Translatoric Spinal Manipulation for Physical Therapists, 2006

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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~. )

• ~ ............ dIo 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

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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

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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,