul se. Positioning - right side bending right rotation
~
Two handed impulse
directed cranially
Facet Distraction Lower cervica l facet distract ion T5M techniq ues use a noncoupled position of side bending and rotation to the oppos ite side to compress th e facets on one side and gap or di stract th e facets on th e other side. To fur t her distra ct a specific facet j oint, t he therapist then uses either a ventrally, medially and ca uda lly direct ed force on th e lamina and art icu lar process of th e cau da l vertebra or he/s he uses a med ially directed force on th e overlapping articular processes of the ca udal and cran ial vertebrae from t he contra lateral side.
Positioning - right side bending left rotation
Facet joint distraction
Facet distraction is facilitated by: Medially directed impulse
the spinal segment sh ifts from the vertebral body to the ove rlapped facet joints.
or
Translaloric Spinal Manipulation
I 45
Biomechanics of Lower Cervical TSM Facet Glide Lower cervica l facet glide T5M techniques use a coupled posi t ion of side bendin g and rotation to th e same side.This positi on facilitates gl iding motions in t he facet join t. The therapist uses eit her a ve ntrall y and crania ll y direc ted force
or a dorsa lly and ca udally di rected force. Ventral cra nia l gli ding of t he left facet assist s in restorin g flexion, side bendi ng ri ght and rot at ion to th e rig ht. Do rsa l cauda l g liding of th e right facet assist s in resto ring extension and side bendi ng right and rotation to t he ri g ht. Th e ca udal vertebra in the trea tm ent seg men t is stabili ze d either with manu al stabil izat ion, spi na l locking or some combination t hereof.
c c c c C
E:
Positioning - the segment in right side bending right rotation
I:
Ventra! cranial d irected
impulse
I: Dorsal cauda l directed impulse
I:
Caudal stabilization for ventral cranial gliding may be achieved by:
c Applying a ventral, medial and slightly cranial force to the right lamina and articular process of the caudal vertebra in the treatment segment.
Applying a ventral, medial and slightly caudal force to the right lamina and articular process of the cranial vertebra in the treatment segment. This sh ifts the axis of
This maintains the axis of motion in the disc
motion to the fight facet
joint and generates greater leverage for stretching on the left.
Locking below in left side bending , right rotation and slight ventral flexion .
c c c
This shifts the axis of motion to the right facet joint and generates greater leverage for stretch ing on the left.
c
46
I Chapter
3 : Cerv ica l Spine Application
EL - HV & LV PP - HV & LV
C2-7-Disc Traction Indication: To improve movement in all directions Position: Supine
o
A belt may be used to support the therapist's hands and to assist in taking up the slack in the spinal segment prior to the manipulation.
placed around the therapist's pelvis and index fingers.
Tro ubleshootin g yo ur tcchnif.l ue: Irthe amplitude oflhe impul se is 100 large, the manipulating hand may slide crani all y resulting ill di scomfort and! or a poorly locali zed and less effecti ve impulse.
Placing the belt on th e th erapist's lumbar spine may resuh in d iscomfOJ1 l'or the practitioner. Note(s)
This tec hnique will effec t vertebral segments caudal to th e treatment segmen t. The actual amount o f traction in the in fra-adjacent segments is dependent upon th e amount of force used, the amplitude o f the mo ve men t and th e amount o f mo ti on availab le at th e indi vidual segments. When performing a hi gh ve locity TSM, the impul se should be del ive red from the therapist's arms, not the pelvis. When perfo rmin g a low ve locity tec hnique th e pelvis is used to ge nerate the TSM . Att empts to generate a HV impul se from the pelvi s typically results in slow impul ses and large ampl itudes ofmovcmen t. Thi s tec hni que may be e l~cc ti ve in redu cing cervicoge ni c upper extremity pain relc rra1.
Tl'anslatol'ic Spinal Manipulation
I 47
t: EL-0 pp- HV
Traction Indication: To improve movement in all directions Position: Side-lying
C
C
I:
_I: _I: _I: ~
_I::
The therapist's right hand contacts the right inferior articular process and lamina of C2.
--= JC ~
E: I: The therapist is positioned behind the patient's head, neck and upper thoracic spine. The therapist's left hand and forearm are positioned under the left side of the patient's head with the index and Slack in the disc joi nt is taken up cranially by the therapist's left hand and chest prior to delivering
the
I: I: I: I: I: I:
I:: I; Troubles hooti ng you r tech ni q ue: If th e am plitude of th e impulse is too large, the ma nipul at in g hand may slid e craniall y resulting in di scomfort an d! or a poorly locali zed and less effecti ve impu lse. Fa ilure to support th e head agai nst the therapi st's chest may res ult in upper cervical fl exio n or too much side bending durin g the manipulation .
Ie
Note(s)
I:
Placing th e upper ce rvical and C2 in sli ght rig ht rot ati o n facil itates con tact to the right infe ri or arti cul ar process of C2 . An impul se de li vered to th e rig ht side ofC2 w ill cause slight left side be nd ing and rotat ion resulting in the treatment segment end in g in neu tra l side bend ing and ro tat ion. This minimi zes stress o n th e VA and ala r ligament. An alternative way of performing thi s manipu lation is to impul se w ith both han ds. Thi s typically res ults in a greater sensation of traction fo r the patient but requ ires exce ll ent coo rdinati on and timin g from both hands.
48
I Chapter 3 : Ce rvica l Spine Appl ication
Ie S;
E: S;
Traction
El-0 PP-HV
I
Indication : To improve movement in all directions Position: Supine
The therapist's right hand conta cts the right inferior arti cular process and lamina of C2.
The therapist's right hand impulses cranially, slightly medially and slightly I
Troubleshooting yo ur technique: If the amplitude of lhe impulse is too large, th e manipulating hand may slide cran iall y res ultin g in discomfo rt and/ or a poorl y loca li zed and less e ffect ive im pu lse. Failure to support th e head against the therapist 's chest may result in 100 mllch side bendin g durin g th e
manipulat ion. No te(s)
Plac ing the upper cervical and C2 in slight ri ght rotat ion and side bendin g fac ili tates contact on the ri ght infe rior arti cular process o f C2 . An impul se del ive red to th e ri ght side of C2 will cause slight leli side bcnding an d rota tion resu lt ing in the treatment segmen t end ing in neutral side bendin g. Thi s min imi zes stress on the VA and Alar ligaments. An altern ati ve way of perfo rmin g th is mani pulati on is to impul se with both hands. Thi s req uires excellent coord inatio n and lim ing from both hands. Whil e th e patient is still in the supine positi on. va ri ous pass ive segmental movements ca n be re-examined after application of this TSM.
Translatoric Spinal Manipulation
I 49
C2-7-Disc Traction
EL - HV & LV PP - HV & LV
Indication: To improve movement in all directions Position: Seated
The thE;!rapist's right hand holds around the left side of the inferior articulating process and lamina of the cranial vertebra in the treatment segment.
The head is supported against the therapist's
chest.
and right hands are in contact with the patient, slack is taken up by the therapist applying (1) a gentle cranial force with their right hand and chest and (2) a caudal and slightly ventral stabilizing force on the bilatera l laminae and articular
~
1£ ~
Another co ntact option for the therapi st's
stands in of and to the right of,
manipulating hand is to hook the fifth
finger around the spinous process of theC:::=::~ cranial vertebra .
therapist's left hand When using this contact, the therapist may overlap the ring finger on the fifth finger (see illu stration to the right) for additional support of the finger.
I C:,~:~:~~
It,
the bilateral the caudal
Troubleshooting you r tech nique: Failure to provide an equa l impulse from the che st and hand ma y result in a side bending mo ve ment during the manipul atio n. If the amplitude of til e impu lse is too large, the right hand may slide craniall y and th e left han d ma y slide ca uda ll y resu lti ng in discom fo rt and/or a poorl y locali zed and less effective impulse. Id ea lly, the stabilizing fo rce sho uld be equal to th e impu lse. Disco mfort may be felt by th e patie nt if th e th erapi st squeezes too much wi th the ca udal stab ili zi ng hand dur in g th e manipu lation.
Note(s) Wh ile it is d ifficu lt to stabili ze the infra-adjacen t ve rtebra specifically. the lise ofa shon amplitude movcment coupled with the ca udal stab ili zing force help to minimi ze th e amount of movement occurring in th e seg mcnts caudal to the impulsed segment. In a sy mptomati c hypomobile segment, manual intervention often inc ludes a ble nd ofrSM , tran slato ri c mobi li za tion and fun cti ona l massage. The sca ted positio n is particula rl y good for the blending of these techniqu es.
50
I
Chapter 3 :
Cervical Spine Applica tion
~
patient's right side.
I:
EL-0 PP -HV
Traction Indication: To improve movement in all directions Position: Side-lying
The therapist's right hand contacts the right inferior articular process and lami na of the cranial vertebra in the treatment
The therapist's left hand and forea rm are positioned under the left side of the patient's head with the ulnar side of the hand contacting the left articular process and lamina the crania l vertebra in the treatment segment.
Slack in the disc joint is taken up cranially by the therapist's left hand and chest prior to delivering the impulse.
Troubleshooting your technique: If the am pli tude ofl he impulse is too la rge, the man ipulatin g hand may s lid e cra niall y resultin g in di scom lorl and/ o r a poorly locali zed and less e fl'e ct ive impulse. The medial fo rce applied by both th e left and ri g ht ha nd s should be firm eno ug h to avo id s lid ing crania lly durin g the impulse but should no t ca use any di sco mfo rt in th e son ti ssll es . Irthe soft ti ss ues arc se ns iti ve, th e therap ist shou ld ap pl y the press ure grad ua ll y unti l e ither the therap ist feel s the underl ying bo ny surlaces or the patient ex presses mild di sco mfort . The therapi st should th en tak e up the s lack in the segm ent in a cranial direc tio n. Irt he hands s lide o flth e segme nt o r the d iscomfort increases to the po int of intole rance fo r the patie nt, th e techniqu e sho uld 110 t be performed. Rath er, techniq ucs that reducc so ft ti ss ue se ns iti v ity should be used. The tec hn ique may be atte mpted aga in upon reducti o n of soft ti ssue tende rness. Failure to s upport th e hea d aga inst the therapi st's chesl may res ult in a no dding motion o rlh e head or too much s ide bendin g during th e manipul ation. Nole(s) Th e medial force app li ed from both hand s are necessa ry to maintain co ntact to the trea tmcnt scgment. All a lte rnative method of perfor min g thi s mani pu lati on uses an im pu lse de live red from both hands. This req uires exce ll ent coo rdin ati o n and liming from both han ds.
Translatoric Spinal Manipulation
I 51
Traction
EL-0 PP - HV
Indication: To improve movement in all directions Position: Supine
The therapist's right hand contacts the right inferior articular process and lamina of the cranial vertebra in the treatment segment.
disc joint is taken up crania lly by the therapist's left hand and
The therapist is positioned beside the patient's head , neck and right shoulder. The therapist's left hand and forearm are positioned under the left side of the patient's head, with the ulnar side of the hand contacting. the left inferior articular process and lamina of the cranial vertebra in the treatment segment.
IIC
Troubl es hooting your tec hnique: Ifill e ampl itude orl he impulse is too large, the manipu lating hand may slide craniu1ly resu lti ng in discomrort and! or a poorly loca lized and less e fTcc ti vc impul se. Fai lure to use a fi rm eno ug h medial force from both hands pr ior to the impulse may result in a cra nial s liding of the hands d uring the manipula tion resu lti ng in di scomfo rt and/or a poo rl y loca li zed and less e ffec tive impulse. Fai lure to support the head again st th e therapi st's ches t may re sult in a noddin g motion of th e head or too much s ide bend ing during the manipulat ion . Note(s) As w ith th e prev ious tech niqu e, both hands may be lIsed to generate the im pu lse during thi s techn iq ue . It is tile author's experience that impuls ing simultaneoLis ly wit h both hand s typ ica ll y genera tes a greater se nsation of trac tion for the patient.
52
I
Chapler 3 :
Cervical Spine Application
Distraction
EL - HV & LV PP - HV & LV
Indication: To improve movement in all directions (R Facet Joint) Position: Supine
The therapist's right hand contacts the lam ina and superior articula r process of the caudal vertebra in the treatment segment. The therapist stands facing the top of the patient's head.
Slack in the facet joint is taken up in a ventral. med ial and caudal direction by the therapist's right hand prio r to delivering the impulse.
The therapist's left hand and forearm are positioned under the left side of the patient's head with the ulnar side of the ha nd contacting the left inferior articular process and lamina of the crania l vertebra in
The therapist's right hand impulses ventrally, medially and caudally.
•
-
T roubl eshoo t in g your t echnique: • Failure to sum ciently support the side bendi ng and rotat ional pos itio;li ng of th e s upra-adjace nt spin al segments may result in unwanted cervical mo ti on dur ing the man ipul at io n. No tc(s) T he treat ment seg me nt may be placed in ve ntra l or do rsal fle xion based 0 11 the patie nt's speci fi c res triction . Lowe r cervical facet tracti o n pe rformed in a nOll co upled posi ti o n w ill fac ilita te maximal di stract ion orthe artic ular sur races. This resu lts in th e g rea test amo un t or racet joint ca psular stretching. T his technique may al so be perfofm ed w ith the pa tient's head/nec k restin g o n a pillow.
Translatoric Spinal Manipulat ion
I 53
I:
Distraction
EL - LV PP -HV & LV
It:
It:
Indication: To improve movement in all directions (R Facet Joint) Position: Seated
I:
C C
I:
I:
I:
I:
I:
The therapist's right hand impulses ventrally, medially and caudally.
I:
I:
patient SUIJoc,rtirlQ the patient's and neck position i left hand, and abdomen.
I:
I:
therapist's left hand SUIDO(JrtS the left side of
I:
Ie
Ie lamina and superior articular process of the caudal vertebra in the treatment
c:
-
•
It:
-
Ie
II:
Troubleshooting your tec hnique:
IC
Fa ilure to s upport th e s ide be nding and rotational pos itioning of t he supra-adjacent spina l segments may result in un wanted s ide bending du ring th e manipu lati on . Press ure aga inst the anterior neck by the stabilizing hand shou ld be avoided and may lead to di scomfort during the
It:
manipulation .
II:
Note(s) During thi s tec hnique, th e OA and AA segments are in a co upl e d position. The rema ining supra-adjacent segments are positioned in a Iloncoupled position. The treatment segment may be placed in ventral or dorsal tlexion based on th e specific rest ri ctio ll . Lower cervica l facet traction performed in a noncoup led position wi ll facilitate maximum distrac tion of the articu lar surfaces. Thi s resu lts in th e g reates t amount of t~lc et joint capsu lar st re tchi ng. Low er cervica l facet traction performed in a noncoupled position is a very specific technique . Thi s tec hn ique is typica ll y tol e rate d well by patients who are expe riencing hypermobility caudal to the treatment segment.
54
I
Chapter 3 .-
Cervical Spine Application
I: \
-=if:
..-=
-= -=
C2-6- Facet Distraction
EL- LV PP - HV & LV
Indication: To improve movement in all directions (R Facet Joint) Pos i tion: Seated
therapist stands beside the patient supporting the patient's head and neck position i their fight hand,
In sitting, the patient's cervical spine down through the treatment
segment is positioned in left side bending and right rotation.
I fore,,,m and chest. ulnar border of the
Ith,eralPist's right hand supports the right
The impulse is directed ventral , medial and caudal with the therapist's left thumb.
posterior edge of the process, articular process and lamina of the crania l vertebra in the treatment segment.
•
"--- ..,.-1 After the left and i are i contact with the patient, slack is taken up by the therapist applying (1) a gentle cranial , medial and slightly dorsal force with their right hand and forearm and (2) a ventral , medial and caudal force with their left thumb.
lamina and superior articular process of the
caudal vertebra in the treatment segment.
-
Troubleshooting yo ur technique: If the impu lse ha s 100 largc an amp litude, th e manipulating hand ma y slide ca uda ll y res ulti ng in di sco mro rt and/o r a poorly locali zed impulse. Failure to support the side be ndin g and rotational pos iti on in g of the supra -adjacent spinal segment s may result in un wa nted side be nd ing during th e man ipulat io n. Note(s) During thi s techn iq ue, the OA and AA segment s are in a coup led position. The rema in ing supra-adjacent segmen ts are positioned in a non co Lipl ed position . Th e race t joint may be placed in neu tral , ven tral or dorsa l ll ex ion based on til e spec i fie re stri ction. Lower ce rvica l racet traction perfo rm ed in a noncoupl cd position w ill rac ilitate maximum di straction orille arti cular s urfa ces. Th is res lI Its in the greates t amount or capsu lar stretching in the facet joint. Lower ce rvi ca l face t traction perfo rmed in a noncollp lcd position is a very specific tech niqu e. This Icc i1'n ique is typica ll y to lerated we ll by patients who are experie nc in g hype rm obil iry ca udal to the trea tme nt segment. This form of lower ce rvica l face t joint tract io n al so g ives the therapist the latitude to appl y the tec hnique whil e g ivin g a c ranially directed traction to the di sc joints. Given thi s, hypomobile facet articu lations can be manipu lated or mobili zed with thi s technique in the prese nce of radicular irritation caudal to the treatment segment.
Translatoric Spinal Manipulation
I 55
C2-6- Facet Distraction
-=
-= -= .E :
EL - 121 PP - HV & LV
Indication: To improve movement in all directions (L Facet Joint) Position: Supine
C
.-= -=
-= -=E:
-=
The therapist is positioned beside the patient's head, neck and right shoulder. The therapist's right hand impulses medially and slightly cranially and
dorsally.
-=II: -= -= -=It: -= -=It: -= -= -=I::
The therapist's left hand and forearm are positioned under the left side of the patient's head with the ulnar side of the hand contacting the left inferior articular process and lamina of the cranial vertebra in the treatment segment.
Ie
i i i uw of noncoupled side bending and rotation .
Additional slack is taken up in the segment and left facet joint by the therapist pressing in a medial and slightly cranial direction with the right hand prior to delivering the impulse.
Troubleshooting your techn ique: If the manipulating hand is placed too lateral , it may contact the tip of the tran sverse process result ing in di scomfort when taking up th e slack and/or during the manipulation . Ifwhen posi tioning the neck, the therap ist positions the side bending prior to add in g rotation, th ere may not be enough space for the man ipu lative hand because orlhe proximity of the shoulder. It is therefore impol1ant to take up the side bending and rotation in combination. The manipu lating hand should be placed on th e cranial vertebra prior to positioning th e neck . Prior to manipulating, the therapist should verify that the patient fee ls a localized stretching sensation over the contra lateral ly treated facet joint. /
Note(s) The facet joint may be placed in neutral , ventral or dorsa illex ion based on the specific restriction . Jf right side bend ing and dorsal flexion are rest ricted on the right side, the thrust mu st be applied to the right inferior articular process of th e caudal vertebra of the segment treat ed. If the imp ulse is direc ted too cranially or ventrally, a gl id ing will occ ur in the right facet joint. Lower cerv ical flexion performed in a noncoupJed position will faci litate max imal dist raction of the articular surfaces. In this case, the facet di straction occurs on the opposite side of the manual co nta ct making this an exce ll ent tech nique if there is soft ti ssue tenderness on the same side as th e facet joint restri ction. 56
I
IC
Chapter 3 ."
Cervica l Spi ne A pplication
-=5=
..-=
-=IF!
EL-0 PP - HV & LV
C2-6-Facet Glide Indication: To improve left rotation (R Facet Joint) Position: Supine
i 'treatment segment is positioned in left side bending and left rotation.
therapist's left hand maintains the caudal spinal lock by supinating forearm and lifting/pulling towards right side of the patient's neck, thus maintaining right side bending of the sub-adjacent spinal segments. By supinating the left lorealrm. the therapist introduces left side bending in the treatment
Slack in the facet joint is taken up in a ventral and cranial direction by th e therapist's right hand prior to delivering the impulse.
The therapist then ca refully takes up the remain ing left rotation in the treatment segment by pulling the vertebra into left rotation . The therapist is positioned beside the patient's head , neck and right shoulder. The therapist's left hand and forearm are positioned under the left side of the patient's head with the ulnar side of the hand contacting the left inferior articular process , lamina and spinous process of the cranial vertebra in the treatment segment.
Troubleshooting your tec hnique: One com mon mi stake made whe n performing this technique is th e loss of right side bending ca uda l to the treatme nt seg ment when the th erapi st side bends th e treatment segment to the len. If thi s occ urs, the loc king w il l be less efTectivc and the technique less specific. To coun ter this mistake , the therapi st shou ld s upinate his/her forearm to ma intai n the caud al lock wh ile creatin g coupled motio n in (h e treatment seg me nt. If the pat ien t is unab le to re lax o r reports di sco mfort once the cerv ical spin e is positio ned for the tec hniqu e, th e th erapi st sho uld attempt to det ermin e if slight adju stm ents in posit ion in g imp rove relaxation and reduce th e patient's di scomfort. Techniqu es suc h as ho ld -relax , soft ti ssue massage or fUll ct io nalmassage may al so be used to facilitate re laxat io n and may be used pri or to thi s tech nique to en hance pat icnt to lcran ce. The use orthe lel't (non-manipu lat in g) hand d urin g th e positioning of th e trea tment segment red uces the stress placed on th e art icular pillar/ lam ina by th e man ipu lating hand. If th e left hand is not used during th e posit ion ing, slack may not be take n up eflec ti ve ly a nd the pati ent may fee l di sco m fort und er the manipul at ing hand.
No te(s) The ax is ror thi s moveme nt will be in the len racet oflh e treatme nt segment.
TranslalOric Spinal Manipulation
I 57
t: EL-LV PP - HV & LV
C2-6-Facet Glide Indication: To improve right rotation (L Facet Joint) Position: Seated
c c c
c C In sitting, the patient's treatment segment is positioned in right side bending and right rotation.
J:
The vertebral segments caudal to the treatment segments are positioned in left side bending and right rotation (locked below).
Jt:
-I: I: I:
The fifth finger of the therapist's right hand contacts the left inferior articular process of the cranial vertebra in the treatment segment.
I: L
The contact of the manipulating hand may be reinforced by overlapping the ring C::~,.;I. and midd le finger dorsally over the little finger.
Slack in the facet joint is taken up in a ventral and cranial direction by the therapist's right hand prior to delive ri ng the impulse.
The therapist's rig ht hand impulses ventrally and cra nially.
Troubleshooting your technique: The ri gh t hand mu st pro vide a sli g ht ventral and medial force (right side bendin g) to create co upl ing in the \ treatment segment. Fai lure to co upl e the trea tm ent segme nt w ill red uce the amount of glidin g avai labl e durin g the manipu lation and may res ult in a less effective tec hnique. Fai lure to maintain the lo ck in g be low may resu lt in a poorly locali zed and in effective manipul at ion. Using the spinous process as described in the "N ote(s)" below w ill a id in maintaining th e ca udal spi na l lock. The therapi st/student must be sure that th ey are on C2 and not C l when performing thi s tec hnique for the C2 s pinal segment. This ca n be chec ked by palpatin g the spina Li s process of C2 (the first spi naLI s process below the occiput). The the ulnar border of th e th erap ist's ri gh t hand shou ld be placed immediately latera l to the C2 sp inous process. Note(s) The caudal spinal lock is maintained by the medial fo rce applied by the therapist 's thumb comb in cd w ith th c th erapi st's ri g ht hand pu lli ng the spinous process of th e cranial vertebra in the treatment segme nt towa rds the left to further reinforce th e ca udal locking.
58
I
Chapter 3 :
Cervical Spine Application
-=
Traction
EL-0 PP - HV & LV
Indication: To improve movement in all directions Position: Side-lying
Slack in the disc joint is taken up cranially by the therapist's left hand and chest prior to delivering the impulse.
Troubleshooting your tcchni(luc: Maintaining co nt act to C7 is orten diffic ult . Irthe amp li tude ofl he impulse is too large, or the medial co ntact forces app li ed by bo th ha nd s is 11 0t forceful eno ugh, the hand may s lide c raniall y resu lt in g in di scom fort o r a poorl y loca li zed impulse. Fa ilure to support the head aga in st th e th e rapi st 's chest ma y result in side be ndin g durin g the manipulation.
Note(s) Th e medi a l forces app lied from the sta bili zi ng and m a ni pu lat in g hand s helps the therapi st maintain co ntac t to the impulsed seg me nt. An a lte rn ative me th od of performing thi s man ipulati on uses a n imp ul se de li ve red from both hand s . Thi s requires exce ll ent coo rd in a tion a nd lim in g from both hands .
Translataric Spinal Manipulation
I 59
EL - f2J PP - HV & LV
Glide Indication: To improve left rotation (R Facet Joint) Position: Supine
The right hand contacts the right inferior articular and transverse processes of the crania l vertebra in the treatment
lifting/pu lling towards fight side of the patient's neck, thus maintaining right side bending of the sub-adjacent spinal segments.
Slack in the facet joint is taken up in a ventral and cranial direction by the therapist's right hand prior to delivering the impulse.
By supinating the left forearm, the therap ist introduces left side
The therapist then carefully takes up the remain ing left rotation in the treatment segment by pulling the vertebra into left rolation.
The therapist is positioned beside the patient's head, neck and right shou lder. The therapist's left hand and forearm are positioned under the left side of the patient's head with the ulnar side of the hand contacting the left inferio r articular process, lamina and spinous process of C7.
Troubleshooting your technique: O ne co mmon mi stake mad e wh en perform ing thi s tec hnique is the loss oflhe cauda l sp inal lock, res ulting in a less s pecific technique. The greatest reason for thi s is dropping of the therapist 's left hand when unlocking the treatment segme nt. To un lock th e treat me nt segme nt without los ing the caudal sp ina l lock, the thera pist Illust use both hands to pos it ion the co up ling in the treatment segme nt, mo vi ng the supra-adjacen t spina l segments as a unit. I f the therapi st's len hand pulls too mllch from the chin, the patient may expe ri ence di scomfort during thi s tec hnique. To reduce this tendency. the th erapi st mllst LIse th e pa lmar and ulnar surface ofhi s/her left hand to pull the transverse process of C7 dorsa ll y to ass ist in le ft rotating as well as fl ex ing and side bending the crania l s pinal segments.
Note(s) The ax is for thi s move ment wil l be in th e len nIcet ofC7.
60
I Chapter 3 :
Cervical Spine Application
It: It: It:
EL-0 PP - HV & LV
C7-Facet Glide Indication: To improve left rotation (R Facet Joint) Position: Side-lying
The patient's C7 segment is positioned in left side bending and left rotation. The right hand contacts the right inferior
articular process and posterior edge of the transverse process of
The spinal segments cranial to the treatment segment are positioned in the resting or actual resting position. The spinal segments caudal to the treatment segment are positioned in right side bending and left rotation. (locked in flexion)
C7.
therapist's left hand maintains the caudal spinal side bending by supinating the forearm and lifting/pulling towards the patient's right shoulder. By supinating the left forearm , the therapist introduces left side bending into the treatment segment. The therapist then carefully uses their left hand to take
The the rapist is positioned behind the patient's head, neck and upper thoracic spine. The therapist's left hand and forearm are positioned under the left side of the patient's head with the ulnar side of the hand contacting the left inferior articular process and lamina of C7 .
Troubleshooting your technique: Maintaining contact to C7 is often difficult. If the amplitude of the impul se is too large the direction o rthe impul se too crani a l o r the med ial co ntact force a pplied by both hand s is not forcefu l e nough, the hand may sli de cran iall y re sultin g in discomfort or a poorly loca li zed impul se. Fa ilure to support th e head against the therapi st's chest ma y result in additional unnecessary movement in spinal segments crani a llO the trcatme nt segmcnt durin g the manipulation . Nole(s)
The medial force s app lied from the stabili zing and manipul at in g hand s he lp th e the rap ist ma inta in contact to the impul sed scgm~nl. The ax is for this movemen t will be in the lett facet ofC7 .
Translatoric Spinal Maniplilation
I 61
EL-LV PP - HV & LV
Glide
Indication: To improve left rotation (R & L Facet Joint) Position: Supine
The therapist stands facing the top of the patient's head. The therapist's right hand contacts the patient's right posterior surface of the transverse process, the lamina and inferior articular process of
C7. The therapist's left hand contacts the patient's left lamina, inferior articular process and left side of the of C7 .
cervical spine, excludi ng C7, is positioned in a neutral position . The C7 segment is positioned in left side bending and left rotation.
The therapist's right hand impulses ventrally and cranially. The therapist's left hand stabil izes the left side of
C7.
are in contact with the patient, slack is taken up by the therapist applying (1) a ventral cranial with their right hand and (2) a caudal and slightly medial force with their left hand.
Troubleshooting your tec hniq ue: O ne co mmon mi stake whcn perform in g th is techn ique is ins ufficient contact 011 th e C7 spina l segme nt. To identify where C7 is located , s lid e both hand s down th e lat era l surface o f the nec k until the first rib is contacted. The ve rtebra crania l to this po int is C7.\ Anot her co mmon mi stake is directing the impul se too medially with the left hand. Th is may ca use d iscomfort for the pat ient and may lim it dorsa l ca uda l gl idin g of the Ic fll acet joint. NOle(s)
By us ing both hands to position C7, th e th erap ist may dete rm in e whe re th e axi s of movemcnt wi ll bc pln ced. The axis for mo vement at C7 is in th e lell facet joint. A belt may be placed across the manubrium to stabili ze against un wanted mo ve ment of TI during th e man ipulation.
62
I
Chapter 3 :
Cervica l Spine Application
EL - HV & LV PP - HV & LV
Glide Indication: To improve left rotation (R Facet Joint) Position: Supine
The therapist is positioned beside the patient's head, neck and left shoulder, The therapist's right hand contacts the patient's right posterior surface of the transverse process, the lam ina and inferior articular process of C7.
The patient's cervical spine, excluding C7, is positioned in a neutral position. The C7 segment is positioned in left side bending and left rotation.
Slack in C7 is taken up in a crania l and slightly medial direction by the radial border of the right hand prior to delivering the impulse.
Troubleshooting your technique: One comlllon mistake when performing this technique is insuffici ent co ntact on the C7 spina l segment. To id en tify w here C7 is located , slide the manipulating hand down th e lateral surface of the neck until the fi rst rib is co ntacted with th e radial border orthe second MCP. Th e vertebra cranial to this point is C7. In sutlicient stab ili zation of the sho ulder may lead 10 a poorly loca li zed and less effect ive manipulation ofC7. When performed properly, ve ry litLl e movement wi ll occur in the spinal segme nts cranial to th e treatment seg ment. Failure to con tact C7 properly, or to deliver the impulse to C7 through the second MCP, may cause unwanted moveme nt above the treatmen t segment. T9 assure con tinued contact to C7 the manipulating hands radial border of the 2nd MCP should maintain contact to the first rib during the TSM .
Note(s) The therapi st supports his/her ind ex finger w ith their middle finger dorsa ll y. The cervical spine above C7 is co ntacted by the remainder oflhe therapist 's hand and is moved as a unit wit h C7. For patients presenting with more thora cic kyphosis , th e impulse may need to be directed more ventrally. In c linical practice, comprehensive manual interve ntion often cons ists of the application of functional ma ssage, translatoric mobilization and translatoric manipulation all being applied to reduce soft tissue sensi tivity and to enhan ce sy mptom free motion. Transitioning from one intervention tec hniqu e to another can occur quite easily
Translatoric Spinal Manipulation
I
63
EL-LV PP - HV & LV
Glide Indication: To improve left rotation (L Facet Joint) Position: Supine
The therapist stands facing the left side of the patient's head , neck and left shoulder. The therapist's right hand contacts the patient's right posterior surface of the transverse process , the lamina and inferior articular process of
C7. The therapist's left hand contacts the patient's left lamina, inferior articular process and left side of the ofC?
After the left and right hands are in contact with the patient, slack is taken up by the applying (1) a ventral cranial with their right hand and (2) a caudal and slightly medial force with their left hand.
The patient's cervical spine , excluding C7, is positioned in a neutral position. The C7 segment is positioned in left side bending and left rotation . r - - - - . J
This technique may be performed with an emphasis on either the right or left facet of
C7 . See below for further details.
For restricted dorsal caudal gliding on the left.
For restricted ventral cranial gliding on the right.
The therapist's right hand stabilizes the right facet joint of C7 by pressing ventrally and medially.
The therapist's left hand stabilizes the left facet joint of C7 by pressing ventrally and medially.
T he therapist's left hand I and
The therapist's right hand I I and
Troubleshooting yo ur technique: For the dorsa l caudal version of th is techn ique, if the manipulating force is directed too medially, the patient may ex perience discomfort during the manipulation. Slack is taken up in an equa l manner by both hand s in order to keep th e axis of movewent in the C7 segment. Too large an amplitude or movement Illay resu lt in unwanted Illovemcnt of the thoracic spine and excess ive stress in the cranial ce rvical seg ments. Note(s) A wedge Illay be used to ass ist in stabi li zing the upper thoracic spinc. To allow clearance for movement of th e manipulat in g hand , th e base of the wedge should be placed und er T2 or T3. The thoracic sp in e may also be stabili zed by placing it in flexion , left rotation and right s ide bendin g.
64
I
Chapter 3 :
Cervical Spine Application
Ie
Ie
Ie
EL - I2J PP - HV & LV
Glide Indication : To improve left rotation (L Facet Joint) Position: Supine
The therapist stands facing the right side of the patient's head , neck and right shoulder. The therapist's right hand contacts the patient's right posterio r surface of the transverse process, the lamina and inferior articular process of C7. The therapist's left hand contacts the patient's left lamina, inferior articular process and left side of the spinous process of C7.
The patient's cervica l spine, excluding C7 , is positioned in a neutral position. The C7 segment is positioned in left side bending and left rotation.
The therapist may impulse with either the right or left hand.
After the left and right hands are in contact with the patient, slack is taken up by the therapist applying (1) a medial and dorsal force with their right hand towards the left facet of C7 and (2) a caudal and medial force with their left hand.
If impulsing with the right hand the impulse is directed mediaUy and dorsally towards the left facet of C7. If impulsi ng with the left hand the impulse is directed caudally and medially.
Troublcshooting your tec hniq uc: To effectivel y mobili ze C7 using thi s techn ique, the therapist mu st stand on the ri ght s id e of th e patient. T he therapist 's right e lbow is supported again st the ri ght side ofh is/hcr abdomen and pelvis. No te(s) A wedge may be used to ass ist in stabil izing the upper th orac ic spine. To a ll ow c learance for move ment of the manipulating hand , the base orthe wedge should be placed under T2 or n. Th e th orac ic spin e may al so be stabili zed by placing it in t1 ex iol1, left rotat,io n and right side bend ing. Durin g thi s technique. the emphas is is placed on th e dorsa l cauda l glide occurring in the left facet joint.
Translatoric Spinal Manipulation
I 65
Glide
EL-LV PP-HV & LV
Indication: To improve left rotation (R Facet Joint) Position: Prone
--= --=
-= -= -= -=
JC
11:
11: JC
a: 11:
JC
a: Jt: C
..IiI:
.It: C IC
Jt: C Tro ubleshooting yo ur technique: As menti oned previously, it is important to be sure th e th erapi st is properly contacting C7 durin g this tec hni que. To avo id any crania l sliding durin g th e manipul ati on, th e uln ar border of th e ri ght hand shoul d maintain contact with th e first rib throughout the tec hni que. InsutTi cient stabili za tion of th e should er may lead to a poorly locali zed and less effective man ipul ati on or C? Irthe manipulati ng hand is located above C7 or if the impul se is too large or de li ve red by the pal mar surface instead or lhe ulnar border of the hand, unwa nted move ment including dorsal ncxiol1 o r the supra-adjacent spinal segments may occur.
TI is stab ili zed by pulling the shoulder girdle posteriorly th ereby approxima ti ng the clav icle into th e first rib and
the first rib into T I. A fi fm pillow or sandbag may be placed under the pati en t's right shou lder to support th e positioning orlh e th oracic spine in ri ght rotation. The th erapist may th en use th e left hand to support th e ri ght when deli ve rin g th e i mpuisc.
I
C
.a: IC
C
Nole(s)
66
IC
Chapter 3 :
Cervical Spine Application
~
EL -/21 PP - HV & LV
Glide Indication: To improve left rotation (R Facet Joint) Position: Prone
The therapist is positioned beside the patient's head, neck and left shou lder. The ulnar border of the therapist's right hand contacts the patient's right posterior surface of the transverse process, the lamina and inferior articular process of
C7.
The patient's cervical spi ne, down to and including C7. is positioned in ventral flexion, left rotation and left side bending. A pillow may be used to assist in supporting the Dalierll's head and neck. The patient's shoulders are positioned in approximately 120. 130 0 of nexion.
Troubles hoo ting your technique: As men tioned previoLisly, it is import ant to be sure th e th erapist is properl y contac tin g C7 during this techni que. To avoid any cranial sliding dur ing the manipulation, th e ulnar border of th e ri gh t hand shoul d maintain contact with the first rib throughout th e tec hnique. Insuni cicnt stabilizati on of th e should er may lead to a poorl y loca li zed and less e ffec tive manipulati on of C7. Irt he manipulating hand is located above C7 or irt he amp litude of th e impul se is too large or delive red by th e palmar surface instead of the ulnar border of th e hand , un wanted mo vement including dorsa l nex ion of the supraadjace nt spinal segments may occur. Notc(s)
T l is sta bilized by the posi tioning of th e shoulders and shoulder girdl e bilatera ll y. For pro per stabilizatio n ofTI the patient must relax th ei r serratus an teri or and allow th eir chest to si nk anterior towa rds the tab le. Th is allows the first rib and clavicle to approxi mate and stabilize Tl . Th is pos ition allows the th erapi st to generate a good deal of force when man ipul at ing C7 with hi gh or low velocity T S M.
Translatoric Spinal Manipulation
I 67
EL -" PP-HV & LV
Glide Indication: To improve left rotation (R Facet Joint) Position: Prone
The therapist is positioned beside the patient's head , neck and left shoulder. Th e therap ist contacts the patient by (1) placing the ulnar border of the left hand on the patient's right posterior surface of the transverse process, the lamina and inferior articular process of C7 and (2) positioning the ulnar border of the righ t hand over the left hand.
in C7 is taken up in a ventral and crania l direction by the therapist's right hand and shoulder prior to delivering the impulse.
II:
Ie Tro ubleshootin g yo ur tec hniqu e: As mentioned previously, it is important to be sure the therapist is properly contactin g C7 dur ing this tec hni que. To avoid any cran ial sl iding durin g the ma nipulation, the ulnar border orthe right hand should maintain contact with the first rib throughout the technique. Insufficient stabi li za tion or the shoulder may lead to a poorly loca li zed and less effecti ve man ipulation o r C7. If the mani pu lati ng hand is located above C7 or the amplitude orthe im pu lse is too la rge or delivered by the palmar surface instead of the ulnar border of the hand. unwanted movement including do rsa l flexion orthe supraadjace nt spinal segments may occur.
NOle(s)
T I is stabil ized by the positi oni ng orthe shoulde rs and shou lder gird le bilaterally. For proper stabilization of T I the patient must relax th ei r serratus anter ior and allow their chest to sink ante ri or towards th e table. This allows the fi rst rib and clavic le to approxima te and stabilize T I.
68 1
Chapter 3 :
Cervical Spine Appli cation
II:
II:
EL -LV PP - HV & LV
Glide Indication: To improve right rotation (L Facet Joint) Position: Seated
The therapist is positioned beside the patient's head , neck and right shoulder. The ulnar border of the therapist's right hand contacts the patient's left posterior surface of the transverse process, the lamina and inferior articular process of C7. cervical spine,
Ie)(CllJdiillg C7 , is Posltioned in neutral or slight left side bend ing.
The impulse may be given in two ways: (1) the therapist's right hand impulses ventrally and cranially and (2) the therapist's left hand impulses medially against the spinous process of T1 while the therapist's right hand , arm and chest stabilize C7.
therapist's left hand pulls the patient's left shoulder girdle and
Itho",cic spine into left rotation. The thumb presses medially on the left side of the spinous of T1 .
Troubles hooting yo ur technique: O ne common mi stake when performi ng thi s techniqu e is ins uffici ent co ntact on the C7 spinal segmen t. To identify where C7 is located, s lide th e manipulating hand down the lateral surface of the neck until th e first rib is contacted. Th e vertebra cra nial to thi s point is C7. Insuffi c ient stabili zat ion ort he shoulder may lead to a poorl y loca li ze d a nd less dTcctivc manipula tion ofC7 . Undesired and extraneo us mid -cerv icalmovemc nt w ill occ ur if th e who le hand contacts ce rvica l segments above
C7 instead or the ulnar border Only the ulnar aspect of the hand should contact the C7 segment and on ly thi s port ion or the hand del ive rs th e tran s latoric im pu lse. Note(s)
The the rapist may a lso tak e up the last portio n o rthe s lack at C7 with a small amoun t of traction appli ed by hi s/her chest and manipulatin g hand. The contact orthe manipulating hand s may be reinforced by overlap ping the rin g and middle finger dorsally ove r the fifth finger. In cl ini ca l pract ice, co mprehen s ive manual int ervention o ften co ns ists of the appl icat ion or fun ctional massage, cont ra ct· re lax manualll1l1sc le stretc hing, trans lalOri c mob ili za ti on and tran s latori c manipulation all being applied to rcdu ce so n tissue se ns iti v it y and to enhance sy mptom Cree motion .
Tmns/atoric Spina/ Manipu/ation
I 69
...
I:
Glide
EL -12/ PP - HV & LV
It:
It:
Indication: To improve right rotation Position: Seated
I: The therapist stands facing the patient.
cervical spine ,
Ie,
The ulnar border of the therapist's right hand contacts the patient's left posterior surface of the transverse process, the lamina and inferior articular process of
C7 segment is positioned in right side bending and right rotation .
C7. The ulnar border of the therapist's left hand contacts the patient's right lamina, inferior articular process and right side of the spinous process of C7. After the left and fight hands are in contact with the patient , slack is taken up by the therapist applying (1) a ventral cranial force ...-_ _ _-. with their right hand and (2) a caudal and medial force with their left hand. A number of options are available to improve movement of C7 using this technique ; two of the more common movement combinations are de:scriberj I below.
The therapist's right knee is positioned against the patient's left anterior shoulder. , left hand right facet by pressing ve rnt",lIv and medially therapist's right impulses ventrally and cranially:-
The therapist's right hand stabilizes the left facet joint of C7 by pressing ventrally and medially The therapist's left hand impulses dorsaUy and caudally.
T roubles hooting your tech ni que : One co mm on mi stake when perform in g thi s technique is insufi'icient contact on the C7 spinal segment. To identify where C7 is located , sl ide the manipulating hand dow n th e late ral surfa ce of the neck until the first rib is con tacted. Th e ve rtebra cranial to thi s po int is C7. Insuffi cient stabili za ti on of the shou lder ma y lead to a poorly locali zed and less e fTecti vc manipu lat ion orC7.
Note(s) This is an cxce llent technique to ap pl y when the C7 segmc nt is ve ry hypomobilc (Grade I). This tec hniqu e ca n provide a very strong and safC stretch to the connective tissue s tllat may be limit ing movc mc nt at the C7 seg ment.
70
I
Chapter 3 :
Cervical Spine Appl ication
I:
Distraction
EL -" PP - HV & LV
Indication: To improve movement in all directions (R Facet Joint) Position: Seated
The therapist stands facing the back of the patient . The patient's cervical spine including C7 is positioned in ventral flexion , left side bending and right rotation.
The ulnar border of the therapist's right hand presses medial and in the direction of the anterior surface of the transverse process of C7.
The patient's thoracic spin e is
positioned in flexion, left side
The ulnar border of the therapist's left hand stabi lizes the left side of C7 by pressing the left lamina, inferior articular process and left posterior surface of the transverse process of C7 ventral , medial and caudal.
bending and right rotation (locked below).
Slack in
taken up in a
dorsal and Slightly cran ial direction by the therapist's right hand prior to del ivering the impulse .
i is positioned against the patient's left lateral shou lder.
/
Troubleshooting you r technique: The therapist 's left leg is used to supportlhe pat ient's trunk posit ion. It should not block the positioning of the thorac ic spine into side bending which is necessary for locking below. Pressure again st the tip of the transverse process ofTI may cause discomfort to the pat ient and should be avo ided . Note(s) Stab ili zation ofTI is generated by the lock in g occurring below in flexion le ft side bending and right rotation . An alternati ve or suppleme ntal method of stabiliz in g TI can be achie ve by placing the therap ist's righ t knee behind th e patient 's ri ght sho ulder th ereby manually stabi li zing the thoracic spine and TI.
Translatoric Spinal Manipulation
I 71
I:
Distraction
EL -121 PP - HV & LV
Indication: To improve movement in all direct i o n s (R Facet Joint) Position: Seated
i j including C7 , is positioned in flexion, left side bend ing and right rotation . The patient's thoracic spine is positioned in ventral flexion, left side bend ing and right rotation (locked below).
The therapist stands facing the front of the patient. The ulnar border of th e th erapist's ' left hand presses med ially and in the direction of the anterio r surface of the right tran sverse process of C7. The ulnar border of the therapist's right hand contacts the patient's left lamina , inferior articular process and posterior surface of the transverse process of C7.
(
taken up by the ulnar border of the therapist's right hand pressing ventrally and med ially to stabilize C7 . Slack in the right facet joint is taken up by the ulnar border of the therapist's left hand pressing dorsally and slightly cranially.
-= -= -= -= -= -= -=
The therapist's right knee is positioned against the patient's left anterior shoulde r girdle.
Tro ubles hootin g yo u r tec hniqu e: T he therapi st's ri ght knee mu st be pressed agains t th e pati ent's le n. sho ul der g irdle to e ffec tive ly stabili ze T l . NOle(s)
A towe l may be placed anterior to the the rap ist's ri g ht knee to reduce an y d isco mfo rt ex perienced during th e stabi lizat io n. Th is techniqu e va riation ge nerally pro vides better stabili zat io n than th e o ne pictured 0 11 th e pre vioLis page, however, it is ty pica ll y more difli cult to push C7 th a n pull ii, as pictured o n th e previous pa ge. The axis of'movc mcnt for thi s tec hnique is the left fa ce! jo in! orC7.
72
I
Chapter 3 :
Cervica l Sp ine Appli cat ion
-= IE:
Distraction
EL -" PP-HV & LV
Ind i cation: To improve movement i n all directions (R Facet Joint) Position: Seated
The therapist stands facing the back of the patient. The ulnar border of the therapist's right hand contacts the patient's right lamina , superior articular surface and right posterior surface of the transverse process efT1. The ulnar border of the therapist's left hand presses in the direction of the patient's left tra nsverse process and ventral latera l aspect of the vertebra l body of C7 . In addition to the contact described above, the therapist's left hand supports the patient's head and neck position.
-----
taken up by the ulnar border of the therapist's left hand pressing dorsally and medially to stabi lize C7. Slack in the right face t joint is taken up by the ulnar border of the therapist's right hand pressi ng ventra lly, medially and caudally.
The therapist's right hand impulses ventrally, medially and
Tro ub les hootin g your tec hniq ue: Discom f'o rt in the len side of tile pati en t's neck may be caused by pre ss ing med iall y w ith the left hand when su ppo rt ing th c pat icnt 's neck. Note(s ) Duri ng thi s techn ique. it is expected and necessary th at so me min ima l move ment occ ur in the th orac ic spine ca uda l 10
TI.
Th e axi s of movement l'or th is techniq ue is the left facet joi nt ofC7. T he im pul se may a lso be given by th e radial bo rd er of the 2nd Mer and ind ex fi nge r of th e rig ht hand with th e forearm pos it ioned in pronat ion.
Transla/oric Spinal Manipula/ion
I 73
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Thoracic Spine u@@[}uuuDCQJQJ]@
.
The Thoracic Spine The stable thoracic segments
Articular surfaces of the thoracic spine
The twelve thoracic motion segments are the least mobile of the spinal column. There are a number of factors that contribute to the rel ative stiffness of this region. The first factor relates to thoracic disc height. The
thoracic disc is narrow relative to other regions of the spine. In addition, the nucleus pulposus ofthe thoracic disc is smaller in size reducing the overall water content within the disc. The smaller disc height relative to thoracic vertebral body height reduces overall segmental mobility. A second factor contributing to the overall stiffness of the thoracic spine is the thickness of the ligamentum ftavum. In the thoracic region of the spinal column, the ligamentum ftavum is thicker and well suited to enhance thoracic segmental stability. The third factor contributing to the stiffuess of the thoracic spine is the attachment of the ribs to the spine and
~e
vertebral body
(
sternum . This thoracic cage increases the res istance of the thoracic spine
to all movements in the sagittal, frontal and transverse planes. Regarding movements in the transverse plane, the thoracic vertebrae that attach to the sternum via the ribs demonstrate the greatest increase in resistance to motion in the transverse plane. The remainder of the thoracic segments not
--=
Lastly, regarding the the overall stability of the thoracic spine, the thoracic facet joint capsular ligaments are thinner when compared to the other regions of the spine. This may be a factor in the relative ease in obtaining joint cavitation with both unilateral and bilateral facet joint distraction
.s: .s: c .s:
manipulations.
Osteological features of the thoracic spine Clinicians providing manual intervention to the thoracic segments
Thoracic facet joints The thoracic facet joints are principally orientated in the frontal plane. Given this, the thoracic facets and the thoracic intervertebral discs are the primary stabilizers to anterior/posterior displacement of any given thoracic segment. In the lower portion of the thoracic spine, typically somewhere between the T I0 and T 12 segments, the general orientation begins to change slightly toward the sagittal plane. In more specific terms, the thoracic superior articular facet in any given segment lies anterior to the inferior articular facet. The articu lar surface of a superior thoracic facet is orientated in a cranial, lateral and posterior direction. The inferior thoracic facet lies posterior to the superior facet and its articular surface faces somewhat caudally, medially and anteriorly. On a clinicallbiomechanical note, significant increases in segmental mobility follow the removal of these facets. Loss of the facets due to tumor, trauma or surgery will result in increased segmental motion. 76
I Chapter 4 :
Thoracic Spine Application
--= --= --= --= --= JC
attaching directly to the sternum show less resistance to torsional motion
should be aware of the general angle of orientation of the thoracic spinous processes. At the T I through T3 segments, the spinous processes point nearly straight backward. At the T4 through T6 segments, the spinous processes angle downward slightly. This trend continues even more so at the T7 through T9 segments. This osteological characteristic is particularly important when locating and contacting the transverse processes in the thoracic spine for testing and treatment purposes. When contacting thoracic spinal segments in the mid-thoracic spine, the tip of the spinous process is more caudal than the transverse process for a given spinal segment. Due to the normal variation of osseus structures between and within individuals, this principle should be used as a guide for the location of transverse processes. The location of the structures may be further clarified/confirmed through the use of translatoric joint play testing in prone, side-lying or in a seated position.
I
--= --= --= --= --=
Thoracic spine articulations
J:
.s: .s: J: E:
II: E:
II: ~
I: ~
~ ~
\
Direction of joint rolling and gliding during thoracic ventral and dorsal flexion Ventral Flexion
Dorsal Flexion
Direction of joint rolling and gliding during thoracic coupled side bending and rotation in ventral flexion Left Side Bending and Rotation
Right Side Bending and Rotation
Translatoric Spinal Manipulation
I 77
II: I
Biomechanics of Thoracic Spine TSM Disc Traction Thoracic disc traction TSM techniques are performed with the patient in a seated or supine postion.The caudal vertebra is stabilized with a wedge or through direct manual stabilization. The impulse is directed cranially through the patient's shoulder girdle and upper trunk.
Position - the actual resting position
-=
E! E! E!
II:i II:i
-=
-= -=
-=
II:
Facet Distraction Thoracic facet distraction TSM techniques can be performed unilaterally or bilaterally. They may also be performed moving the cranial vertebra (typically in supine or sitting) or caudal vertebra (in prone). Stabilization of the cranial or caudal vertebra is achieved through either the use of the hand, the wedge or through spinal locking above or below. Unilateral distraction techniques are performed with sidebending away and rotation towards the treatment side.
Bilateral Facet Distraction Positioning - actual resting position
Unilateral Facet Distraction Positioning - sidebending away, rotation towards the side of facet distraction
Impulse directed posteriorly towards the left facet joint Facet joint compression
Caudal stabilization
Caudal stabilization
Cranial stabilization Facet joint distraction
Cranial stabilization Facet joint compression Impulse directed ventrally, medially and slightly caudally
-= -= -= -= -= -= -= -= -= -= -= -=s: -=
-= -=
• 78
I
Chapter 4 :
Thoracic Spine Application
F
Thoracic-Disc Traction
EL - LV PP - HV & LV
Indication: To improve movement in all directions Position: Supine
The therapist faces the patient's chest. The therapist supports the patient posteriorly with their left hand and forearm supporting the patient's upper back and neck. The therapist's right hand is placed on the midline of the patient's crossed forearms.
The patient is positioned in supine with their thoracic spine, including the treatment segment, positioned in the actual resting position. The patient's arms are positioned across their chest along the ribs connecting to the cranial vertebra in the
Troubleshooting your technique: Monitor that the patient's cervical region is relaxed, well supported and not hypertlexed or hyperextended when performing this technique.
Note(s) Translatoric thoracic disc traction is a good initial treatment option if a thoracic segment is very hypomobile (Grade I restriction on the 0-6 KE mobility scale). Once the thoracic segment demonstrates improved mobility, translatoric thoracic unilateral or bilateral facet traction manipulation may be applied. Translatoric thoracic disc traction is a good initial treatment option if there is intercostal pain radiation. In technique variation A pictured above, the therapist uses a "pistol grip" (see illustration on next page) to support the caudal vertebra. A pillow or the movable head section of a manual therapy table may be used to support the position of the treatment segment and the spinal segments cranial to the treatment segment. In technique variation B, a wedge is used to support the caudal vertebra in the treatment segment. The therapist then uses both oftheir hands placed on the patient's overlapping forearms and elbows to generate the manipulative impulse.
Translatoric Spinal Manipulation I
79
Thoracic-Facet Traction
EL - HV & LV PP - HV & LV
Indication: To improve movement in all directions Position: Supine The therapist faces the patient's chest. The therapist's right wrist is positioned in ulnar deviation. The fingers are positioned with the index finger straightened and fingers 3-5 flexed. The distal phalanx of fingers 3-5 are positioned perpendicular to the palm. The spinous process of the caudal vertebra is placed between the flexed fingers and the thenar
The therapist contacts the patient posteriorly with their right hand stabilizing the transverse processes of the caudal vertebra in the treatment segment (see box 3). Slack in the treatment segment is taken up by pressing dorsally and cranially towards the transverse process of the caudal vertebra in the treatment
The therapist's left hand is placed on the midline of the pat.isnt's crossed forearms.
The patient is positioned in supine with their thoracic spine, including the treatment segment, positioned in the actual resting position. The impulse is directed against the therapist's flexed fingers and thenar eminence and slightly cranial to the transverse process of the caudal vertebra in the treatment segment.
-=
-= -= -=
-= &:
&: &: &: JC
&: &: JC IC IC IC IC IC
-= -= II:
s: Troubleshooting your technique: It is important to maintain a light contact with the patient when positioning for this technique.
This may require additional support for the patient's upper body to minimize discomfort prior to and immediately following the manipulation. This may be accomplished by reaching behind the patient's upper back as illustrated on the previous page.
Note(s) The section of the table located under the thoracic spine may also be elevated to reduce pressure against the stabilizing hand or thoracic wedge. For these pictures, the middle thoracic spine is treated with the patient's head and upper thoracic spine positioned
on the head section of the table which is then elevated slightly. The lower thoracic spine is treated with the head and the middle thoracic spine positioned on the foot portion of the table which is then elevated. The patient's anns are positioned across hislher chest cranial to the treatment segment.
Note the orientation of the therapist's arm and hand under the patient. The therapist's arm and hand should be placed medial to the inferior angle and medial border of the scapula.
80 I
Chapter 4 : Thoracic Spine Application
-=
II:
s:
II: II:
-=
Thoracic-Facet Traction
EL - HV & LV PP - HV & LV
Indication: To improve movement in all directions Position: Supine
The therapist supports the patient's upper back and neck .-.:::::...-, posteriorly with their left hand and forearm. The therapist's right hand is placed on the midline of the no';onll'. crossed forearms.
Slack in the treatment segment is taken up by the therapist's chest and hand pressing dorsally and cranially towards the transverse process of the caudal vertebra in
The patient is positioned in
supine with their thoracic spine, including the treatment segment. positioned in the actual resting position. The patient's arms are positioned across the chest along the ribs connecting to the cranial vertebra in the
The base of the wedge is placed against the transverse process of the caudal vertebra in the treatment segment.
Troubleshooting your technique: , As with any of the thoracic facet traction techniques, care should be taken to avoid movement into thoracic dorsal flexion during the impulse. Note(s) In cases of significant hypomobi lity, in order to generate the greatest improvement in motion in a given spinal segment, it is necessary to manipulate the treatment segment in the position where the greatest joint play is nonnally felt. Specifically, if the therapist is unab le to determine where the joint moves the easiest or greatest, then the manipulation should be performed where the segment's resting position is estimated to be. To achieve this position in the treatment segment, wh ile stabilizing the caudal vertebra, the therapist must test the movement of the treatment segment in varying degrees of ventral and dorsal flexion. The impulse is performed in the position where the movement is felt to be the greatest and the end feel the most firm and nonmuscular. The patient's arms are positioned across hislher chest cranial to the treatment segment. The dorsa l cranial movement should occur immediately above the wedge during this technique. In the Haltemative arm position" picture, the patient's arms are not crossed, rather the shoulders and elbows are fl exed and the hands are overlapped behind the neck.
Translatoric Spinal Manipulation
I 81
F
-I:
Thoracic-Facet Traction
EL - 0 PP - HV & LV
Indication: To improve movement in all directions Position: Supine
The therapist stands on the right side of the patient facing the patient's chest.
The therapist supports the patient posteriorly with their left hand and forearm supporting the patient's upper back and neck. The thenar
eminence of the right hand stabilizes the caudal vertebra as described under box 2. Anteriorly, the therapist contacts the patient's elbows with their chest.
--= --= --= --= --= --= --= --= --= --=
11:
--= --= treatment segment, is positioned in ventral flexion , right side bending and left rotation
segment is taken up dorsally and cranially towards the left transverse process of the caudal vertebra in the treatment
~
.s: ~
c placed under the left transverse process of the caudal vertebra in the treatment
Troubleshooting your technique, It is important to be sure that the stabilizing hand is positioned medially and on the spine as described above. If the hand is positioned laterally on the rib and the impulse is directed dorsally, the rib may bend. This may result in pain and potentially a rib injury, including fracture, if treating a patient with osteoporosis. Note(s) This technique is often app lied when thoracic rotation is restricted and painful. This technique is also good when a therapist with a small stature is treating a patient with a relatively large stature. This technique may be applied prior to bilateral facet traction in a segment that is slightly more hypomobile.
If the arm/hand used to stabilize the caudal vertebra is not long enough to reach around the patient, this technique may be perfonned with tbe therapist using bis/her right hand while standing on the left side of the patient (see next page).
c c ~
-=1m
•
-=II:
•IF
• IF
82
I Chapter 4 : Thoracic Spine Application
EL - I2J
Thoracic-Facet Traction PP - HV & LV Indication: To improve movement in all directions Position: Supine
The therapist stands on the left side of the patient facing the patient's chest. The therapist contacts the patient posteriorly with their
right hand stabilizing the transverse processes of the caudal vertebra in the treatment segment (see box 2). Slack in the treatment segment
The therapist's left hand is
is taken up by pressing
placed on the midline of the
dorsally and cranially with the therapist's chest and left hand towards the left transverse
patient's crossed forearms.
The impulse with the chest and left hand is directed slightly cranial to the left transverse process of the
caudal vertebra in the treatment segment. The therapist's right wrist is positioned in the midposition . The thumb is adducted and placed anteriorly to the second metacarpal and index finger. The thenar eminence is placed under the left transverse process of the caudal vertebra in the treatment segment.
spine, down to and
.....~" ~=__~ including the cranial vertebra in the treatment segment, is positioned in ventral flexion, right side bending and left rotation (locked above).
,..-_....:::=-.c= '---== '--__-'
Troubleshooting your technique: The patient should feel greater pressure posteriorly on the side of the spine that the therapist's hand is positioned under.
Note(s) During the impulse, support under the left transverse process of the caudal vertebra will allow the cranial vertebra in the treatment segment to rotate to the left, generating traction in the left facet joint during the manipulation. The spinal positions, therapist contacts and arm placements, all of which have been described in the previous bilateral facet distraction techniques in supine. may be used with this technique to create unilateral facet distraction .
When choosing the arm position for this or any other thoracic techniques using pressure through the shoulders, the therapist must confirm that the patient's shoulders are comfortable throughout the technique. The alternati ve ann position pictured above uses a cross armed position where the right hand is placed on the left shoulder and the left hand is placed on the right shoulder.
Translatoric Spinal Manipulation
I 83
-'=
Thoracic-Facet Traction
EL - HV & LV PP - HV & LV
Indication: To improve movement in all directions Position: Supine
The right transverse process
of the cranial vertebra in the treatment segment is placed on the right side of the base of the wedge.
--= --=
---=
--= --= --= --= --= --= --=
--= --=
-
__ facet traction. A notch is cut on one side to remove stabilization of one side of the
cranial vertebra in the treatment
Troubleshooting your technique: The patient's treatment segment should be positioned without side bending or rotation prior to the manipulation, however, segments cranial to the treatment segment may be locked in either dorsal or ventral flexion.
Note(s) During the impulse, the notch in the wedge will allow the cranial vertebra in the treatment segment to rotate to the left, generating traction in the left facet joint during the manipulation. The spinal positions, therapist contacts and arm placements, all of which have been described in the previous bilateral facet distraction techniques in supine, may be used with the modified wedge to create unilateral facet
distraction.
-= -= --= -= -=c:
c: c:
s: s: s:
-=s:
s:
.
~
84
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Chapter 4 :
Thoracic Spine Application
Thoracic-Facet Traction
EL - HV & LV PP - HV & LV
Indication: To improve movement in all directions Position: Prone
The therapist stands facing the patient's head. The base of the wedge is placed on the transverse processes of the caudal vertebra in the treatment segment. The therapist places both hands on the base of the wedge as illustrated below.
The manubrium is supported on a firm roll when T1 and T2 are treated with
The slack and impulse are directed ventrally, ' 0 : " - -_ _
ventrally caudally and ventrally cranially depending on where in the thoracic spine the facet traction is performed. See arrows for the general direction of
movement.
ILIiII..::il1iI
Troubleshooting your technique: Failure to properly contact the caudal vertebra with the wedge or failure to identify the proper direction of the impulse may lead to a less effective technique. Note(s) The direction of the impulse used during this technique must be adjusted to compensate for patients with either extremes of thoracic flattening or kyphosis.
Translatoric Spinal Manipulation
I 85
I:
Thoracic-Facet Traction
EL - LV PP - HV & LV
Indication: To improve movement in all directions Position: Prone
I: I:
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The therapist stands on the left side of the patient facing the patient's thoracic spine. The therapist contacts the patient posteriorly with their left pisiform on the right articular process, lamina and transverse process of the caudal vertebra in the treatment segment.
I: I:
I: The patient's thoracic ;""_ _.J spine, down to and including the cranial vertebra in the treatment segment, is positioned in dorsal flexion, right side bending and right rotation (locked above).
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I:
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II: ~ Troubleshooting your technique: The thoracic spine is supported in dorsal flexion , right side bending and right rotation through the use of a firm roll. If the roll is too soft, the locking may not be firm resulting in a less specific and potentially ineffective technique. To be most effective, the impulse should be directed at a right angle to the articular surface of the facet joint.
II:
~
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Note(s) Locking in dorsal flexion may not be comfortable for patients who are kyphotic and significantl y hypomobile. In
86
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these cases, the thoracic spine may be positioned in flexion left side bending and right rotation.
II:
This technique may also be performed by pulling the shoulder in a dorsal and caudal direction with the right hand. This is technique variation is illustrated in the lumbar spine on page 119.
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I Chapter 4 : Thoracic Spine Application
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Thoracic ribs There are different anatomical classifications for the thoracic ribs and rib joint articulations. For example, ribs 2 through 9 can be referred to as the typical ribs. Typical ribs articulate with their vertebral body and the vertebral body one level above. The atypical ribs are numbers I, 10, II and 12. These ribs articulate only with their numerically corresponding vertebrae. The articu lation of ribs to the vertebral body is known as the costovertebral joint. These are very stable articulations with strong capsoligamentolls reinforcement. The costovertebral joint are synovial and subject to the development of symptomatic motion restrictions. The ribs may also be classified based on their attachment to the sternum. For example, ribs I through 6 can be referred to as the vertebrosternal ribs in that they have direct attachment into the sternum. Ribs 7 through 10 can be referred to as the vertebrochondral ribs. The development of symptomatic irritation at these anterior rib articulations can at times be improved by the appl ication ofTSM to hypomobile posterior rib articulations. Regarding the other posterior rib articulations, the recognition of the positional relationship between the ribs to the corresponding thoracic transverse process is of both anatomical interest and clinical importance. Regarding the upper (vertebrosternal) ribs, they articu late both anteriorly and inferiorly to their numerically corresponding thoracic transverse process. The lower (vertebrochondral) ribs lie anteriorly and slightly superiorly to their transverse process. These articulations are known as the costotransverse joints. Similar to the costovertebral joints, these synovial articulations are also subject to the development of symptomatic movement impairments. Lastly, and very generally, is a brief review of rib movement or kinematics. From an osteokinematic perspective, all ribs can be generally seen to move obliquely upward, outward and forward during inspiration. On an arthrokinematic level, the motion thought to produce this rib cage movement is a long axis rotation through the mechanically combined costovertebral and costostemal articulation.
Position of the ribs relative to the transverse processes Orientation of the transverse costal facet
Direction ofTSM impulse
Upper thoracic
Upper thoracic
Middle thoracic
Middle thoracic
Lower thoracic
Translatoric Spinal Manipulation I
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,
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Biomechanics of Rib TSM Costotransverse and Costovertebral glides and distraction Arthrokinematic movements occurring during rib T5M vary depending on the direction of force used. When the impulse is directed more ventrally, distraction occurs at the costotran sverse (CT) jOint and gliding occurs at the costovertebral (CV) joint. When the impulse is directed more laterally, gliding occurs at the costotransverse joint and distraction occurs at the costovertebral joint. During rib T5M, it is difficult to generate much lateral movement of the rib due to lateral sliding of the manipulating hand on the rib. Therefore, ventral forces combined with inferior, superior and lateral forces (dependant on the level of the rib) are most commonly used to treat the costotran sverse joints. During rib T5M, the spine may be stabilized (prone and seated techniques) and the rib moved or the rib may be stabilized and the spine moved (supine technique).
Positioning -In prone, the spine and rib are in the actual resting position; in seated and supine, the spine is in flexion, side bending away and rotation towards the treatment rib. CT and CV joints at rest
Prone technique with spinal stabilization Ventrally and slightly laterally directed
impulse
--= --= --= --= --= --= --= --=
-= -= -=E E ~ ~ ~
~ ~ ~ Seated and supine technique with rib stabilization
-=
II;
11m
IE
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-= ~
. 5
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I Chapter 4 : Thoracic Spine Application
First Rib-Distraction
EL - LV PP - HV & LV
Indication: To improve movement in all directions Position: Supine
The therapist is positioned the left side of the patient's head. The therapist's left hand presses ventrally and medially through upper trapezius muscle in the direction of the first rib. The therapist supports the
= =====. position of C7 by (1) stabilizing ~_..,
against the lamina and tra'1Sv
patient's head with the right side of the therapist's chest.
costotransverse joints is taken up in a ventral and caudal direction by the therapist's left hand prior I
the
Troubleshooting your technique: In order to lock from above and maintain the lock, right side bending must be maintained when the neck is left rotated. Note(s) Tbe therapist may also apply a craniall y directed traction to the neck by using the right side ofbislher cbest and right hand. The traction acts as a counterforce to the caudally directed force used during the manipulation. If the cervical muscles on the left side of the neck are significantly tight, they may hinder the movement of the first rib during this technique wben using locking above. In these cases, stretching of the muscles (i.e. the scalene muscles) should be perfonned prior to and following successive high and low velocity translatoric manipulation. In addition, locking from below may be used to stabili ze Tl, ifllsing locking above is contraindicated due to patient discomfort or pathology in the cervical spine.
Translatoric Spinal Manipulation
I 89
_I:
First Ri b - D i st racti 0 n
EL - LV PP - HV & LV
Indication: To improve movement in all directions Position: Seated
I:: -I::
I:
--= -I:
The therapist stands . patient. The therapist contacts the patient (1) posteriorly and cranially on first rib with the radial border of their right second MCP and (2) anteriorly and laterally with their left medial forearm and distal arm
against the left side of the patient's neck supporting the position.
I: I:
--=
.J:
--'= -I: I: -I:
.J: I: JC The therapist's right hand impulses taken up in a ventral and '---I ventrally and caudal direction by the r caudally. therapist's right hand to delivering the
costotransverse joints is
JC JC JC
11: Troubleshooting your technique: The therapist's left forearm must be firmly placed agai nst the left side of the patient's cervical spine for proper stabilization of the cranial vertebra in the locked position. Caudal pressure against the shoulder girdle and sternum should be avoided and may cause patient discomfort. If the scalene muscles are tight and are restricting the movement of the first rib, the therapist should perform manual muscle stretching prior to mobilizing the first rib. This principle is typically used in cycles where the muscles are stretched, the joints are mobilized and the muscles are stretched again until the movement is restored. Note(s) This technique can also be performed as a facet traction manipulation by moving the right hand medially onto the articular process, lamina and transverse process of the caudal vertebra.
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I Chapter 4 : Thoracic Spine Application
-=11: -=
-=
• -=
• ••
First Rib-Distraction
EL - 121 PP - HV & LV
Indication: To improve movement in all directions Position: Seated
The therapist stands behind the patient. The therapist contacts the patient (1) posterior1y and cranially on the first rib with the radial border of their right second MCP and (2) anterior1y with their left hand and forearm on the patient's crossed arms, supporting thoracic flexion. right side bending and I
After the slack in the lock is taken up with the therapist's left arm and body, slack in the costovertebral and costotransverse joints is taken up ventrally. caudally and slightly medially.
The patient's thoracic spine is positioned in ventral flexion, right side bending and left rotation (locked in flexion).
The patient's lumbar spine is positioned in dorsal flexion, left side bending and left rotation (locked in extension).
A roll is placed behind the low back. A wedge is placed under the left ischial
Troubleshooting yo ur technique: The position used for locking below must be painfree for the patient. If the patient experiences pain during positioning, the therapist should try to vary the position and lock accordingly to find a position of minimal to no discomfort prior to performing this technique. Note(s) The movement used during treatment will facilitate greater locking in the thoracic spine. In this position, the right cervical muscles are slackened and will not hinder the movement of the first rib during this technique.
When two forms of locking are used during a technique it is called "double locking".
Translatoric Spinal Manipulation
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EL - I2J PP - HV & LV
Ri bS2-12- Distraction Indication: To improve movement in all directions Position: Supine
The therapist contacts the patient posteriorly with their left hand and
forearm supporting the patient's upper back and neck. The thenar eminence of the right hand stabilizes the rib being treated as described under box 2. The right side of the therapist's chest
contacts the patient's right lateral humerus and left distal forearm and hand. The i directed across the body in the direction of the tip of the thumb to maximize vertebral
movement on the rib, while minimizing rib compression. In supine, the patient's thoracic
spine is positioned in ventral flexion , right side bending and left rotation . The patient's arms are positioned across their chest above the level of the rib
Slack in the costotransverse and costorvertebral joints is taken up during the positioning of the thoracic spine in flexion , right side bending and left rotation .
The thumb is adducted and placed anterior to the second metaca rpal and index finger. The thumb and thenar eminence are placed under the rib, with the tip of the thumb placed immediately lateral to the left transverse process of the adjacent vertebra.
Troubleshooting your technique: A direct dorsal pressure may "bend" and injure the rib. Note(s) Ifthe therapist is having difficulty generating the impulse using the chest alone, the right hand may additionally apply a quick, short lateral impulse along the the rib.
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I Chapter 4 : Thoracic Spine Application
Ri bS2-12- Distraction
EL - LV PP - HV & LV
Indication: To improve movement in all directions Position: Prone
The therapist stands either at the head of the patient (upper-middle ribs) or beside the patient (lower ribs).
The therapist contacts the patient with the ulnar border of their left hand placed next to the spinous process. pressing in the direction of the patient's left transverse processes and ~~1)' I'l ribs and the pisiform of their right hand on the rib slightly lateral to the corresponding thoracic vertebra's transverse process.
transverse and costovertebral joints is taken up in a ventral and slightly lateral direction with the right hand.
Troubleshooting your technique: During this technique. failure to properly stabilize against the transverse processes can lead to movement of the vertebral segment. In order to properly stabilize the vertebra, the stabilization pressure should increase during the impulse. Note(s)
Jfthe stabi1ization force is reduced, this technique can be used to begin small rotational movements in the thoracic spme. The stabilization force should be gradually increased as the slack in the costovertebral and costotransverse joints is taken up prior to the manipulation. When giving the impulse, the right hand may slide in the direction of the arrow which will help generate a quicker impulse.
Translatoric Spinal Manipulation
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EL - 121 PP - HV & LV
Ri bS2-12- Distraction Indication: To improve movement in all directions Position: Prone
The therapist contacts the patient (1) with their right hand on the patient's right shoulder girdle pulling the shoulder posterior1y to rotate the thoracic spine to the right and (2) with the ulnar border of their left hand on the rib. The pisiform is placed lateral to the transverse process of the vertebra adjacent to the treated rib.
c: c:
-=c
side of the patient.
-=c:
The left hand impulses ventral, ventral caudal or ventral cran ial depending on which rib is being treated . See the
s: c c c c
c Slack in the treatment segment is taken up during the positioning of the thoracic spine in dorsal flexion, right side bending and right rmatlc,n.'
A roll. pillow or other support may be placed under the patient's right arm, shoulder girdle and torso to assist in positioning the patient in right rotation. The therapist may then use their right hand to support their left wrist and hand the
Troubleshooting your technique: The therapist should confirm that the patient tolerates the contact to the anterior shoulder when positioning for this technique. If the contact is not tolerated, the therapist may ( I) try diffusing his/her contact pressure throughout the hand or (2) try positioning the patient by pull ing from the anterior/superior chest instead of the shoulder. If the force used during th is technique is directed too ventral, the rib may be bent and potentially injured. Note(s) The superior ribs are suspended below the transverse process, so the direction of the impulse is ventral and slightl y cauda l. The middle ribs are positioned in front of the transverse process, so the direction of the impu lse is ventral. The inferior ribs are positioned slight ly above the transverse process, so the direction of the impu lse is ventral and slightly cranial. The direction of the impulse will also further reinforce the locking above.
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I Chapter 4 : Thoracic Spine Application
c
C I: C C I: II: II:
II:
-=II: -=E It It
. ~
Ri bS2-12- Distraction
EL - LV PP - HV & LV
Indication: To improve movement in all directions Position: Seated
The therapist contacts the patient (1) posteriorly and laterally with the left side of their lower chest and abdomen (supporting the locked noncoupled ventral flexion position of the thoracic spine), (2) anterior with their left hand and arm holding the patient's right shoulder and controlling the patient's ventral flexion, left side bending and right rotation and (3) posteriorly on the rib , lateral to the thoracic transverse process with the radial border of the right hand and index I
The right hand impulses ventrally, ventrally cauda lly or ventrally cranially. See the I "n"tel's)" section below
I In" I"rth,,, detail.
take up the slack, the rib is stalbiilized the thoracic spine above is moved into right rotation (while the ventral flexion and side bending are maintained). Next, the right hand takes up the slack in the costotransverse and costovertebral by pressing the rib in a ventral, ventral caudal or ventral cranial direction dependant on which rib is treated.
Troubleshooting your technique: Failure to adequately lock through the adjacent vertebral segments may lead to motion in the spine in addition to the rib. The patient's arms must not be pressed against the rib cage as this may block movement of the rib undergoing treatment. Note(s) The seated position is potentially less aggressive than the supine position because the patient's trunk weight is not being used to generate the stretch. The superior ribs are suspended below the transverse process, so the direction of the impulse is ventral and slightly caudal. The middle ribs are positioned in front of the transverse process, so the direction of the impulse is ventral. The inferior ribs are positioned slightly above the transverse process, so the direction of the impulse is ventral and slightly cranial.
Translatoric Spinal Manipulation
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C II:
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II:
IC II: II:
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II: II: II:
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Lumbar Spine u@©W ITiJ 0CQ] OJ]@
The Lumbar Spine Osseous anatomy
Articular surfaces of the lumbar spine
The smallest functional unit of the spinal column is the motion segment. The motion segment consists of two adjacent vertebrae and all of their interconnecting structures. Vertebrae can also be divided into other
I:
pedicles and the posterior elements. What follows is a brief review of
I:
these components in the lumbar region.
The lumbar vertebral body is clearly larger than both thoracic and cervical vertebral bodies. It is flat on its superior and inferior surfaces and slightly concave on the anterior and lateral surfaces. The vertebral body has a greater transverse diameter as compared to its anterior diameter and height. The shape of the lumbar vertebral body reflects its responsibilities in terms of supporting longitudinally applied loads. While stable for these longitudinal loads, the lumbar segments are dependent on the posterior structures for stability in other planes. The body of the vertebra and the intervertebral disc support 85% of the weight-bearing requirements of the movement segment. The pedicles attach to the upper posterior portion of the vertebral body. They are the only connection between the posterior elements and the vertebral bodies. All forces sustained by any of the posterior elements are ultimately channeled to the pedicles which then transmit these forces to the bodies. The posterior elements provide attachment sites for many of the lumbar ligaments and muscles. They provide rigid levers for the restriction and enhancement of movement. The laminae project from each pedicle
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towards the midline and serve to protect the contents of the sp inal canal.
Forces that act on the spinous and articular processes are transmitted to
I:
the laminae . The part of the lamina that is found between the superior
posterior extension of the lamina is the spinous process. This structure represents the uniting of the two laminae in the midline. The spinous
processes are broad and thick and extend horizontally. Another structure considered a part of the posterior elements is the transverse process (TP). The TPs extend from the junction of the pedicle and lamina. The TPs are flat and rectangular and extend in a posterior and lateral direction. The facet joints are also an important component of the lumbar posterior elements. In the most basic sense, the facet joints are formed
by the articulation of the inferior art icular process of the cranial lumbar vertebra and the superior articular process of the caudal vertebra in the
spinal motion segment. The facet joints support 15% of the weightbearing requirements of the lumbar motion segment. Viewed from behind, the articular facets appear as straight surfaces, suggesting that they are planar. When viewed from above, it can be seen that the lumbar facets vary in the shape of their articular surfaces and in the general direction they face. In the transverse plane, the articular facets may be flat, planar, slight ly curved or curved in a "C" or "J" shape. The class ic C-shaped orientations are particularly we ll suited to resist and constrain against excessive motion in
two principal directions. The sagittal portion of a C-shaped facet will limit excessive rotation in the transverse plane while the more frontal portion of the facet surface wi ll limit excessive anterior translation. Certain
developmental and degenerative changes reduce the ability of the facet joint to resist loading. When these joints develop with an asymmetrical unilateral variation it is ca lled facettropism. Articular cartilage covers the superior and inferior articular 98
I Chapter 5 :
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anatomica l or functional components such as the vertebral body, the
and inferior articular process on each side is the pars interarticularis. The pars is thicker than other portions of the lamina and is typically able to withstand large bending forces. Individuals with insufficient bone structure in this area are susceptible to fractures (spondylolysis) as a result of excessive or sudden forces applied to the interarticularis region. The
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Lumbar spine articulations
I: I: I: II:
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processes and assumes the same concave or convex curvature of the underlying facet. The cartilage is generall y thickest over the center of eac h facet. Around its dorsal, superior and in ferior marg ins, each lumbar facet joint is enclosed by a fibrous capsule. The anterio r capsule is reinforced by the ligamentum flavom. The posterior portio n of the lumbar facet joint capsule blends with fibers of the deep lumbar extensor mu scles. Situated aro und the borders and within each facet joint are meniscoid bodies co mposed of fat and surrounded by fibrous ti ssue. These meni scoids move into and out of the facet joints during movement to enhance the articular congruency. The vertebral foramen is formed anterio rly by the vertebral body, the intervertebral disc and the posteri or longitudinal ligament. The posterior aspect of the vertebral foramen is formed by the lamina and li ga mentum flava. The lumbar vertebral fo ramen shows three ty pical shapes, oval, triangular and trefo il. Genera lly, the upper lumbar reg ion foramen are ova l in shape and the lower lumbar regio n are more triangular or trefoil in shape. When articulated together, the fi ve lumbar vertebrae form the lumbar canal. The size and shape of the lumbar cana l will vary based on a number of potential factors, including th e size and shape of the pedi cles and facets.
Ligamentous anatomy There are three princi pal li gamentous structures that interconnect the lumbar vertebral bodies. These structures include the annulus fibrosus, the anterio r longitudin al li gament (A LL) and th e posterior longitudin al ligament (PLL). Based on its size and strength, the peripheral po rti ons of the annulus fibrosus are arguably the princ ipal stabilizing structure that unites the lumbar vertebrae at the intervertebral di sc joint. The ALL consists of muhiple sets of both long and short collagen fibers. The most superficial fibers are the longest and may traverse four to five vertebral segments. The deep sets of fibers connect adj acent segments. The principal function of the A LL is to res ist excessive separati o n o f the anterior aspects of the lumbar vertebral bodies. The PLL runs alo ng the dorsal surfaces of the vertebral bodies and w idens laterally over the posterio r surface ofth e intervetebral di scs where it blends with the annulu s fibrosus. This ligament run s inside of the vertebral canal and anterior to the spinal cord and cauda equina. Its princ ipal biomechanical function is to resist separation of th e posteri or aspects of the lumbar vertebral bodies. Simil ar to the PLL, the ligamentum flavum is an intraca nalli gament. This structure is primaril y composed of elastin fibers. It is short, fa irly thick and connects successive lumbar laminae. The li gamentum flavum primarily resists excessive separation of the laminae.
The intervertebral disc (lVD) The IVD consists of three principal components, the nuc leus pulposus, the annulus fibrosus and the vertebral endplates and form s the principa l connectio n between the vertebral bodies. The nucleus pulposus is a semi-fluid substance that is subj ected to muhi-directio na lloads. Given its structu re and anatomical constituents, the nucleus w ill deform, aher its shape and subsequentl y transmit or di stribute loads equall y in all di rections. The annulus fibrosus co nsists of 6 to 20 sheets or rin gs , also known as lamellae. The annul ar rings are arranged in a concentric fashi on aro und the nucleus. Centrall y, the annul ar fibers become more loose ly arranged and blend wi th the nucleus pulposus. Similar to other ligamento us structures, the princ ipal function of the annulus fibrosus is to constrain motion. The annulus not only binds th e two vertebral end plates together, but also functions as the principa l stabilizing structure between the two vertebral bodies at the lVD joint. Examination, eva luation and biomechanical intervention for the IYD j oint is paramount to the practice of TSM. Joint play testing examines the translato ric mobility at the IYD joint and various translatoric disc tractio n manipulation techniques seek to improve mobil ity and reduce load at this same articulation. The vertebra l end plates are fo und between each IYD and adjacent vertebral bodies. The end plates consist of both fibrocartil age and hyaline cartil age. This structure covers the nucleus pul posus, allows fluid diffusion into the IYD and further serves to protect the vertebral body by transmitting a po rti on of the we ig ht-bearing requirement.
Vascular anatomy In brief, the principa l blood supply fo r the lumbar spine comes from the lumbar arteries. Pa ired lumbar arteries arise from the aorta and descend along the anterior and lateral aspect of the lumbar vertebra l bodies. Do rsally directed branches of the lumbar arteries pass under the transverse processes and supply the deep lumbar extensor/rotator muscles as well as the facet joints. Further branching of thi s artery occurs opposite the lumbar intervertebra l foram en. These branches suppl y important anatomical structures w ithin the vertebral ca nal.
Translatoric Spinal Manipulation
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Direction of joint rolling and gliding during lumbar ventral and dorsal flexion Ventral Flexion
Dorsal Flexion
-= -=E: E: E: E:
Direction of joint rolling and gliding during lumbar coupled side bending and rotation in ventral flexion Left Side Bending and Rotation
Right Side Bending and Rotation
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I Chapter 5 : Lumbar Spine Application
Biomechanics of Lumbar Spine TSM Disc Traction T5M techniques generate lumbar disc traction by either (1) lifting the thoracic spine off the lumbar spine in sitting, (2) moving the pelvis and sacrum caudally in side-lying or prone or (3) moving the pelvis away from the thoracic cage by performing a body drop into the side of the patient while simultaneously pressing the pelvis and sacrum caudally. In effect, these techniques elongate the lumbar spine, reducing the lumbar lordosis. Traction provides a uniform stretch to the discal tissues and surrounding segmental structures in addition to facilitating intervertebral foraminal decompression.
In side-lying
In sitting
force patient's
loil,e",non. humerus
i generated by
the supoort roll and treatment table.
The arms and forearms are pulled against the patient's rib cage prior to the Ii
Translatoric Spinal Manipulation
1101
... Biomechanics of Lumbar TSM Side Bending Lumbar side bending techniques are used to restore side bending while minimizing associated coupled rotation. Side bending techniques are performed in side-lying with the spine side bent toward s or away from th e surface of the table. When performing a right side bending technique in ventral fiexion, the thoracic and lumbar spines are positioned in right side bending and left rotation prior to the TSM, thereby locking the spine, to minimize coupled right rotation. When performing a right sidebending technique in dorsal fiexion, the thoracic and lumbar spines are positioned in right side bending and right rotation prior to the TSM, thereby restricting the coupled left rotation that w ill occur w ith right side bending. When performing side bending towards the table, a towel roll or bolster is used to position the spine. Side bending may then be applied to one or more spinal segments. When treating a specific spinal segment, the TSM impulse is directed over the cranial portion of the roll (when positioned in ventral flexion) or over the caudal portion of the roll (when positioned in dorsal fiexion).
L1-4 Side Bending Right side bending TSM in ventral flexion
Right side bending TSM in dorsal flexion
Side bending towards the table
Side bending toward s the table
Side bending away from the table
Side bending away from the table
The patient is positioned in side-lying with their lumbar
The patient is positioned in sidENying with their lumbar and thoracic spine in dorsal flexion , right side bending and right rotation.
and thoracic spine in ventral flexion, right side bending
and left rotation.
L5 Side Bending Right side bending TSM in ventral and dorsal flexion Side bending TSM for the L5 segment can be performed in both ventral and dorsal flexion, the same as when treating L1-4. However. when side bending lS, the sacrum is stable. Therefore. the direction that L5 is moved is relative to the pelvis. To improve right side bending at LS, L5 is translated to the right. To improve left side bending at LS. L5 is translated to the left. Noncouplingllocking is used as described above to stabilize against coupled rotation at L5 .
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Biomechanics of Lumbar TSM Facet Distraction As discussed previously, the lumbar facet joints are typically (- or J-shaped. Therefore, facet distraction TSM techniques in the lumbar spine generate different amounts of facet distraction between the anterior, middle and lateral surfaces of the facet joint depending on how they are performed. To emphasize distraction at the anterior aspect of the joint, a bilateral ventral force is applied to the caudal vertebra in the treatment segment. To emphase distraction of the lateral aspect of the right facet joint, a unilateral ventral, lateral and slightly caudal force is applied to the right lamina and posterior aspect of the transverse process. The thoracic and lumbar spine, down to and including the treatment segment, is positioned in extension, right side bending and right rotation (locked in extension). This position causes compression of the facet joint on the left and assists in generating facet distraction of the right facet.
In prone Bilateral facet distraction
Unilateral facet distraction
fStiiliiiii:afu~
i
above in extension, right
sidebending and right rotation.
i ventrally. laterally and slightly caudally against
the caudal vertebra in the treatment segment.
Translatoric Spinal Manipulation
1103
I: Biomechanics of Lumbar TSM
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Facet Glide
I:
Lumbar glide techniques may be performed unilaterally, with the therapist's hands, or bilaterally with a firm wedge.
Ventral cranial glide to improve ventral flexion Bilateral technique To improve flexion the patient is positioned in ventral flexion, the caudal vertebra is stabilized and the cranial vertebra is moved in a ventral, cranial direction with a bilateral force.
I:
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E ~ ~
E ~ ~
S
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I: Unilateral technique When applying a unilateral force to improve ventral flexion in the right facet joint, the patient is positioned in coupled ventral flexion, left side bending and left rotation. The caudal vertebra is stabilized and a unilateral ventral cranial force is applied in the direction of the right lamina and posterior edge of the transverse process of the cranial vertebra. i is directed the lamina, articular and posterior edge transverse process of caudal vertebra.
~-...!~~
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5
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Chapter 5 :
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•
Biomechanics of Lumbar TSM Facet Glide Lumbar glide techniques may be performed unilaterally, with the therapist 's hands, or bilaterally with a firm wedge.
Ventral cranial glide (relative dorsal caudal glide) to improve dorsal flexion Bilateral technique To improve extension, the patient is positioned in dorsal flexion, the cranial vertebra is stabilized anteriorly with a cuff weight and the caudal vertebra is moved in a ventral and cranial direction.
Anterior stabilization
Unilateral technique When applying a unilateral force to improve dorsal flexion in the right facet joint the patient is positioned in non coupled extension, right side bending and right rotation (locked above in extension). The T5M is applied in the direction of the right lamina and posterior edge of the transverse process of the caudal vertebra.
_---"1
The thoracic and lumbar spine, down to the cranial vertebra. are positioned in
noncoupled extension (locked in extension).
is directed
Translatoric Spinal Manipulation
1105
a:
Lumbar-Traction
EL - HV & LV PP - HV & LV
Indication: To improve movement in all directions Position: Side-lying
The therapist stands facing the patient's abdomen and pelvis. The therapist contacts the patient posteriorly on the sacrum with their right forearm and anteriorly on the pelvis with the side of their torso.
-= -= -=a: a::: a::: a::: a::: 8:
a::: a:
-=a::: a:::
-=a::: Slack in the lumbar spine is taken up caudally by the therapist's right arm and torso.
The patient is positioned in side-lying with their lumbar spine in a resting or actual resting position (see ~ note(sr seclion below for further information regarding positioning). A sandbag or a towel roll may be used to support the resting position for narrow waisted
arm.
individuals or to accommodate an antalgic
position.
Troubleshooting your technique: Do not let your proximal medial forearm slide over the skin of the sacrum. The impul se remains very short.
Note(s) This technique is most effective if performed on a tab le with a sliding foot section. If a sliding foot section is not available, the patient's lumbar spine must be positioned in slight left side bending prior to the impulse to avoid ending in an right side bent position . When providing a sustained or intermittent low ve loc ity traction using this technique, the therapist uses his/her
arm and body to generate the traction. When performing a high velocity traction, the therapist uses bis/her arm to generate the quickest impulse. A painful lumbar shift or list can be accommodated and supported using the moveable head section of a mobilization table. This wi ll allow the tran slatoric traction technique to be delivered in the patient's actua l resting position .
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Chapter 5 :
Lumbar Spine Application
a::: a::: a: a:::
-=a::: -= -=a: -= -=
Lu m ba r-Traction
EL - HV & LV PP - HV & LV
Indication: To improve movement in all directions Position: Side-lying
The therapist stands facing the patient's abdomen .
The therapist contacts the patient (1) with the flexor surface of the right forearm on the dorsal midsurface of the patient's sacrum, (2) with the left arm and forearm
on the left side and dorsal surface of the rib cage and (3) with the abdomen
between the lower ribs and pelvis.
To provide an impulse using a body drop, the therapist must
maintain the same pressure the patient anteriorly, laterally and posteriorly. The therapist then lifts their head, neck and upper thorax slightly while maintaining the
tension in the slack described in box 3. The impulse is directed medially by dropping the chest and head towards the patient, in combination with a caudal impulse delivered by the right forearm.
Slack in the lumbar spine is taken up
caudally by leaning fOlWard and pressing the therapist's body between the patient's thorax and pelvis. It is necessary to take up a small amount of slack with the right forearm avoid extending the lumbar spine when taking up the slack with the body.
The patient is positioned in side-lying with their lumbar spine in a resting or actual resting position (see "note(sr section below for further information regarding positioning). A sandbag or a towel roll may be used to support the resting position for narrow waisted individuals or to accommodate an antalgic
Slack is taken up prior to delivering the impulse.
Troubleshooting your technique: During the body drop, avoid excessive pressure on the lateral aspect of the patient's pelvis or lower ribs. Note(s) This technique is most effective ifperfonned on a table with a sliding foot section. If a sliding foot section is not available, the patient's lumbar spine must be positioned in slight left side bending prior to the impulse to avoid ending in a right side bent position . When treating a unilateral radicular condition, the therapist must determine which position improves the patient's signs and symptoms the most. This can be assessed in side-lying by examining key signs such as muscle strength and nerve tension sensitivity. In addition, the therapist may monitor dural tension symptoms after taking up the slack in the spine prior to the impulse. If dural symptoms are worsened after taking up the slack, the impulse should not be delivered. Rather, the therapist should attempt to find a position which relieves dural symptoms. L5 translatoric disc traction may assist in reducing patient symptoms by subtly moving the L4, L5 or S I nerve root(s) away from an anatomical source of irritation such as a degenerated and/or hypertrophic structure.
Translatoric Spinal Manipulation 1107
EL - LV PP - HV & LV
Lu m ba r-Traction Indication: To improve movement in all directions Position: Seated
The therapist contacts the patient posteriorly by placing a mobilization wedge, base down, against the transverse processes of the cranial vertebra in the treatment segment. The therapist places both hands anteriorly on the patient's abdomen or crossed arms. The therapist then pulls the patient posteriorly against the and the torso.
taken up cranially by the slight straightening of the therapist's knees. The impulse is directed cranially and is generated by a quick straightening of the therapist's knees.
belt may be placed around the table and the proximal anterior
portion of the patient's thighs to stabilize the lower extremities/pelvis to the table.
The patient is seated with their lumbar spine positioned in a resting or actual resting position.
Troubleshooting your technique: If the table is positioned too high, it may be difficult/impossible for the therapist to generate enough cranial movement to effectively traction the lumbar spine.
Note(s)
The picture above illustrates a lower rib cage and abdominal contact by the therapist. This technique may also be perfonned by contacting the patient's foreanns and elbows. With this second contact, the therapist must pull the anns against the rib cage prior to taking up the slack. The actual resting position of the lumbar spine can be found by making slight adjustments in lumbar ventral flexion, dorsal flexion, side bending and/or rotation. This position may be used in the treatment of acute conditions when it may be necessary to maintain the patient's antalgic position during treatment.
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I Chapter 5 : Lumbar Spine Application
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Lumbar-Traction
EL - HV & LV PP - HV & LV
Indication: To improve movement in all directions Position: Seated
The therapist stands behind the patient. Slack in the lumbar spine is taken up cranially by slightly
The therapist contacts the patient posteriorly by placing a
elevating and retracting the shoulder girdle bilaterally and slightly adducting and extending both shoulders.
mobilization wedge, base up, against the caudal vertebra in the treatment segment.
When taking up the slack, the
The therapist places both hands anteriorly and inferiorly on the
therapist flexes their knees as they pull up on the patient's
patient's crossed arms. The therapist then pulls the patient
posteriorly against the wedge and
The impulse is directed cranially and is generated by
the therapist's torso.
quickly elevating and retracting the shoulder girdle bilaterally while slightly adducting and extending both
A belt may be placed around the table and the proximal anterior portion of the patient's thighs to stabilize the lower I i to the table.
The patient is seated with their lumbar spine positioned in a resting or actual resting position.
Troubleshooting your technique: The therapist must make sure that all the slack in the patient's shoulder girdle is taken up in a cranial direction prior to the impulse.
Tfthe table is positioned too high it may be difficult/impossible for the therapist to generate enough cranial movement to effectively traction tbe lumbar spine.
The therapist should avoid leaning back prior to delivering the impulse as this may lead to spinal dorsal flexion over the wedge during the manipulation. The therapist must not straighten hislher knees when taking up the slack or delivering the impulse.
Note(s) Further slack can be taken up in a caudal direction by lowering the treatment table immediately prior to delivering the impulse. The actual resting position of the lumbar spine can be found by making slight adjustments in lumbar ventral flexion, dorsal flexion, side bending and rotation. This technique can be very effective for unloading, providing traction and assisting in the correction of a lumbar
lateral list (antalgic position/sciatic scoliosis). The antalgic position can be supported by the therapist while the lumbar spine is unloaded (tractioned) by lowering the treatment table.
Translatoric Spinal Manipulation
1109
r
L1-4-Side Bending
EL - HV & LV PP - HV & LV
Indication: To improve right side bending Position: Right side-lying & ventral flexion
The therapist stands facing the patient's abdomen. The therapist contacts the patient posteriorly with both hands pressing medially on the right side of the spinous processes of the lumbar vertebra.
--= --= --= --= --= --= c
--= c c
-= The right forearm contacts the left side of the pelvis posteriorly and laterally. The left forearm contacts the left side of the rib cage posteriorly and laterally. The therapist supports the patient anteriorly by contacting the patient's abdomen with their torso.
The impulse is directed medially with the fingers, caudally with the right forearm and cranially with the left forearm and is generated by quickly flexing the elbows, extending the shoulders and retracting the shoulder girdle bilaterally.
.II: .II: .II: In side-lying, the patient is positioned with their lumbar and thoracic spine in ventral flexion, right side bending and left rotation down to and the treatment
Troubleshooting your technique: This TSM uses a very short amplitude movement. Do not let your fingers slide laterally to the left side of the spi nous processes.
.II: Ie
II: Ie Ie
Note(s) The therapist can also change his/her contact to the left side of the spinous processes and provide functional massage to the left lateral paraspinal muscles. In clinical practice, it is common to blend various intervention techniques such as translatoric manipulation, translatoric mobilization and functional massage. All three fonns of intervention can be readily applied in this position. By virtue of this contact on the lumbar spinous processes, this technique is less forceful then the manual contact used for the specific translatoric lumbar side bending. As such, this is an excellent first manipu lative maneuver to apply as a therapist begins to integrate quick movements into his or her treatment session. Choosing to perform this or any lumbar side bending techniques in either lum bar ventral or dorsa l flexion is based on the position of greatest side bending restriction. When the onset of restricted side bending is recent and the disc or facet joint is suspected as the cause of the restriction, it is often beneficial to treat by side bending away from the direction of greatest restriction. As movement improves, the patient position can be progressed towards the midline. 110
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I Chapter 5: Lumbar Spine Application
Ie Ie ~
-=WI
EL - LV PP - HV & LV
Ll-4-Side Bending Indication: To improve right side bending Position: Left side-lying & ventral flexion
The therapist kneels on the table facing the patient. The therapist's right thigh is pressed gently but firmly against the patient's
lower abdomen. The therapist presses in the direction of the right articular sulfaces of the cranial and caudal vertebrae with the ulnar
border of the right hand. The therapist's right wrist is slighUy extended and radially deviated. The therapist uses their left hand to reinforce the position of the right wrist.
To provide an impulse using a body drop, the therapist takes up the slack
medially (described in step 3). The therapist then lifts their head, neck and upper thorax slightly while maintaining the same end slack tension within the segment (described in step 3). The impulse is directed medially through the dropping of the chest and head towards the patient.
The patient is posiUoned in left side-lying with their lumbar and thoracic spine in ventral flexion, right side bending and left rotation .
Troubleshooting your technique: The manual contact will be uncomfortable if it is too lateral and on the lumbar transverse process. Note(s) The entire lumbar spine is locked in noncoupled ventral flexion. This allows for much of the nonnal soft tissue slack to be taken up prior to application of the translatoric impulse. Utilizing noncoupled spinal locking and straight-line impulses will minimize rotational movement that may occur in the treatment segment. Subtle adjustments in the amount of dorsal fle xion, side bending and rotation can be made if the set-up position causes discomfort.
Translatoric Spinal Manipulation
1111
EL - HV & LV PP - HV & LV
L1-4-Side Bending
R: E: E:
Indication: To improve right side bending Position: Right side-lying & ventral flexion
E: I:
The therapist kneels on the table facing the patient.
I:
The therapist's left knee is pressed gently but firmly against the abdomen to support lumbar ventral flexion . The therapist presses in the direction of the left
articular surface and spinous process of the cranial vertebra with the ulnar border of either the left or right hand (lett hand pictured on the lett, right hand pictured below).
I: I:
The hand contacting the patient's spine is slightly extended and radially deviated.
I:
The therapist uses their other hand to reinforce the position of their wrist.
I: I: I: I: I: I: I: I:
i drop, the therapist takes up the slack mediaUy (described in step 3).
The therapist then lifts their head, neck and upper thorax slightly while maintaining the same end slack tension within the segment (described in step 3).
The impulse is directed medially through the dropping of the chest and head towards the patient.
I: The patient is posiboned in right side-lying with their lumbar and thoracic spine in ventral flexion, right side bending and left rotation. A roll is used to support the caudal vertebra in the treatment
s""m,mt.
Troubleshooting your technique: In addition to the medial direction, lumbar side bending impulses using this manual contact should also be applied in a slightly ventral direction. The therapist must lean over the patient and roll the patient toward him or herself in order to facilitate a translatoric impulse that is in a slightly ventral direction.
Note(s) This is a very specific technique and can be applied to the adjacent segments of a bypennobile and sensitive lower lumbar segment. As noted previously, specific side bending impul ses are applied in a medial and ventral direction. In comparison to a rotational movement, this ventraVrnedial translational movement promotes greater arthrokinematic motion
of one facet joint in relation to another, given the common saginal and frontal plane development/orientation of a mid-lumbar facet joint. Furthennore, emphasis on the creation ofa side bending motion during the application of these techniques will more effectively elongate the connective tissue of the intervertebral disc joint.
112
I
Chapter 5 :
I:
Lumbar Spine Application
II:
I:
•
II: II:
•
II:
-= -=
Ls-Side Bending
EL - HV & LV PP - HV & LV
Indication: To improve right side bending Position: Right side-lying & ventral flexion The therapist kneels on the table facing the patient. The therapist presses in the direction of the left side of the spinous process of L5 with the ulnar border of either the left or right hand (right hand pictured). The therapist's right thigh is placed anteriorly against the lower abdomen to support lumbar ventral flexion. The therapist's right thigh also contacts the patient's left thigh and is used to control the pelvic position and subsequently the right side bending at L5.
The hand contacting the patient's spine is slightly extended and radially deviated. The therapist uses their other hand to reinforce the position of their wrist.
To provide an impulse using a body the therapist takes up the slack medially (described in step 3). The therapist then lifts their head , neck and upper thorax slightly while maintaining the same end slack tension within the segment (described in step 3). The impulse is directed medially through the dropping of the chest and head towards the patient.
The patient is positioned in right side-lying
1_"";;;;"'';'';''==''1 with their lumbar spine, including L5, in slight ventral flexion. The patient's left hip is flexed approximately 90°.
Troubleshooting your technique: If the impulse is directed dorsally, the therapist's hand may slide off of the lumbar spinous process resulting in a less effective technique.
Given the anatomy of the L5 segment, the therapist must finnly press the ulnar aspect of his or her manipulating hand in a ventral direction in orde r to achieve so lid contact on the L5 spinous process.
Note(s) Pre-positioning the L5 segment in noncoupled dorsal flexion will constrain rotational movement during the application of this technique. To pre-position L5 into further right side bending prior to this manipulation, a roll may be placed under the patient's ilium to right side bend the lumbar spine down through L5. To further restrict rotation from occurring at L5, the patient may be positioned in further left rotation from above down through the L5 segment.
Translatoric Spinal Manipulation
1113
&:
Ll-4-Side Bending
EL - HV & LV PP-HV&LV
Indication: To improve right side bending Position: Right side-lying & dorsal flexion
The therapist stands facing the patient's abdomen. The therapist contacts the patient posteriorly with both hands pressing medially on the right side of the spinous processes of the lumbar vertebra. The right forearm contacts the left side of the pelvis posteriorly and laterally. The left forearm contacts the left side of the rib cage posteriorly and laterally.
The therapist supports the patient anteriorly by contacting the patient's abdomen with their torso.
&':
&':
&':
-=C C C C C C
-=E E
-=E
c: The impulse is directed medially with the fingers, caudally with the right forearm and cranially with the left forearm and is generated by quickly flexing the elbows, extending the shoulders and retracting the shoulder girdle bilaterally.
In side-lying, the patient is positioned with their lumbar and thoracic spine, down to and including the treatment segment, in dorsal flexion, right side bending and right rotation.
Troubleshooting your technique: This TSM uses a very short amplitude movement. Do not let your fingers slide laterally to the left side of the SplllOUS processes. Note(s) The therapist can also change his/her contact to the left side of the spinous processes and provide functional massage to the left lateral paraspinal muscles. In clinical practice, it is common to blend various intervention techniques such as translatoric manipulation, translatoric mobilization and functional massage. ~11 three forms of intervention can be readily applied in this position. By virtue of this contact on the lumbar spinous processes, this technique is less forceful then the manual contact used for the specific translatoric lumbar side bending. As such, this is an excellent first manipulative maneuver to apply as a therapist begins to integrate quick movements into his or her treatment session. Choosing to perform this or any lumbar side bending techniques in either ventral or dorsal flexion is often based on where the side bending restriction is the greatest.
1141 Chapter 5: Lumbar Spine Application
-= -= -= E -=E E
E
-= -= -=
•
L1-4-Side Bending
EL - LV PP - HV & LV
Indication: To improve right side bending Position: Left side-lying & dorsal flexion
The therapist kneels on the table facing
Slack in the lumbar spine is taken up medially by leaning the body weight onto the right hand .
the patient. The patient's right knee is pressed gently
but firmly against the patient's lower ribs anteriorly. The therapist presses in the direction of the right articular surface of the cranial and caudal vertebrae with the ulnar border of the right hand.
The therapist's right wrist is slightly extended and radially deviated. The therapist uses their left hand to reinforce the position of the right wrist.
To provide an impulse using a body drop, the therapist takes up the slack medially (described in step 3).
The therapist then lifts their head, neck and upper thorax slightly while maintaining the same end slack tension within the segment (described in step 3). The impulse is directed medially through the dropping of the chest and head towards the patient.
The patient is positioned in side-lying with their lumbar thoracic spine in dorsal i right side bending and right rotation.
Troubleshooting your technique: The manual contact will be uncomfortable if it is too lateral and on the lumbar transverse process. Note(s) The entire lumbar spine is locked in noncoupled dorsal flexion. This allows for much of the nonnal soft tissue slack to be taken up prior to application of the translatoric impulse. Utilizing non coupled spinal locking and straight-line impulses will minimi ze rotational movement occurring in the treatment segment. Subtle adjustments in the amount of dorsal flexion, side bending and rotation can be made if the set up position causes discomfort.
Translatoric Spinal Manipulation
1115
Ll-4-Side Bending
EL - HV & LV PP - HV & LV
Indication: To improve right side bending Position: Right side-lying & dorsal flexion
The therapist kneels on the table facing the patient. The therapist's right thigh presses gently but firmly against the lower abdomen. The therapist presses in the direction of the left posterior surface of the transverse process, the left articular surface and left side of the spinous process of the caudal vertebra with the ulnar border of either the left or right hand (right hand pictured). The therapist's wrist, for the hand contacting the patient's spine, is slightly extended and radially deviated. The therapist uses their other hand to reinforce the of their wrist.
..:........;,.,..,,...:..:;
provide an impulse using a body drop, the therapist takes up the slack medially (described in step 3). The therapist then lifts their head, neck and upper thorax slightly while maintaining the same end slack tension within the segment (described in step 3). The impulse is directed medially through the dropping of the chest and head towards the patient.
The patient is positioned in right side-lying with their lumbar and thoracic spine in dorsal flexion, right side bending and right rotation. A roll is used to support the cranial vertebra in the treatment segment.
Troubleshooting your technique: In addition to the medial direction, a lumbar side bending impulse using this manual contact should also be applied in a slightly ventral direction. The therapist must lean over the patient and roll the patient toward him or herself in order to facilitate a translatoric impulse that is in a slightly ventral direction. Note(s) This is a very specific technique and can be applied immediately adjacent to a hypermobile and sensitive lower lumbar segment. As noted previously, specific side bending impulses are applied in a medial and ventral direction. In comparison to a rotational movement, this ventral/medial translational movement promotes greater arthrokinematic motion of one facet joint in relation to another given the common sagittal and frontal plane development/orientation of a mid-lumbar facet joint. Further, emphasis on the creation ofa side bending motion during the application of these techniques will more effectively elongate the connective tissue of the intervertebral disc joint.
1161 Chapter 5 :
Lumbar Spine Application
-= -=
Ls-Side Bending
EL - HV & LV PP - HV & LV
Indication: To improve right side bending Position: Right side-lying & dorsal flexion
The therapist kneels on the table facing the patient. The therapist's right thigh is placed anteriorly against the lower abdomen. The therapist presses in the direction of the left side of the spinous process of LS with the ulnar border of either the left or right hand (right hand pictured). The therapist's wrist. for the hand contacting the patient's spine, is slightly extended and radially deviated. The therapist uses their other hand to reinforce the position of their wrist.
i the therapist takes up the slack medially (described in step 3). The therapist then lifts their head, neck and upper thorax slightly while maintaining the same end slack tension within the segment (described in step 3).
The patient is positioned in right side-lying with their thoracic and lumbar spine, including L5. in dorsal flexion , right side bending and right rotation (locked above).
The impulse is directed medially through the dropping of the chest and head towards the patient.
A roll is used to support the position of right side
Troubleshooting your technique: If the impulse is directed dorsally, the therapist's hand may slide off of the lumbar spinous process resulting in a less effective technique. Given the anatomy of the L5 segment, the therapist must firmly press the ulnar aspect of hislher manipulating hand in a ventral direction in order to achieve solid contact on the L5 spinous process. Note(s) Pre-positioning the L5 segment in noncoupled dorsal flexion will constrain rotational movement during the application of this technique.
Translatoric Spinal Manipulation
1117
-I:
L1-S-Facet Distraction
EL - HV & LV PP - HV & LV
Indication: To improve movement in all directions (bilateral facets) Position: Prone
Slack in the treatment segment is taken up in a ventral and slightly caudal direction by the therapist leaning their body weight over the wedge. segment.
The therapist places their hands, one over the other, on the base of the wedge.
--= --= --= --= --= --= --= JC JC JC
.II: JC
.II: .II:
C C A cuff weight or sand bag is placed anteriorly and in the midline to stabilize the cranial vertebra of the treatment
II: II: II:
It Troubleshooting your technique: Prior to the application oftranslatoric mobilization in the prone position, correct placement of the mobili zation wedge may be confirmed by palpating at the interspinous space as th e caudal vertebra of the treatment segment is translated with a ventral/caudal test pressure. Note(s)
By moving the caudal joint partner, a hypomobile LS/S I segment can be loosened even when the L4/S segment is hypermobile and sensitive.
•
It It
• It
.: ~
• 11 B
I Chapter 5 : Lumbar Spine Apptication
L1-S- Facet Distraction Indication: To improve movement in all directions Position: Prone
The therapist places their left hand next to the spinous process of the caudal vertebra in the treatment segment and presses in the direction of the lamina and transverse
EL - LV PP - HV & LV
(right facet)
The therapist contacts the patient's right anterior-lateral shoulder with their right hand. The therapist pulls the shoulder in the direction of the treatment seg ment, thereby moving the cranial segments into right side bending, right rotation and dorsal flexion.
Once both hands are in contact with the patient, slack in the treatment segment is taken up by pulling the right shoulder towards the treatment segment and subsequently right side bending, right rotating and dorsiflexi ng the thoracic spine down to and induding the treatment segment. The caudal vertebra in the treatment segment is stabilized with the manipulating hand when the slack is taken up.
The patient is positioned in prone with their thoracic and lumbar spine , down to and including the treatment segment, in right side bending , right rotation and dorsal flexion (locked in extension).
Troubleshooting your technique: A common mistake occurs when the therapist does not take up enough slack when pulling dorsally with the nonmanipulating hand. To ensure complete locking above, the therapist must pull the patient's shoulder caudally as well as dorsally. Note(s) The moveable head or foot section on a mobilization tab le may be elevated to support and hold the thoracic spine dorsal flexion portion of this locking pattern. This technique may be applied to specifically loosen the upper and mid lumbar spine when L415 and L5/S I are hypermobile and sensitive.
Translatoric Spinal Manipulation
1119
Ll-S- Facet Glide
EL - HV & LV PP - HV & LV
Indication: To improve dorsal flexion (bilateral facet joints) Position: Prone
The therapist stands beside the
patient's thigh. A wedge is placed against the caudal vertebra in the treatment segment. The therapist places their left hand over their right on the base of the wedge.
-=s: c c
-= -= -= -= -= JI:
-=
-= -= -= -= -=a:
A cuff weight or sand bag is placed in the midline anteriorly to stabilize the cranial vertebra in the treatment
a: a: a:
-=
Troubleshooting your technique: Pressure on the wedge should be placed evenly so the patient does not feel more on one side of the spine verses the other. Note(s) The we ight may be moved cranially when the treatment segment is higher in the lumbar spine. Pressure on the xyphoid process may be uncomfortable for the patient and may require additional padding to increase patient comfort.
•-= -=
• • •
. ~
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I Chapter 5 : Lumbar Spine Application
Ll-S- Facet Glide
EL - HV & LV PP - HV & LV
Indication: To improve ventral flexion (bilateral facet joints) Position: Prone
Slack in the treatment segment by pressing the wedge in a ventral and
cranial direction. i i hand on the base of the wedge. The therapist stabilizes the caudal vertebra (the sacrum in
this illustration) with the ulnar border and palmer surface of their left hand.
~-
Troubleshooting your technique: An additional folded towel or soft cushion may reduce pressure from the edge of the table. Too much hip flexion may cause the pel vis to move off the table resulting in a less specific and ineffective technique. Note(s) This is a recommended treatment position if the lower lumbar segments are hyperrnobile and sensitive in dorsal flexion. Patients with movement restrictions and severe degenerative changes (stenosis) often find this treatment position comfortable.
Ventral/cranial impulses promote improved dorsal flexion at mid and upper lumbar segments and may reduce mechanical stress and symptoms coming from L4/S and LS/S I.
Translatoric Spinal Manipulation
1121
L1-S- Facet Glide
EL - HV & LV PP - HV & LV
Indication: To improve ventral flexion (right facet joint) Position: Prone
The therapist places the ulnar border of their right hand next to the spinous process of the cranial vertebra in the treatment segment and presses in the direction of the lamina and transverse process (L5 illustrated). The therapist stabilizes the caudal vertebra (the sacrum in this illustration) with the ulnar of their left hand.
r====------.:=..l
1: 1: 1:
1: 1: 1: 1: 1: I: I: I: I: I: I: J: J: J: J:
-= -= -=
Troubleshooting your technique: The L5 transverse process is a deeply located structure. Therefore, the manipulating hand must attempt to "catch" the tip of the L5 spinous process and move it ventrally and laterally during the translatoric impulse. Too much hip flexion may cause the pelvis to move off the table resulting in a less specific and ineffective technique. Note(s)
This technique is used to loosen a hypomobile L5/S I segment. It can be applied even when the adjacent L4/5 segment is hypermobile.
• • • ••
•5
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1221 Chapter 5 :
Lumbar Spine Application
TS
The 51 Joint u@cg[}u UU 0CQJ Ql]@
SI Joint The SI joint is included in this text because of its proximity to the lumbar spine and because of the common tendency for patients with lumbar pathology to experience pain that is referred over the SI joint. This is due in part to the fact that the SI joint is innervated by multiple spinal segments (anteriorly by the L2-S2 spinal levels and posteriorly by L4-S2 levels). While it is the author's experience that pain in the SI region is seldom caused by SI dysfunction, there are situations where primary SI joint dysfunctions occur. Primary SI joint dysfunctions typically result from either trauma or ligamentous laxity. Two common traumas that may result in SI joint dysfunction (i.e. positional fault) include MVAs where the passenger's knee strikes the dashboard or walking injuries where the lower extremity is forced in a cranial direction. Trauma not withstanding, SI joint positional faults may occur as a result of ligamentous laxity. During pregnancy or other times (such as when breast feeding or during menstruation) when there is a higher circulating amount of the female hormone relaxin, it is possible for the sacrum to become slightly displaced in relation to the ilium(s) when an individual bends fully forward. This can potentially result in a symptomatic positional fault where the sacrum is nutated in relation to the ilium. The purpose of SI joint translatoric manipulation (TM) is to reducefcorrect painful positional faults. These faults are diagnosed using symptom localization techniques and joint play techniques described by Evjenth and Kaltenbom in their respective texts. Upon reduction! correction of these positional faults, the movement of the SI joint must be retested. Ifhypermobility is present, it is often necessary to use an SI belt to stabilize the joint until the ligaments have healed or the hormone levels of relaxin have decreased.
Osseous anatomy
Ligamentous anatomy The SI joints are supported by several strong ligaments. The posterior sacroiliac ligament limits anterior rotation of the innominate
Fitting the 51 joint together
Chapter 6 :
5t Joint Application
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Articular surfaces of the iIIium
The sacrum is a fused block of five bones that is situated at the base of the lumbar spine. The sacrum supports the weight of the vertebral column and transmits loads from the trunk into the lower extremities and from the lower extremities into the trunk. The SI joint is classified as part synovial and part syndesmosis. The size, shape and roughness of the articular surface varies greatly among individuals. In a child, these surfaces are relatively smooth. In an adult, they develop irregular depressions and elevations that interlock. The sacral articular surface consists of hyaline cartilage that is approximately 1-3 mm in thickness. The iliac articular surface is composed of approximately I mm of fibrocartilage.
1241
Articular surfaces of the sacrum
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or sacral countemutation. The short posterior sacroiliac ligament limits all pelvic and sacral movements. The posterior interosseo us ligament forms part of the sacroiliac articulation (the syndesmosis). The sacrotuberous and sacrospinous li gaments limit nutation and posterior rotation of the innominate. The anterior sacroiliac ligament stabilizes the Sf joint anteriorly. Lastly, the iliolumbar ligament stabilizes L5 to the ilium.
Muscular support of the SI joint The sacroiliac joints and symphysis pubis joint have no muscles that control their movement directly. although there are muscles that provide pelvic stability. These joints are influenced by the action of muscles that move the hip and lumbar spine because many of these muscles attach to the pelvis. The muscles that support the pelvic girdle, as well as the lumbar spine and hips, can be divided into two groups. The inner group consists of deep muscles including the transverse abdominus, diaphragm, multifidus and pelvic floor muscles. The outer group consists of four groupings that act primarily in crossing or oblique patterns of force couples to stabilize the pelvis. The superficial posterior oblique system includes the latissimus dorsi, gluteus maximus and the intervening thoracolumbar fascia. The deep longitudinal system consists of the erector spinae, thoracolumbar fascia and the biceps femorus muscle along with the sacotuberous ligament. The lateral system consists of gluteus medius and minimus and the contralateral hip adductors. The anterior oblique system consists of the internal and external obliques, the contralateral hip adductors and the abdominal fascia in between. The muscle systems help to actively stabilize the pelvic joints and contribute significantly to the load transferred during gait and pelvic rotational activities.
Kinematics of the SI Joint In terms of joint kinematics, the principal SI joint axis is in the transverse plane at the S2 level. The SI joint is unique in that its range of movement is extremely small and there are no muscles that directly produce active motion at thi s joint. In effect, SI joint movements are pass ive and occur in response to the loads it must transmit and the stresses it must relieve. The SI joint has two principle motions, nutation and counter nutation. During nutation, the sacral promontory moves anteriorly and inferiorly and the coccyx moves posteriorly. During counter nutation, the sacrum moves in an opposite direction with the sacral promontory moving posteriorly and superiorly and the coccyx moving anteriorly. The movements that occur in the SI joint and symphisis pubis are small compared with the movements occurring in the spinal joints.
51 joint kinematics
Movements of the ilium in relation to the sacrum involve movement of the entire innominate bone. This means that a positional fault of the ilium in relation to the sacrum would have to involve movement through the pubic symphysis joint. Clinical evaluation of the pubic symphysis joint is required if a positional fault of the ilium in relation to the innominate is suspected. Although these joints are relatively mobile in young people, they become stiffer with age. In some cases, ankylosis occurs. The pubic symphysis
The symphysis pubis The symphisis pubis is a cartilaginous joint. A fibrocartilage disc, called the interpubic disc, separates the two joint surfaces. The joint is supported by the inferior and superior pubic ligaments. The inferior pubic ligament is thought to provide the primary stability to this articulation. The superior pubic li gament is more easily palpated and may be tender if there is displacement or hypermobility affecting the joint.
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Mechanisms of injury at the 51 joint The stepping injury
--=
The ground reaction forces are transmitted through the hip creating a dorsal and cranial force on the right innominate relative to the sacrum.
---= -I:
If the force is great enough. the
resultant positional fault would be a ventra l caudal position of the sacrum
-I:
relative to the ilium.
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The dashboard injury
i
are
i
through the left femur and hi p joint located inferior to the transverse axis of motion for the SI joint. This results in an anterior rotation of
the inominate and a counter nutation of the left 81 joint. The resultant positional fault for this injury is a dorsal cranial position of the sacrum relative to the ilium o n the
1261 Chapter 6 :
SI Joint Application
Biomechanics of 51 joint Translatoric Manipulation Translatoric manipulation (TM) techniques are used to reduce/correct SI joint positional faults. The principle directions of intervention with TM techniques include moving the sacrum in a cranial direction relative to the ilium and moving the base of the sacrum ventral or dorsal relative to the ilium subsequent to the traumas discussed on the previous page.
To correct a caudal positional fault of the sacrum TM techniques to correct a caudal positional fault of the SI may be performed by either gliding the sacrum cranially on a stable innominate or gliding the innominate caudally on a stable sacrum.
The therapist's left hand contacts the right iliac crest.
Innominate caudal"
'The authors do not recommend this technique unless there is an associated malposition of the pubic symphysis joint.
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•
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Biomechanics of 51 Joint Translatoric Manipulation To correct a ventral positional fault of the sacrum TM techniques to correct a ventral positional fault of the 51 are performed by stabilizing the sacrum and gliding the illium ventrally.
-II:
]I:
-II: II: II: II:
To correct a dorsal positional fault of the sacrum TM techniques to correct a dorsal positional fault of the 51 are performed by stabilizing the sacrum and gliding the illium dorsally.
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C E E II: II:
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II: II:
II: II: ~
~
1281
Chapter 6 :
SI Joint Application
EL· HV & LV pp. HV & LV
Sacrum Cranial
Indication: Pain reduction and correction of caudal positional fault of sacrum (R side) Position: Prone The therapist stands to the left of the
patient's left thigh and pelvis. The ulnar border of the therapist's right hand contacts
The therapist's lett hand contacts and
the right lateral angle of the
placing the radial border of their left index finger, hand and ulnar border ot their thumb the right iliac crest.
stabilizes the patient's right innominate by
,..-------
Troubleshooting your technique: One common mistake made during this technique is failure to properly contact the sacrum, either by positioning the hand too caudally or too mediall y. When properly positioned, the therapist's ann should be roughly parallel to the table. Another common mistake is failure to properly stabilize the pelvis resulting in a right side bending of the lumbar
spine. Note(s)
The lumbar spine may be side bent slightly to the left, if discomfort is felt in the lumbar spine during this technique.
Note how the therapist uses the right side of his chest to support his right hand. This will facilitate greater force generation during the technique.
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Illium Caudal
EL - HV & LV PP - HV & LV
Indication: Pain reduction and correction of caudal positional fault of sacrum (R side) Position: Prone The therapist stands to the left of the patient's left thigh and pelvis. The therapist's left hand contacts and stabilizes the patient's right innominate by placing the radial border of their left index finger, hand and ulnar border of their thumb along the patient's right iliac crest. The ulnar border of the therapist's right hand contacts the right lateral angle of the sacrum.
Troubleshooting your technique: In addition to the stabilization comments made on the previous page, the most difficult aspect of this technique
is properly timing the impulse and the stabilization between the two therapists. Failure to properly stabilize may result in lumbar side bending to the left. This technique should not be used ifthere is pathology that is intolerant to traction at the ankle, knee or hip. Note(s) This technique allows for the generation of a greater amount offorce at the SI joint but may also stress the lower extremity joints and soft tissues.
-= -= -= -= -= -= -= -= -= -= -= -= -= -= -= -= -= -=
-= -= -= •-= .:
.:
•
•
5:
130
I
Chapter 6 :
SI Joint Application
EL - HV & LV PP - HV & LV
Sacrum Cranial
Indication: Pain reduction and correction of caudal positional fault of sacrum (R side) Position: Side-lying The therapist stands in front of the patient. The therapist's left arm and forearm stabilize the patient's left leg against the left side of the therapist's chest and waist.
A belt is used to stabilize the patient's rtght thigh to the table.
Troubleshooting your technique: Care must be taken to assure that the therapist is properly contacting the sacrum. Note(s) While this technique is particularly awkward in appearance, for pregnant patients with SI pain there is little recourse other than trying to reduce the positional fault in side-lying. Taking up slack in hip flexion with the therapist's left shoulder, ann, foreann and hand may assist in reducing a positional fault where the sacrum is in a ventral and caudal (nutated) position. The therapist may try reducing the patient's discomfort in supine by pulling from the distal leg as illustrated on the previous page. However, the movement of the sacrum will be less direct and potentially less effective than this technique.
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II: EL - HV & LV PP - HV & LV
Illium Ventral
Indication: Pain reduction and correction of ventral positional fault of sacrum (R side) Position: Prone
-= -=II:
I:
II: The therapist stands to the left of the patient's pelvis.
The ulnar border of the therapist's left hand and fifth finger contact the patient's right
The heel of the therapist's
iliac crest.
right hand contacts and stabilizes the left lateral
angle of the patient's sacrum.
I:
I: I: II:
-= -= -=II:
Ii:
Ii: Ii:
Ii:
Ii:
Ii:
Ii:
I; Troubleshooting your technique: Care must be taken to assure that the stabilization of the sacrum is equal in magnitude to the TM force. This can be achieved by the therapist leaning his/her torso over his/her hands to take up the slack in the joint. Failure 10 stabilize with equal force will result in a less specific and potentially less effective technique. Another common mistake when perfonning this technique is failure to contact the sacrum properly resulting in ineffective stabilization.
Note(s) The patient may be positioned in slight right side bending to slacken the right iliolumbar ligament and minimize movement at L5 during this technique.
Ii:
Ii:
I: I:
-=5:
• 132
I
Chapter 6 :
51 Joint Application
EL - HV & LV PP - HV & LV
Illium Dorsal
Indication: Pain reduction and correction of dorsal positional fault of sacrum (L side) Position: Supine
The therapist's left anterior thigh supports the patient's left thigh . The therapist's right thenar eminence contacts the patient's left AS IS.
patient's sacrum is positioned at the edge of the table. The patient's left hip is flexed approximately 80' .
Troubleshooting your technique: Care should be taken to avo id pressing medially when using this TM. Medial pressure may provoke symptoms from an irritated SI joint secondary to joint compression. Note(s) One challenging aspect of this technique is controlling the patient's left thigh and body position. To reduce any perception by the patient that he/she is not well supported on the table, the patient should be instructed to lay at a slight angle with hislher trunk fully supported.
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r
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21. 22 . 23. 24.
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