Companion DVD Included

Translatori c Spinal Manipulation™ ISBN 978-1-59975-1 95-5

Written by - John R. Krauss PhD, PT, OCS, FAAOMPT, Olaf Evjenth , PT, OMT and Doug Creighton OPT, OCS, FAAOMPT

Illustrated By - John R. Krauss

A Lakeview Media L. L.C. Publicati on

This laboratory guide is intended to be used by licensed phys ica l therapists or phys ica l therapist students studyi ng under the superv ision of an instructor sk illed in the applicati on of TSM.

Other Ka ltenborn- Evjenth based instructional materia ls are ava ilable through O PTP at www.optp.com. These inc lude:

Manua l Mobili zati on of the Jo ints Volume I: The Extremiti es 6th Edition by Freddy M. Ka ltenborn ISBN 82-7054-043-3. Manua l Mobili zati on of the Jo ints Volume II : The Spine 4th Edition by Freddy M. Kaltenborn ISB 82-7054-069-2. Evjenth , O. and Hamberg, J . Muscle Stretching in Manua l Therapy: A Clinica l Manual, Volume I. Alfla Rehab Forlag: Alfta , Sweden, 1998 . ISB : 9 1-85934-02-X. Evjenth , O. and Hamberg, J . Muscle Stretching in Manua l Therapy: A Clinica l Manua l, Volume 2. A lfta Rehab Forl ag: Alfta , Sweden, 1998. ISBN: 9 1-85934-03-8. Evjenth, O. and Hamberg, J. Auto Stretching. A lfta Rehab Forl ag: A lfta, Sweden, 1997. ISBN: 9 1-85934-05-4.

Copyright 2006 - rev 1.3 Th is manual is the copyright property of John R. Krauss. This manual is di stributed by O PTP. 800-367-7393 www.optp.com

Acknowledgements

The development of thi s book was an enormous undertaking, taking over three years to complete. We would like to thank the individuals li sted be low for volunteering their time as models, technica l consultants and ed itors. This project could not have been completed without all of your generous

assistance.

Dawn Gilbert, PT, OMPT Jill Marian, PT, O MPT

Chri stina Michajlyszyn, PT, OMPT Jess ica Wetzel, PT, O MPT

Melodie Kondratek, DSc, PT, OMPT Marie-Eve Pepin, MS, PT, OMPT

Derek Chan, PT, O MPT James Wold, MS, PT, OMPT

Dedication

For our wives, Jennifer, Grella and Kristin

our children, David, Kri stin , Ane, Karleigh, Katie and Cam

and our grandchildren, Oli via and Vendela

Thanks for your love and support ...

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

Acknowledgements - II

Dedicat ion - iii

Introducing TSM Background - 3 Joint motion - 3 Indications and contraindications for TSM - 4 Goa ls ofTSM - 4 Research in TSM - 5 Mechan ics ofTSM techniques - 5 Features of this text - 6

Applying TSM Patient & therapist pos itioning for TSM 8 Locali zation of the treatment segment - 8 Locking: an introduction - 9 Locking the segment(s) above the treatment segment or joint (locking above) - 10 Locking the segment(s) below the treatment segment or joint (locking below) - 10 Testing prior to using locking during manipulation - \I The amplitude of the translatoric mobilization & impulse - \I Generating 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 intervention techniques used in conjunction with TSM - 13 Clinical conditions, examination findings and common sequencing ofTSM techniques - 14 Developing skill with TS M - 24

Cervical Spine The Upper Cervical Spine - 26 Osseous anatoniy - 26 Upper cervical arti culations - 26 Ligamentous anatomy - 27 Vasc ular anatomy - 27 Kinematics - 28 Translatori c manipulation of the upper cervical Spine - 30 Selecting a contact for OA traction - 30 OA-Traction Side-lying - 31 OA-Traction Supine - 32 OA-Traction Seated - 33 OA glide techniques - 34 Occiput-Dorsal - 35 Atlas-Ventra l - 36 Al ias-Dorsa l - 37 Selecting a contact for AA traction 38 Frequency of AA manipulation - 38

Translatoric Spinal Manipulation I v

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 Biomechanics of Lower Cervica l TSM - 45 C2-7-Disc Traction Supine - 47 C2-Disc Traction Side-lying - 48 C2-Disc 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- lying - 59 C7-Facet G lide Supine - 60 C7-Facet Glide Side-lying - 61 C7-Facet G lide Supine - 62-65 C7-Facet Glide Prone - 66-68 C7-Facet G lide Seated - 69-70 C7-Facet Distraction - 71-73

Thoracic Spine The Thoracic Spine - 76 The stable thoracic segments - 76 Osteological features of the thoracic spine - 76 Thoracic facet joints - 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 - 93 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 - 134

TranslalOl'ic Spinal Manipulation I vii

TSM Introducing TSM

Forward The fo llowing tex t is intended to be used by physica l the rap ists and physica llherapist students inte res ted in deve loping the ir thcorClicalundcrstanding and phys ical sk ill level in the ~lpp li ca t io n of translatoric spinal mani pulation (TSM). In keeping

consislenl wi lh Ihc slandard of praclice defi ned by Ihe American Physical Therapy Associal ion. Ihe aUlhors ha l e adopled Ihe fo llowing de fin ition of manipulation: '"A manual therapy technique comprised of a continuum of ski lled passive movements to the j o int and/or re lated so il tissue that arc applied at vary ing speeds a nd a mplit udes. including a small amp litudclhigh veloci ty therape utic 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 (EL) physica l lherapisl educat ion and olhers Ihal are more appropriale fo r posl-professional (PP) phys ica llhcrapis l educa tion. This is due in part lO the ent ry- level student 's lack o f experience in evaluating, mnnaging and phys ically handling patients who are ex perienc ing spina lmovcmc nt impa innents. This does not imply that post-profess iona l students do no t lack similar skill s. however. they a re no t faced wi th the daunting task of lea rning the w ide range of sk ills necessary to become tI licensed physical the rapist in addition to the highe r leve l cognitive and psychomolor skill s necessary to deve lop a high level o f profi c iency in a ll o f the techniques presented w ithin th is tex t.

To identify w hether o r not the a utho rs feel a g i\cn technique is a ppropriate for an ent ry- level or post-pro fess iona l student and w hether high or low ve locity is recomme nded, each technique page includes two boxes in the upper right corne r. nexllo Ihe lechnique lille (sec Ihe illuslra lion below for fun her delai l).

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2 I Chapter I : Inlroducing T5M

Examples

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Key

EL = Entry-level PP = Post-professional

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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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 Norway, 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 study and critica l eva lualioll oftcchniqucs used by osteopaths, chiropractors and physical therapists they concluded that thesc issues and problems stemmed rrom the lack or spccific application of rorces to \ ertebra l segments and from the reliance on larger. angular and principally rotational forces during manipulation.

With these issues in mind. they endeavored to develop a method of manipulation that more specifica lly isolates motion to a single spi nal segment. What they developed is now called '"Translatoric Spinal Manipulation" (TSM) and consists ofa system of manipulative techniques which emphasize the use of small amplitude and straight line (Iranslatoric) traction or gl iding impu lses delivered 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 stabiliza tion or the usc of spinal pre-positioning to restrict the amount or motion occurring al adjacent 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 the malllial therapist with a manipulative tool that has a predictable c lrcct in terms of symptom reduction and motion rcstoration with minimal potcntial ri sk or 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 osseous 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 rolling 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. lumbar braces corsets and taping. Hypomobility is managed through physica l therapy interventions such as manual muscle stretching. fl.lllclionalmassage and low and hi gh velocity TSM.

Table I - R'llings of joint motion. theral)ist I)Crcept ions ~lnd joint end feels

Ratin g of Joint Motion (6 point Resista nce Perceived During Testing Endfeel

sca le)

6 ~ Unstable Little force required to move segment. little Least firm, if non-guarded resistance to movement perceived. Finn. if significant guarding

present

5 = Moderately increased Illotion Moderately decreased resistancc to spinal Illotion Less firm. soficr and later endrecl

4 = Mildly increased motion Mildly decreased resistance to passive spinal Firm and later end feel motion.

3 - Normal Motion Anticipated resistance. similar in quality LO Firm adjaccnt spina l segment (assuming no regional hypermobil ity)

2 ~ Mildly decreased motion Mildly increased resistance to spinal Illo tion. Firm. endreel pcrccived mildly Increased force required to move spina l segment earlier in range of motion

I - Moderately decreased motion Moderately increased resistance to spinal mot ion. Finllcr cndfeel percci\ cd Moderate force rcquired to move spinal segment modcrntely earlier in the rangc of

motion 0 - No perccivable motion Segment resistant to mOlion. even when l'lard endreel perceived

significant force is used immediately upon initiation of passive motion

Translaloric Spinal Manipulation I 3

The diagnosis o f segmental or regiona l spinal hype r or hYPOlnobility is deteml ined th rough the careful ana lys is o f the patient history. observa tion of ac tive motions and passive angular and translatoric motion testing. For example. if a patien t/client: ( I) reports that he/she feels worse wiLh static posi tioning o f his/her lumbar spine and bctter during and fo llowing movcment , (2) demonstrates early excessive motion in the lumbar spine upon backwa rd bending, (3) demonstrates increased lumbar spinal motion upon passive segmental motion testing and (4) reports tenderness upon pa lpation o f the interspinous space at the corresponding spinal segment(s) then he/she would be categori zed as hypennobile in the involved lumbar spinal segmenl(s). The amount o f spinal motion can be categorized by the therapi st by using a six point sca le (see Table I). When perfo rming passive segmenta l motion testing, the therapist will perceive less res istance to movement and a larger range o f available motion in hypermobile spina l segments (assuming there is no muscle guarding due to segmenta l irritability). Conversely, the therapist will percei ve inc reased resistance to movement and a decreased range o f available motion in hypomobilc spina l segments (i.e. an early endfee l). Lastly, the therapist may perceive a difference in the resistance rell at the end o r pass ive motion testing. Abnormal/pathological endl'eels may be perccived as e ither ( I) less finn, as may be the case wi th hypermobil ity, (2) more firm as may be the case with hypomobility or (3) more firm ove r a region o f spina l segments when the patient is using his/her muscles to res ist movement due to pa in or apprehension.

Indications and contraindications for TSM In simple and brief temls, TS M is indicated when patient/c lients are diagnosed with decreased joint motion. This

corresponds with the motion ratings of grade 2 and grade I li sted in Table I . Typically. patients ex perienc ing motion res trictions o r a grade 2 will demonstrate the quickest and best response to TSM . Patients with grade I motion restrictions Illay sti ll respond to traction TSM s, however, improvement in segmental range of motion typically requires a longer time period and lower velocity TSMs in addition to mallualmuscle sLretching procedures.

Factors that the authors have found to be associated with good manipUlati ve outcomes include: ( I) recent onset or impaired motion. (2) lower level or j oint or segmenta l irritation. (3) endleels that are firm and a rri ve s lightly ea rly in the passive range or motion, (4) good patient and therapist rapport and (5) good compliance with selrmanagement programs. Factors that the authors have found to be associated wi th poor manipulative outcomes inc lude: ( I) constant unremitting pa in, (2) pain that is pulsa tile and wavel ike in qua lity. (3) pa in that awakens thc patient from s leep and is unrelated to position or changcs in position . (4) pain and associated sensory disturbanccs that are expe rienced more peripherally than centrally. (5) pa in that is provoked by a ll spina l movements, (6) significant ske leta l de rormity. (7) poor response to prior spinal manipUlati ve intervention, (8) patients who are apprehensive about moving the ir spine and (9) patients who a re unwilling! unable to relax enough during TS M. Additiona l factors associated with poor outcomes from TSM are listed in Table 2.

Table 2 - Reasons for poor outcomes with TSM

Therapist Related Reasons Patient Related Re~lson s Pathological and Structural Related Reaso ns

Inadequate diagnostic skills Emotiona l liabi lity Connective ti ssue laxity/weakness

Inadequate experience recognizing Psychologica l involvement

Worsening o f an inflammatory and managing spina l pathology episode

Reliance on a positiona l vs. Too much pain in too many Multiple medica l comorbidities movement re lated diagnos is d irections. (e.g. c irculatory compromise)

Inadequate manipulative skill s Significant jo int restriction Significant osteophytosis

Casua l use o f manipulation without 1-1 istory of Illulti ple manipu lations Centra l cord signs adequate phys ical exa mination with only transient benefit. Long track signs

Goals ofTSM The overall goal or TSM is the restoration o r motion in hypomobi le spina l segments and the reduction orpai n in

symptomatic spina l segments. The exact mechanisms behind thc e ffect of a ll spinallllanipulation techniques. including TS M. have been disc llssed amongst practitioners for many years. Proposed mechanisms include: ( I) mechanical. (2) ncurologic. (3) hydraulic. (4) c irculalOry and (5) psychologiGal. Mechanical e nects inc lude the breaking o f connective ti ssue adhesions. stretching o f ligaments and joi nt capsules and restoration of gliding within fasc ial planes. In additi on. intra-art icula r meniscoids that a re trapped or impinged between joint surfaces may be freed. Neuro logical e ffects include those e ffects generated by stimulation of the mechanoreceptor system and inc lude changes in resting musc le tone and pain pe rception. Hydraulic e fTects incl ude changes in synovia l fluid distri bution within the joint as well as synovia l flu id viscosity. Circulatory elfects inc lude a reduction o f c irculatory congestion and are postulated to occur secondary to reduction in prcssure in the intervertebral foramen and muscle ti ssues. Psychologica l. e ffec ts include those that result rrom thc pa tient's belief that manipulation will be e ffecti ve, the ir trust in the phys ica lthcrapist's compctence and the benefits associated with human touch.

While the authors do not cla im to have any particularly un ique insight into the specific mcchanism(s) behind

4 I Chapter I : tntroducing T5M

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the effect of manipu lation. we have seen 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 segmental function have been seen with TSM s delivered using Kaltenborn 's grade II and II I at both high and low velocity. 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 scicntific theory regarding the proposed efTects 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 regarding this research is discussed below.

Research in TSM The authors strongly encourage further research into the effectiveness of TSM . A number of case studies and case

series 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 controlled case series and randomized controlled tria ls in order to assess the efficacy ofTSM in terms o f motion 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 symptomatic segment but should also assess the outcomes of joint manipulation of hypo mobile segments that are adjacent to symptomatic hypermobi le segments.

Table 3 ~ Ka ltcnborn 's three treatment gr ades

Defin ed Trentment Use

A very small traction force used to nullify the normal compress ive lorces acting in a joint. No

Grade I appreciable joint eparation or movement occurs. No tissue resistance is perceived by the therapist. Grade I and II are used to reduce Movement from grade I to the end pain/symptoms and restore qua lity o rthe slack in ti ss lles surrounding o f motion within the joint. the joint. Little resistance is

Grade II perceived in the beginning of grade II while a great deal of resistance is relt at the end or grade II . A greater amount of motion is relt by the therapist.

Stretching of the ti ssue surrounding the joint occurs. Little to

Grade II I is used to stretch tight Grade II I 110 movement is felt by the

practitioner, however a great deal structures crossing the joint.

of resistance is perceived.

Mechanics ofTSM techniques There are three primary types o fTSM techniques: disc traction. facet distraction and face t gliding. Disc tractions

are applied at a right angle to the SU rf~lCC orthe disc joinl and are intended La un load/decompress the disc and intervertebral foramen. During disc trac tion techniques, the patient is positioned in his/her actual resting position (the position of greatest comfort or ymptol11 relief). Irthe patient is mosl comfortable 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 therapist is using a bilateral contact and force 10

generate the spinal traction. then the patient may start in a mid-posi tion. If a unilateral force or contact is being used. the patient will be placed in slight side bending towards the side o rthe impulse prior to the manipulation. The resultant manipulative fo rce generated during the technique wili return the spinal segment to a mid-position.

Facet jo int distrac tions are generally performed with the spinal segment posi tioned in side bending and rotation in opposi te directions. These techniques use facet joint compression on one side of the spinal segment to create facet joint distraction on the other. While the patient's spinal segment is only placed in this position for a short time, two factors should be considered. One. the articulations undergo ing compress ion must tolerate the compressive lorces and two. the position and movement used during facet distraction may cause narrowing to occur in the intervertebral lora men.

Cervical disc traction example

TrclI1slalOric Spinal Maniplllalion I 5

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Facet joint glide techniques a rc pcrfonncd with the spina l segment in a coupled position (see Chapter 2 for a description of coupled patterns in the various spinal regions). The TSM impulse is directed parallel to the articular surface during facet gliding techn iques. Stabilization of adjacent spinal segments is achieved through direct manual contact or through spinal locking (see Chapter 2 for further details).

Cervical facet distraction example

Ventrally. medially and ...... 'V caudally directed impulse

Features of this tex t

Cervical facet glide example

A ventral cranial directed impulse on the left.

Caudal stabilization

A dorsal caudal directed impulse on the right

The technique pages of this text have been designed to reduce the I11cntalload imposed on the learner 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

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6 I Chapter I : tntroduclng TSM

TSM Applying TSM

Translatoric thrust technique consists of a series of manipulati ve maneuvers which arc quite complex and present a learning challenge to even the Illost experienced c linic ian. The following section provides a de tailed description of techlliquc parameters such as patient and therapist positioning. loca liza tion of movcmcnt within the spine and the gene ration of speed, force and appropriate amplitude ofmovcmcnt when performing TSM . Finally, suggestions regarding training arc discussed.

Patient & therapist positioning for TSM As with a ll phys ica l examination and trea tment techniques, proper positioning is essential for both the patient and

therapist. When posi tioning a patient for translatoric manipulation, it is cnlc iai that he/she is comfortable and able to relax his/her whole body, espec ially the region of the body that wi ll be treated. In addition to selecting a position that promotes patient relaxation, the therapist must also consider patient posi tions where they are most effective in achieving a success fu l manipU lation. This text inc ludes a number of different positions the therapist may use to achieve the same manipulative effect. Therapists studying these various positional options are encouraged to practice a ll va riations to ach ieve the same cflectiveness regard less of patient position. The therapist should always posit ion themselves with : ( I) a stable (wide) base of support, (2) good spinal alignment/position and (3) a relaxed upper body. This will ass ist in the process of correct patient positioning and promote more precise control of the patient's body part during the manipulative technique.

Finally, the skillful application ofTSM requires thc therapist to be in close proximity to his!her patient. Regarding th is, the therapist should be aware of all physica l contacts that occur when positioning the patient. These contacts. in addition to the specific pre-posi tioning, manual stabilization and pre-stressing ofa vertebral segment , should at the minimum, be non-painful and shou ld also allow the pat iel1l to relax. Patient relaxation is facilitated by providing adequate and skillfu l suppon of all body pans supponed by the therapist 's hands. In add ition, the movement used to posi tion the patient for the translatoric thrust technique should be preCise and purpose/ul. Therapists should avoid repetitive pre-positioning. The consideration of our phys ical presence and the use of precise and purposeful movement enhances patient confidence in Ollr ab il ities as experienced and professional practitioners of manual therapy. Ultimately, both patient re laxa tion and patient confidence in our abilities will furth er improve the outcome ofTSM.

Localization of the treatment segment TSM emphasizes the localized applica tion of joint specific

and segment specific manipulat ion. This is achieved by manua l contacts directly on the joint or segment to be moved. The use of stabi lizat ion techniques such as locking or direct manual stabilization of the adjacent vertebra further enhances treatment specificity. This

Therapist & patient positioning i

i with his/her spine in good alignment avoiding excessive ventral. dorsal and lateral flexion.

To achieve this the patient is positioned dose to the edge of the table, the table is adjusted to an appropriate height and the therapist uses a wide base of support.

Localization of the treatment segment

is in contrast to some commonly applied methods of manipulative treatment that lISC contacts which may be far away from the intended treatment segment, such as the pelvis or the head. Typically, these techniques are combined with larger rotational motions that move mUltiple spinal segments. These nonspecific rotational techniques not only produce multiple cavitations in an unpredictable pallem bUlmay also unnecessarily stress weakened and sensit ive oft tissue structures including the facet j oint capsules, the intervertcbral disc and other supportive segmental ligamentous structures. This is panicularly problematic whcn applied over degenerative hypermobile segments. Even manipulative techniques which use manual contacts on adjacent spinous processes but still incorporate the rib cage and pe lvis into the manipulati ve movemcnt are nOltruly specific techniques and have the

potential to irritate hypcnnobilc spinal segments. For reade rs who are L ____________ ~====:::!J 8 I Chapter 2 : Apptying TSM

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unl.1nu "lth the con\.. oft mg r for th'" reader \\ ho \\ Ishes to fe\ ie\\ the concept. please read the fo llowing section .

Locking: an introduction Locking is a technique used to re (riel intersegmental motion for the purpose of stabilizing/constraining the 110n­

mampulated \ enebra in the spinal motion segment. The underlying principle behind locking is that the spinal motion :tegment ha!t a finite amOllnt or motion. \Vhen Illotion ill one plane is taken up, less mOLion will be available for movement in the remaining planes. To illustrate this point , try the following:

I) With your cervical spine in a mid-posi tion, rotate your neck (0 the right being careful not to dorsal or ventral flex or sidebend your neck at the sa me time. Note how far you can move and how easy it is to move into righ t rotation.

2) Return your neck to the mid-position. 3) Next, s ide bend your neck all the way to the len. At the

end of your available range of cervical side bending to the len. add rotation lO the right. Note how far you can rotate and how difficult it is to rotate from this s ide bent position compared to when YOLI started in mid-position. It is much harder to rotate from a fully side bent position then it is from a non-side bent position.

This simple example can be tried with a number of combinations of movement. For each combination. the first cardinal plane motion will decrease when additiona l cardinal plane motions are added prior to performing the primary motion. In addit ion to changes in the range of movement available wi th these various combinations of movcment, there will also be changes in the ease in which the end of motion is reached by the patient and the sensc ofstiflness perceived at the end of motion . This endfeel wi ll typically vary from a morc clastic/muscular end feel to a fiml er or more articular endfcel. How quickly the motion in the segment will re~l c h its end range and the

Comparison of right rotation in neutral and left side bending

Compare how it feels to rotate from a mid cervical position , to easy it is to rotate from a left side bent position.

endfeel pcrceived by the patient and therapist at the end range of move men 1 will vary, depending on how many and in what order planes of motion are combined inlhe movement segment.

Examples of two and three plane movement combinations and their typica l endfeels are provided in the tables below.

C2- T3

Movement End reel Movement C lass ifica tion

Side bending and rotation opposi te Finn Noncoupled

Side bending and rotation same Elastic Coupled

Ventral flexion, side bending and rotation oppos ite Firm Noncoupled

Ventral fl ex ion. side bending and rotation same Elastic Coupled Dorsa l flexion , side bending and rotation opposite Firm Noncoupled

Dorsal fl ex ion, side bending and rotation same Elastic Coupled

T3-L5

Movement Endreol Movement CI1Iss ification

Ventral fl exion. side bending and rotation oppos ite Firm Noncoupled Ventral fl ex ion. side bending and rotation same Elastic Coupled Dorsal fl exion, side bending and rotation opposite Elastic Coupled

Dorsal fl ex ion. side bending and rotation same Fiml Noncoupled

Translatoric Spinal Manipulation I 9

It is important to remember tha t these movements and spina l coupling patterns are dependent 0 11 the specific anatomical and biomcchanica l characteristics orlhe indi\ idua l spinal mot ion segments. Because the anatomy orlile vertebrae (specifica lly the facet joints) may \ ary between and \\ ithin spinal levels. it is necessary to pay c lose atlention to the end feels pcrcci\cd with these dilTerent mo\ement combinations during the patient examination. When variations are round. the subseq uent mm'cmenl used to constrain 1110tion must also be modified in order to lock or constrain motion al the segmcnt(s) adjacent to where the TSM will be applied.

For the purposes of this text. movement patterns that produce finn endleels arc c lassified as l1ol1collpled molions. MO\cmcnt pa tterns \\ hich produce morc clastic endfeels are classified as coupled mOlionf. The finnness or the endfccl associated \\ ith non coupled motions is attributed to the interaction of the facet joints and the interconnecti ng ligamentous tissues. Conversely. the e lastic nature or coupled mOl ions is attributed to the lengthening of muscular tissues.

Because the combination of spinal segmcnt mO\cments that may be used during locking is extensive. noncouplcd positions. as identified in the table abo\'e. are uscd to illustrate locking in association with TSM \\ ithin this text. Howevcr, il is important to remember Ihat locking can be achic\ed through a numbcr of combinations ofsevcral planes ormation.

When using TSM to restore segmental motion. the therapist may either mobilile the cranial or caudal \crtebra. When mobili7ing the caudal \ ertebra. locking may be used to constrain and protect the vertebral segments cranial to the segment or joint being manipulated. This is called locking above. When mobilizing the cranial vcrtebra, locking is used to stabi lize/constrai n and protect thc vcrtcbra l segments caudal to the segment or joint being manipulated. This is ca lled locking belo\\ and is described in further detail in the following two scctions.

Locking the segment(s) above the treatment segment or joint (locking above) When locking is llsed to stabilize, constrain and protecl

the \crtebra l segments cranial to lhc segment or joint being Locking above manipulated it is called locking abo\ e. An example of the use (see page 54 for fu rther detai ls regarding this technique) o r locking abo\ e is trans lato ric C5 cen ical facet Joinl traction manipulation. During this technique. in order to traction the right facct joint at lhe CS spinal segment, the supra-adjacent spinal segments. including the C5 spinal segment. are Side bent lell and rotated righ t in cnect locking thcm against lcn rotation. The therapist Ihen applics a translatoric \entral. mcdial and caudal fo rce on the right lamina and superior articular proccss ofC6 c reating a sligh l lell rotation ofC6. In Ihis example. C5 and the scgments above arc restrai ned from turning 10 the left with C6 by their pre-positioning in lell side bending and right rotation. The segments 010\ ing caudal to C6 \\ ill follo\\ into slight len rota tion \\ hi le a lready pre-positioned in lell side bending. This combination of len side bend ing and len ro ta tion is a couplcd motion. In this situa tion. segments that end in a coupled position or scgments that are mmed into or tm-.ard a coupled position are refe rred to as III1/ocked.

Locking the segment(s) below the treatment segment or joint (locking below) When locki ng is used to stabi lize, constrai n and protect

the vertebral segments cauda l to the segmcnt or joint bcing Locking below manipulated il is ca lled locking belo\\ . A good exa mple of (see page 57 for further details regarding this technique)

locki ng belm\ is the translatoric C:? facet glide manipulation. Duri ng this techn ique. in orde r to treat the right lacet joi nt at the C2 spinal segment wilh a ventral-crania l trans latoric gl ide, the infra-adjacent spina l segments a re side bent right and rota ted lell. By right side bend ing prior to le n rotaling when positioning the lock, the thera pist compresses the right racet joints and takes lip ligamentous and mllscular slack in the sidebcnt portion of lhe spine. This in turn restricts the amount of avai lab le left rotation in the locked portion or the spine. ext, the therapi t pass i\ e ly and specifica lly side bends the C2 segment to the len to unlock only that segment (C2/3). At this pOint. \\ hen C213 is placed in a coupled position (unlocked). a short quick translatoric movement is perfomled in H ventra l and c ranial direction on the right lamina and inferior art icular process ofC2.

10 I Chapter 2 : Applying T5M

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Placing the C2 segment, or any other spinal segment. in a coupled position (in this case len side bending and left rotation) facilitates greater ease of movcment for the scgmcnt during the translatoric g liding manipulation . Therefore, segmcntal mo\ ement ofC2 during the impulsc will generate the most effective stretching of intersegmental connective tissues while minimizing articular compression at the segment.

Testing prior to using locking during manipulation \Vhile locking may prO\ idc greate r s tabilizat ion than direct manual stabilization during TSM, there arc timcs

when the pre-pos itioning used during a locking maneuver may still cause too much stress across an irritable or hypennobile spinal segment. To best determine if locking \\ ill provoke signs and symptoms in a patient . the therapist must first perform a comprehcnsi\c ~I ctive and passive movement examination on the section of the spine which will be placed in a locked position . Afier the movemcnt examination has becn performed and hypermobility has not been identified , the therapist should then passively move the section of tile spine to bc locked into a locked position and apply a small amount of overpressure to determine if the segments are still nonreactive. An example orlhis is when the therapi st is performing a ventral crania l glide ofC]: on the right and they want to usc lock ing belo\\. Ancr the acthe and pass ive movement examination has been performed and hypcrmobility has not been identified, the therapist will contact C3 and passively position C3 and belo\\ into a locked position. Thc therapist monitors the patient's reaction to the locking through both \erba l responses from the patient regarding the posi tioning and through nonverbal rcsponses such as facia l grimacing and muscular guarding of the cervical paraspinals during the passive positioning. Ifhypermobi lity is identified during the movement examination or if the patient to lerance to the locking is poor, the therapist shou ld e ither abandon the usc oflocking or supplement the locking \\ ith manual stabi liza tion.

To determine \\ hether the locking should be abandoned all together, the therapist must decide if plac ing the segments to\\ ards a locked position \\ ill prevent Ihem from mO\ ing into a position that is further irritating. An example of this is \\ hen a therapist wants to imprO\ e ven tral cranial glid ing at C1 and the patienl does nOltoleratc len rotation at CS. By posi tioning C5 i11l0 right ide bending but not rotating C5 to the left. the segment is in elTect partially stabilized aga inst len rotation bccause movement has been taken up at the scgmcnt. This position is then flu1hcr re inforced through manual stabili /a tion.

When applying a manual stabi liLa tion procedure, the phys ica l therapist must continuously monitor the amount of contact pressure he/shc is applying to a patient 's vertebral segment and related soft ti ss lles. The pressure must be e fTecti ve in restrai ning movement and tolerable lor thc pat ient. Thc the rapist may use a broader contac t such as the pad o f the thumb as opposed to the tip ofthc thumb to enhance patient tolerance. In addi tion. otht: r port ions of his/her hand may be used simultaneously to further minimize contact pressure points and stabilize the non-manipulated \ ertebra. Furthennore, the stabi liL.ation pressure shou ld be app lied in a graded manner with a light relaxed grir> initially. building to a more secur~ stabi lization as the slack in the segment is taken up. and then reducing back to a light re laxed grip follo\\ ing the translatoric th rust technique.

T he amplitude of the translatol'ic mobiliza tion & impulse 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\ Cl11cnt in a spinal motion segmcnt or region of motion segments. Grade 3 translatoric motion is used to stretch the intersegmental ti ssues restricting spi nal segmcnta lmotion. Thcse ti ssues may include segmental musclc(s). facet joint capsular ti ssue and discal ti ss llc. For a more detailed re\ ic\\ o f the three grades of movement advocated by the Kaltenborn-E\jenth concept, please consu lt Kaltenborn's Manual Mobilization o f the Joi nts Vo lume I or II.

In genera l terms. \vheJ1l1sing high velocity movement the translatoric impulsc should bc as short 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 occurs). In order to generate a joint Cin itation and therapeutically streIch joint related restrictions. the impulse must cross the final stop. In ordcr for this to occur. the amplitude ofa TSM may \ary sl igh tly dependent upon the technique in qucstion. Other factors that will also play a role in determining the 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.

Generating speed during high velocity translatoric manipulation When performing high \elocity TSM. the therapist uses an impulse or quick. high speed movemcnt to distract or

glide the IVD or facet joints. One challenge encountered by c linicians learning this type o f movement intcr.ention is the tendency to gcnera te higher amplitude mo\ cments when trying to generate a higher \elocity movement. To properly protect the joints and segments undergoing manipulation during this learning phase. the cl inic ian should reduce the amplitude and at times the fo rce. That said. the practi tioner o fTSM must always bear in mind that when speed and force arc increased the am plitudc of the movemen t must always rcmain sma ll.

Trans latoric Spinal Manipulation I 11

There will be some natural va riations in how speed is generated when performing TSM to different parts of the spine Generating speed during TSM dependent on the TSM technique used. For example, when a cervical facci traction or glide is performed the impu lse is generated by the shoulder and shoulde r gi rdle. In contrast. when pcrfom1ing a TSM lumbar disc traction technique the impulse may be generated lIsing a body drop.

To generate a high speed movement , the manipulator must determine how they can prepare themselves to move quickly. This is no t an easy task. As mentioned previously. a ll phys ical interfaces (manual contacts) w ith a patient must convey a sense 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 can be best described as an ""active tension" in the muscle groups that wi ll power the manipulating hand/a rm . This active tension is an athletic concept that a lso needs to be app lied to the therapist's lower ex trem ities and spinal alignment. Grea ter neuromuscular enort is required to reach a ready state in individuals who have a tendency towards lower molor tone. poor hand/eye coordination and poor postural sense. Conversely. for indi vidua ls with higher motor tone 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 can only be learned through repeated practice and guidance from an expe rie nced and skilled TSM practitioner. A therapist interes tcd in developing a n advanced level of ski ll in the application of these techniques should creative ly find ways to practice improvi ng the ir motor sk ills in the area of speed generation. The therapist should cont inue to train the mselves to genemte as high a ve loci ty moveme nt as Lumbar disc traction TSM possible us ing all of the techniques illustratcd within this text.

Using enough force with TSM: " As little as necessa ry, as much as needed" The force applied during TSM is dependent on the treatment grade desired (Kaltenborn's grades 1-3) and the degree

of stiffness present within the spina l segment. It is not uncommon to find greater degrees of joint restriction in cases of advanced segmenta l degeneration and afler prolonged periods ofsegrne ntalmovement restriction. In these clinica l si tuations, g rea ter fo rce is ty pica lly required to resto re 1110tion us ing TSM. If too much fo rce is required, then high velocity TSM is not indicated. Rather, low velocity TSM which is under vo litional control orthe patient is used to reduce the st iffness to the point

where a high ve locity TSM can be eflect ive. I f performing a grade 3 high o r low ve locity techn ique. enough force must be lI sed to crea te joint separa tion/traction

o r g liding. This applied fo rce may vary based upon the length of time the motion segment has been res tricted, the s tage of degenerative change and resultant connec tive tissue changes and the physical s ize of the patient (i.e. more force is typically required to move larger patients).

Integrating TSM into clinical practice As c linicians put these newly Icamed techniques into prac tice we would caution individua ls to pay carefu l attention

to technique select ion and the tcrnporal proximity of the use ofTS M to o ther interventions. Specifically. if the manipulative intervention is used in combinat ion wi th other techniques it may be difficult (if not impossible) to son out the specific effects ofTSM . Regarding this, a clinician will never develop a sense of which TSM technique appears best suited for certa in cl inica l presentations. On the other hand, wi th prope r mentoring from an experienced TSM practitioner and with increased experience using the techniques it is possible for the novice to effecti ve ly integra te TSM with other therapeutic interventions to optimize patie nt outcome from trea tment.

12 I Chapter 2 : Apptying TSM

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Prior to applying TSM , the clinician may want to use isolated short arc active spi nal movements, hold/relax manua l muscle stretching. convent ional son tissue massage and functional massage to reduce muscle tension. TSM should also be fo llowed by movement reeduca tion aimed at cont ro lling movement at adjacent symptomatic hypermobile spinal segments and encouraging isolated movement at hypomobilc segments that were recently mmlipulated. This general practice ph ilosophy provides not only good immed ia te results ror pat ients, but is a lso crucial ror the long term management or ymptomatic hypermobi le segments that are adjacent to hypomobile spinal segment(s). For example, TSM may be used to improve movement at the C7rrl motion segment when there is symptomatic hypennobili ty at the CS/C6 and/or C6/C7 spi nal segments. With improved movement at C7rr 1 segment (a fter TSM). the pat ient will potent ia lly recruit motion th rough the cervicothoracic j unction and into the upper thoracic region more efTecti vely. This will reduce movement stress at the symptomatic hypermobile segments. The pa tient wi ll then be instructed in speci fi c selr-mobiliza tion M the C7ff l segment, and the upper thoracic segments and also instructed in movement reeducation techniques that Ini nil11ize motion through the mid-cervical region. This comprehensive plan of care is based upon sound orthopedic biomechanics and should serve as a plan for long itudinal management o f symptomatic spinal degenerative change or inj ury.

Aft er years of clinica l prac tice, the authors have observed trends in segmental movement patterns. These trends include reduced Illotion (hYPoI11 obili ty) or illcreased 1110tion (hypermobility) in both symptomatic and pre-symptomat ic spinal segments. Some or these trends are as ro llolVs: ( I) decreased movement at 011, C2/3, C7ff I. TI -8 and L 1-3 and (2) incrcased movemcnt at C4/5. C516, C617, T I2/L I. L4/5 and L5/S I. Failure to recognize and acknowledge these common motion tendencies leads to manipulat ive techn 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 changes in spinal motion segments that a re hypermobile. Because or th is commonly observed tendency, a thorough intervention plan must include both the identi fication and management of the pri mary spinallevel(s) involved. as well as a care ful examination o f and intervent ion fo r the surrounding regions of the spine that may contribute to symptoms and impaircd function at the primary spinal level(s).

Supportive a nd corrective intervention techniques used in conjunction with TSM

Additiona l Aspects of Intervention: Implementation of intervclltion for a patient with orthoped ic spinal pathology and associated movement impairments requ ires a comprehensive examination and onen a multi -faceted plan fo r intervention. Typica lly, the authors blend many d ifferent forms o f intervention. In addition to TSM techniques, our approach will consist o f:

Suppor tive biomechanical ~,dv ice regarding: Motion segment(s) protection through movement reeducation techniques including correct use o f spinal motion coupl ing and restricted or substitute forms of joint movement in order to minimize 1110tion th rough symptomatic hypennobi Ie segments. Contro ll ing vert ica l loading th rough symptomatic load sensitive motion segments th rough the instruction of variolls and multi ple fonns of spinal self- traction.

Instruction in spin al muscle training exercises: Postura l and movement pattern instruction that emphasizes correct use or the deep cervical ventra l Hexor muscles and pelvic/hip positioning and movement pa tte rns that fac ilitate the correct use o f the deep lumbar extensor muscles and abdominal muscles. Spinal isomet ric and spinal short arc isotonic movement panerns that train the deep spina l stabi lizer musc les without causing significa nt or pat hologica l segmental translation. Spinal stabilizat ion training that incorporates the use of equipment that supports the trunk, unloads the trunk and trai ns patients in non-symptomatic spina l positions.

Self LV TSM exercises : A combination of specific active and passive segmental movement exercise prescribed to ma intain and enham:c segmental mot ion after a session of manua l intervent ion.

Soft t issue intervention: Functional massage techniques which incorporate gentle repetiti ve and pain free pass ive or active assisted spinal motion while at the same time providi ng a comfortable massagi ng of the spinal muscle . Hold-relax spi na lmusde stretching which provides a means to re lax, warm up, stretch and train spinal muscles.

Translatoric Spinal Manipulation I 13

Clinical condit ions, examination findings a nd common sequencing of TSM techniques

The following section 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 performed, rather it is sequenced to faci litate the reader in tracking and comparing the techniques listed under the intervention tab le and lhe reassessment table. The techniques listed are intended to serve only as examples. 110 t as a prescription for the practice orTSM .

The dosi ng orany physical therapy intervention, including TSM , requires careful consideration of the benefits and ri sks assoc iated wi th the intervention. The benefits of adept applica tion ofTSM include the immediate improvement of segmental movement and reduction of symptoms fo r the patient. The risks of improper or overly aggressive applications of TSM include worsening o f the patient's symptoms and reduct ion of segmenta l movement following its application. Because TSM techniques are short and quick linear passive movements, they arc extremely sare when applied ski II 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 techniques ca nnot completely guarantee that certa in patients wil l not experience minor or brief flares of his/her symptoms.

Regarding this, there a re historical fea tures and examination 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 endfce 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 lity or lack thereof is factored into the formation ofshon and long term goa ls and the selection of intervention s trategies for the patient.

While there are no hard and last rules for the opt ima l nlll11ber oftota ltcchnique app licat ions and the optimal number 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 application 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. Patients 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 segmcnta lmotion. T he movements used to retest movement after the application ofTSM are identical 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 therapist wants to stretch a dilTcrent joint or tissue within the same segment, the therapist may change TSM techniques and work on other pa ilS of the struClU res potentially restricting motion. During this 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 sensation 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. Soreness that lasts morc than 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 llowing 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 lly. 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 continuolls exploration of the techniques and technique parameters pro\ idcd within this text it is possible to build a knowledge base orhow patients genera lly 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 should especia lly avoid any "fix it" language. This is especially true when providing manual imen-enllon for comll1on degenerative orthopedic spinal conditions. In thesc cases and e\en in cases where there 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 " his/her therapist'· when he/s h~ experiences a symptomat ic Illotion loss in the cervical. thoracic or lumba r spine but the therapist benefits by seeing how spinal motion and certain spinal conditions tend to change over the years.

14 I Chapter 2 : Apptylng TSM

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Case I C6 nerve root irritation with segmental hypomobility (Grade 2) at C2/3 and C7rrl.

Sequeuciug o/TSMtecimique(sl

Tl!chnlque Grade Veloclly Treatment Segment(s)

I.

Bt Facet distraction III LV ipsilateral progressing to II V C2/3 segment

contralateral gapping

2.

Bt Disc traction II LV C5/6 segment

3.

et 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(rSAJ 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 the irritubility or the C6 ne"e roo\.

3. C7ffl Ventral cranial (VC)/dorsal caudal (DC) facet g lide testing

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 gutter. The specific Spurling's test incorporales the passive translation ora superior facet in the movement segment into the cen ical inten c rtebra l forame n. Both examination procedures are used to assess the provocability of the spinal nerve undergo ing compression.

Translatoric Spinal Maniplllation I 15

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.

Sequencing ojTSM reclmique(s)

Technique Grade Velocity Treatment Segment(s)

I.

, Traction III LV progressing to HV COli

2.

Et Facet distraction III LV ipsilateral progressing to HV C213 segment

contralateral gapping

3. Bilateral fa cet III LV progressing to HV T 1-4 segments

~ distraction

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4. Cervical movement reeducat ion and stabilization training for C4/S, CS/6.

Select examination techniques applied to evaluate the results ojTSM imen'el1liOI1

Spinal Level(s) Examination Techniquc(s)

I. COi l Joint play and pass ive coupled rotation testing

2. C2/3 Passive facet distraction testing

3. C4-C6 Joint play testing and re-examination of symptom localization· testing for these spinal levels.

4. TI-4 Joint play testing

Note(s) • Symptom localization 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.

16 I Chapter 2 : Apptying T5M

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Case 3 Generalized grade I hypomobility at all cervical motion segments

Sequencing o/TSM lechniqlle(s)

Technique Grade Velocity Treatment Segment(s)

I.

~ Traction & disc III LV progressing to I-I V COli, C2/3, C3/4 and C7IT I traction segments

2.

et Ventral/cranial III LV progressing to H V COli. C2/3. C3/4 and C7fT l dorsa llcaudal facet segments glide

3.

Et Facel distraction III LV progressing to HV COli, C2/3. C3/4 and C7fT I

segments

Select exomil1C1liol1lecilniqlles applied fO el'o/uale the results oj TSM inlen'el1liol1

Spinal Lc\cl(s) EX3minaiion Tcchnique(s)

I. 011 Traction joint play testing and passive coupled Illation testing

2. C2/3, C3/4, 71T1

Translatoric joint play testing, passive segmental side bending testing, passive segmental coupled motion testi ng and passive segmenta l facet distraction testing

3. Cervica l Spine CROM measurements pre- and POSI intervention

Note(s) I. For further infomlation regarding passhe motion testing in the cervical spine consult Kaltenborn's flvfclI1l1ol Alfobili:alion

of lite ) oil1ls. Volume II. The Spine. 2. 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 . 3. Facet distraction is applied unilaterally in the cervical spine. Irboth sides are restricted the technique is applied to both

sides. one at a time. 4. Grade I restrictions are tre.:1ted with LV TSMs until movement is improved to a grade 2 and then HV TSMs may be used

to further restore motion.

Translatoric Spinal Manipulation I 17

Case 4 A painful block of left cervical rotation with a recent onset.

Seqllencing ojTSM tec!l/Jiqlle(s)

Technique Grade Velocity Treatment Segment(s)

I.

Bt Disc Traction II -III !-IV Involved segmcnt(s)

2.

st Facet distraction III LV progressing to !-IV Involved segment(s)

3.

et 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

Spina l Le, el(s) Examination Tcchniquc(s)

I. Involved spinal segments Joint play testing and fe-examination ofsymptorn loca lization· testing for these spinal levels prc- and post treatment.

2. Cervica l Spine CROM measurements taken pre- and post intervention

Nole(s) 1. Left rotation can be limited due to either restricted ventral cranial gliding or the right facet of restricted dorsa l caudal

gliding of the len facel. 2. If the motion is limited due to restricted dorsal ca udal gliding of the len lacet it may be treated wih facet joint distraction

!-IV TSM with the ccrvica l spine placcd in right 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 the caudal vertebra while stabilizing the cranial vertebra generates a relati ve dorsa l cauda l glide of the len facet in the treatment segment .

18 I Chapler 2: Apptying TSM

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Case 5 Right sided upper cervical pain with referral of discomfort to the right posterior aspect of the head and grade 2 motion restriction at COIl and C2/3.

Sequencing oj'TSM feclll1ique(s)

Technique Grade Velocity Treatment Segment(s)

I.

, Traction III HV COi l

2.

et Ventral/crania l III 1-1 V C2/3 segment dorsal/cauda l facet glide

Select eraminCll ion leclmiqlles applied 10 eva/lime lite results ofTSM inten'enliOI1

Spinal LeI el(s) Examination Tcchnique(s)

I. COli Traction joint play testing, passhc coupled motion tes ting and recheck of symptom localization testing for COli

2. C2/3 Tra nslato ric joint play testing. pass ive segmcmal side bend ing testing, pass ive segmental coupled motion testing and pass ive segmental face t distraction testing and recheck of symptom loca li:U1tion tes ting for C2/3

'ote(,) 1. Pass ive upper cervical ro tation testing involves manual stab il ization of the caudal vertebra orthe segment being tested,

e ither COi l or C 1/2. The examincr generates passive rotation with sidebcnding in the opposite dircction. Quantity o f movement. quality of movement and endfeel are evaluated.

2. Pass ive upper cervica l coupled rotation testing and symptom loca lization testing may a lso be performed at C I/2 though th is segmcnt is rarely restric ted given its inherent capsular and ostcological fea tu res.

Translaloric Spinal Manipulation I 19

Case 6 Mid-thoracic pain, decreased active ROM and grade I hypomobility at the T4-8 spinal segments.

Seqllencing o/TSM lecllll iqlle(s)

Technique Grade Velocity Treatment Segment(s)

I.

~ Disc traction III LV progress ing to HV T4-8 segments

2.

~ Bilatera l facet II oscillations, progressing LV progress ing to HV T4-8 segments distraction to susta ined grade II ,

progressing to sustained grade III

Select examination techniques applied 10 eva/uole the results ofTSM intervention

Spinal Level(s) Exami nat ion Techniquc(s)

I. T4-8 Translato ric j o int play testing. pass ive segmenta l ex tension testing and recheck o f symptom localization testing fo r T4-8

2. Thorac ic Spine Movement quantification us ing tape measure techniques or double inc linometers (universal goniomcters) be lo re and at the conclusion o f eac h intervention.

Nole(s) I . The authors commonly tes t pass ive segmenta l ex tension in the thoracic spine with the patient positioned in sidc ly ing.

For funh cr deta i Is consult Kaltenborn 's Mall llal Mobili=alion o/Ihe Joinls, Volllllle II, The Spine.

20 I Chapter 2 : Applying TSM

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I:

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C

C

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Case 7 Mid-thoracic pain that wraps around the rib cage with loss of segmental motion at the same level(s) as the referred pain pattern .

Sequencing oj TSM teclll1ique(s)

Technique Grade VeiocilY Treatment Segment(s)

I. Disc traction III LV progressing 10 HV Involved segmenl(s)

2. Bilaleral facel II osci llations progressing to LV progressing 10 HV Involved segmenl(s)

.Ii.". distraction grade III

3.

rr:: Costotransverse II osci llations progressing to LV Involved segmenl(s) distraction grade III

SeleCI examination techniques applied 10 evaluate the resulls ojTSM il1len'entiol1

Spinal Level(s) Examinalion Technique(s)

I. Mid-Ihoracic Mid-thoracic joint play tesling. manual compression and lraclion tesling. recheck o f symptom (involved loca liza tion testing for mid-thorac ic. segmenls)

2. Rib joints Rib distraction joint play testing and symptom loca lization testing or the rib joints. adjacent to involved spinal regIon

Note(s) I . Rib dis traction jo int play tes ting can be performed in a number of examination positions. For fu rther deta ils consult

Kaltenbom's Manllal Mobili:otion ojthe )oil1ls. Volullle II. The Spine. 2. For details regarding symptom localiza tion for the rib articulat ions, refer to Symptom Locali::atiol1 il1 the Spine and

£rtl'emity Joil1ls by Evjenth a nd Gloeck.

Trallslatoric Spinal Manipulation I 21

Case 8 Lower lumbar nerve irritation with segmental motion restrictions from L 1-3_

Seql/ellcillg ofTSM techniql/e(s)

Technique Grade Velocity Treatment Segmcnt(s)

I.

~ Side bending III HV L 1-3 segments

2.

~ Disc traction II LV progress ing 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 bending testing.

2. L4-5 Translatoric joint play testing and sciatic nerve tension testing and bowstring testing to monitor the results of LV and HV traction TSM.

Note(s) I. Lumbar disc traction LV TSM applied to the L4/5 L5/S I segments if nerve bowstring testing is consis tent with a very

irritated nerve root. Progression to HV lumbar disc traction T SM ifnerve bowstring signs show mild irritation. Self

management with lumbar disc self traction techniques. 2. Lumbar joint play and pass ive side bending is often examined wi th the patient in a side-ly ing pos it ion. For fu rther

deta ils consult Kaltenbom 's Malll/al Mobilizatioll of the Joillts. Voll/Ille II. The Spille.

22 I Chapter 2 " Apptying 15M

Case 9 Symptomatic grade 4 hypermobility at L4/S with concurrent grade 2 hypomobility at LS/Sl.

Sequencing of TSM rec/lI1iql/e(s)

Technique Grade Veloci ty Treatment Segment(s)

l.

l3 Bilateral facet III LV L5/S I segment ' distraction

2.

~ Ventral cranial and dorsal caudal facet III LV L5/S I segment" g lides

3. LUlTIbo-pclvic movement reeducation and stabil ization training.

SeleCI eraminotiolilechlliques applied 10 e\'o/UGle the results oj TSM inlerl'el1fion

Spinal Level(s) Exami nation Technique(s)

l. L5/S 1 Translatoric j oint play testing and passive segmental flexion and extension testing.

Note(s) * To protect the L4/5 hypermobility. a firm lowe I ro ll or cufTweight is placed anterior 10 the L3-5 vertebrae. then a wedge is used to press the sacrum ventrally. " VC gliding of the L5 segment can be achieved by ha\ ing the L5 vertebra positioned at the edge of the table and the pelvis and legs dangling. ext, 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 the L3-5 vertebrae and the base of the sacrum is manipulated in a ventral 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 ofTSM rechniql/e(s)

Technique Grade Ve loc ity Treatment Segment(s)

I.

~ Disc traction II HV Involved segment(s)*

2.

~ Side bending II progressing to grade III LV Involved segment(s)*

Selecl examination techniques applied 10 eWlluate the results ofTSM intervention

Spi nal Level(s) Examination Tcchniquc(s)

I. L5/S 1 Le ft sciatic bowstring test monitored while in right side lying and L5/S I joint play assessed pre-and post HV TSM. Antalgie posture re-evaluated rollowing BV TSM

Notc(s) * During these techniques the patient is placed in right side-lying with the len latera l list supported (i.e. patient in hislher actual resting posit ion) . •• In cases ofaculc lumbo-sacral pa in. it is onen beneficial to combine ho ld-relax and functional massage with TSM.

Developing skill with TSM Developing a high level orsk ill in the application orTSM req uires detailed and accurate instruction. continual

feed back, years of psychomotor refi nement and a refl ecti ve practice pattern. Th is text and companion DVD are designed to act as instructional/learn ing aids to facilitate in this developmenl. Ifyo ll are interested in learning more about TSM. the author's encourage you to contact one of four established U.S. res idency/ fe llowship programs which specia lize in the instruction of TSM: Oak land Uni vers ity in Rochester, Michigan, The Institute of Manual TherJpy in Boston. MassachusclIs. Folsom Physical Therapy and Training Center in Folsom. Ca li ro rn ia and The Inst itute or Rehabil itation and Tra ining in Pra ttville. Alabama. Non-US res idents may contact Lasse Thlle, the president or K-E International, at lasse-th@:onl ine. no ror inrormation regarding TSM based courses olre red worldwide.

24 I Chapter 2 : Applying TSM

Cervical Spine u@©lffi D1J 0 C9J (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.

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 : Cervical Spine Application

Articular surfaces of the upper cervical spine

OA joint articulations

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facet on the posterior aspect of the anterior arch of at las. The posterior aspect o f the dens contains a groove which articulates with the transverse ligament.

The lateral AAjoint comprises the two art icu lations fonned between the infe rior articular surfaces of at las and the superior articular surfaces of axis. The articular surfaces of C I are slightly convex and face inferiorly and medially. The superior articular surface ofC2 faces superiorly and laterally. The capsular ligaments of the two lateral facet joints are thin and loose allowing between 35-45° of transverse plane rotation.

Ligamentous anatomy There are a number of supportive ligaments in the upper cervical reg ion, some of which are continuations of their

lower cervical counterparts. These ligaments include the tectorial membrane, anterior atlanto-occipital membrane, posterior atlanto-occipital membrane, anterior atlanta-axial membrane and posterior 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 primarily supported by ligaments. Critical to the maintenance of upper cervical stability is the transverse portion of the cruciate ligament (transverse ligament) and alar ligament. These stabilizing structures are unique to the upper cervical region and will be the focus of the remainder of this section .

The transverse ligament is the primary ligamentous constraint to excessive ventral flexion at the at lanto-axial joint. This ligament is a strong and thick 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 posterior port ion of the dens. Together with the anterior arch of at las, the transverse ligament form s an osteoligamentous ring around the dens preventing anterior translation of the atlas on the axis. An intact and healthy transverse ligament wi ll a llow less than 3 mm of separation between the anterior arch of atlas during ventral flexion 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 divided into two bands. These bands run from the superior and posterolate ral aspect of the dens traveling in a superior, ventral and lateral direction to their eventual attachment on the medial aspect of the occipital condyles. In a mid or neutral cervical spine position, this ligament is taut. The alar ligaments (I) limit rotation and side bending of the occiput and (2) limit distraction of the OA and AAjoints. According to White and Panjabi, there is a reported 30% increase in rotation of the head when the opposite a lar ligament has been cut. Clinically. if there is greater than 56° of AA rotation or greater than go of OA rotation, significant instabil ity of the upper cervical region should be suspected.

Laxi ty in the alar or transverse ligament has important implications for two primary structures, the spinal cord/brain stem and the vertebral artery. Speci fi cally, if the transverse ligament is lax or weakened due to injury, pathology or other abnormal physical stresses, the dens may move relatively dorsally 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 supine without support under C2 . As mentioned previously, laxity in the alar ligament may allow excessive rotation between occiput, atlas and ax is which in tum may cause excessive tensile stress, lumen compromise or intima l wall damage to the vertebral artery. To understand this it is important to review the anatomy o f the vertebral artery which will be presented in the next section.

Vascular anatomy The vertebral arteries are a major source of blood supply

to the cervical spine and spinal cord. The arteries arise from the subclavian arteries as the fi rst and largest branches. They enter

The transverse ligament and upper cervical flexion

The vertebral artery and upper cervical rotation

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

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 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 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 flexion (10-20°). This is evident by an increase or decrease in the distance between the posterior arch of atlas and the spinous pro­cess of axis during ventral and dorsal flexion viewed on a lateral 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 ofup­per cervical ligament laxity.

The arthrokinematics of the AAjoint are the most complex of all the spinal segments. Assuming normal joint shape 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 arch of atlas slides superiorly and inferiorly respectively along the anterior edge of the dens. As discussed in the previous section, the amount of anterior translation of the 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 I Chapter 3 : Cervical Spine Application

Direction of joint rolling and gliding occuring during OA ventral and dorsal flexion

Ventral Flexion

Dorsal Flexion

Upper cervical dorsal and ventral flexion radiograph

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.

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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 previously 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

When one articulation between atlas and axis is restricted, the axis rotation is displaced to the restricted joint. If the testing or treatment procedure involves 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 neurological, articular, ligamentous

and vascular structures associated with this region of the spine, only certain short amplitude techn iques are recommended. At the OAjoint, low velocity and high velocity manipulations are performed in three translatoric directions: ( I) join t traction (separation), (2) OAjoint ventral gliding and (3) OA joint dorsal gliding.

At the AAjoint, low velocity mobilizations are only performed by a dorsal gliding of C I on C2 and rotational manipulation is avo ided all together. This is due to the ri sks assoc iated with anatomical 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 traction 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 manipulation. There are two possible contact points on the occiput, the mastoid process laterally and the base ofthe occiput posteriorly.

The posterior contact on the occiput is typica lly 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 described in th is tex t. To counter any unwanted side bending that may occur between occiput and atlas during the manipulation, the OA joint is positioned in slight side bending towards the manipulating hand prior to the manipulation (see illustration below).

Lastly, the tip of the mastoid process may be sensitive 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 ~ ~ underlying 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 these 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

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--= -= --= .c -= c c s: -= -= -= -= -= -= -= -= -= -= -= ~

OA-Traction EL - I2J PP -HV

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:

Note(s)

One cardinal sign that too much slack is being taken up by the manipulating hand is di scomfort on the mastoid 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 the amplitude of the impulse is too large, the manipulating hand may slide over the mastoid process during the technique resulting in an ineffecti ve and potentia lly uncomfortable manipu lation. Fai lure to support the head against the therapist's chest may result in unwanted flexion of the OA joint during the manipulation.

During this manipulation the lower cervical spine remains in a neutral or slightly extended position. The author's have found both the 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

Slack between occiput and atlas is taken up cranially by the therapist's left hand and chest prior to delivering the impulse .

;;;;;-~;;; 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 with the index and middle

cupped around the ~ 0,,1;001'< chin .

Troubleshooting your technique:

Nole(s)

Fai lure to correctly locate the mastoid process w ith the manipulating hand is a COl11mOIl error. The manipulating hand shou ld be pos iti oned laterally under the mastoid (not pos terio r and medial under the base of the occ iput ). O ne cardinal s ign that too much slack is being taken up by the manipulating hand is discomfort on the masto id process prior to the impul se. If the amplitude of the impulse is too large, the manipulat ing hand may s lide over the masto id process during the technique resulting in an ineffecti ve and potentia lly uncomfortab le manipulat ion. Failure to support the head aga inst the therapi st 's chest may result in excessive side bending motion of the OA jo int during the manipulation.

In some cases, the therapist must s lightly fl ex the patient ' s lower cervica l spine in order to ga in access to the mastoid process pri or to pos itioning the OA joint for the TSM.

32 I Chapter 3 : Cervical Spine Application

• • •

OA-Traction EL --:-[v - 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:

Nole(s)

Fai lure to provide an equal impulse from the chest and hanclmay resu lt in a side bending movement at OA during the manipu la tion. [fthe amplitude of the impulse is too la rge, motion may be felt lower in the cervical spine during Ihe manipulation. Discom fort may be felt by the patient if the therapist squeezes the atlas and/or occ iput with too much force during thi s techn ique.

While it is difficult to stabilize the at [as, the use ofa short amplitude movement and the caudal stab ilizing force wil! help to minimize the amount of movement occurr ing at AA and below. In clinical practice, it is common to blend var ious intervention techniques . TSM, translatoric mobilization and fun ctional massage can be read il y applied in the seated posit ion. This is true when treat ing throughout the cervical sp1l1e.

Tt"anslaloric Spinal Manipulation I 33

OA glide techniques While OA traction TSMs are excellent treatment techniques, there are times when they are not sufficiently effective

in restoring ventral or dorsal gliding of the occiput. In these instances, a more isolated approach that is directed speci fi ca lly at restoring ventral and dorsal gliding movement may be necessary. When using TSM to restore ventral flexion, the therapist may either perforo, a dorsal g lide of the occiput or a ventral glide o f the atlas. Performing a dorsal glide of the occiput in supine is a particularly good technique because it can be easily combined with PNF hold-relax stretching techniques to treat both OA glide restrictions and suboccipital muscle tightness. The seated technique may be easily combined w ith functional massage which may help relax the suboccipitals. In addition, the seated position is particularly useful because cervical motion can be measured using a CROM immediately preceding and following treatment without 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 stabilize 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 anterior portion of the transverse process ofatla5. Because there are a number of sensitive soft tissue structures located in this area, precise instructions on how best to contact atlas are included on the technique page.

Direction of gliding used to improve OA vental and dorsal gliding

Ventral Flexion Dorsal Flexion

34 I Chapter 3 : Cervical Spine Application

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Occiput-Dorsal EL - LV PP-LV

Indication: To improve left rotation and flexion (Left OA Joint) Position: Supine

Slack between occiput and atlas is taken up in the direction of the stabilization hand.

The left OA joint is mobilized by the combina­tion of a dorsally applied mobilization force applied by the therapist's right shoulder while the atlas is simultaneously stabilized by the therapist's left hand. __ - --L.-

Troubleshootin g your techniq ue:

The therapist stands facing the top of the patient's head.

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 bending 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

their i shoulder.

The therapist's left hand contacts the posterior suriace 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 extended and the fingers "stacked" over each other. This position provides support for the index finger and the hand.

Compress ion through the top of the pat ient's head shou ld be avoided during this technique. Pressure over the o rb it , temple o r bridge or the nose shou ld be avoided during thi s techni que.

Note(s)

Fai lure to properly pos it ion the occiput during thi s technique may lead to a poor ly loca lized and potentially ille fTective techn ique.

Th is technique is predominantly used as a mobi lizat ion technique. Whilc an impu lse is not nccessari ly contraindi ca ted, it is di ffi c ult to de live r an e ffecti ve impul se in this position. See the "A tlas vent ra l" technique on the next page fa r a more eOecti ve manipu lat ive tech nique to improve dorsal gl iding o f the O Ajo int. This technique as illustrated is a unilateral technique . It may al so be performed as a bi lateral technique. To

perform this as a bilateral technique, the stabi lization hand is moved to the midline poste riorly, the therap ist ' s shoulder contac t is moved to the middle orthe forehead, the occipu t is positioned in ventra l fl ex ion (minus the side bendi ng a nd rotati on) and the mobil ization force is directed purely 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

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.

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.

The therapist stands behind and to the left of the patient.

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.

Troubleshooting yo ur technique:

Nole(s)

The stab il izing force and impu lse occur in an equal and opposite d irec tion. Fai lure to provide adequate stabili zation aga inst the mid-portion o rthe face andlor an impulse w ith an amplitude that is too large may result in upper cervical dorsa l flexion dur ing the manipu lat ion. Prcssure app lied on the top or lhe head or agai nst the eye may result in discomfort for the pat icnt and should be avo ided.

Th is technique is onen effec ti ve at restori ng coupled rotat ion at the OAjoints. Translatoric mobi lization and fUll cli ona ll11assage are eas ily integrated into a comprehensive sess ion of manua l intervention to the upper cervical region.

36 I Chapter 3 : Cervica l Spine A pplication

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Atlas-Dorsal EL - 121 PP - HV & LV

Indication : To improve right rotation (Left OA Joint) Posit i on: Supine

The therapist's right hand presses in the direction of the anterior surface of the transverse process of the patient's atlas.

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.

therapist's left hand is placed against the left

'-_AlIt...--t side of the patient's head above the ear.

Tt'oubleshooting your technique:

Note(s)

To maximi ze pat ient comfort during thi s technique, the contact on at las should be spread out over the therapist 's hypothenar em inence. In addition , the hand delivering the impulse shou ld be re laxed prior to the man ipula tion. 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 technique, the therapi st shou ld sta rt with their right hand 0 11 the son tissues sligh tly anteri or to the lett transverse process of atlas . The tissues are then slackened by pulling mcdia lly being ca reful not to slide over the skin. The therapi st then presses in the direction of the anterior surlnL'c of the transverse process of atlas until a firm stop is felt. Failure to slacken the skin or position the hand medial enough may cause discomfort and may lead to the ha nd sliding off the tra nsverse process.

Positioning the patient's occiput on the edge of the table and the therapi st's ri ght thigh on the side ortlle head will provide addi tional stabilization of the occiput. This is a very specific manual technique that will ass ist in the restoration of dorsifl ex ion and coupled rotat ion between occiput and alias. The therapist should vary 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, the therapis l should treat in the position where the greatest amount ofmovelllcnl is felt during tes ting.

Translatoric Spinal Manipulation I 37

Selecting a contact for AA traction Obtaining a good contact on Atlas to generate a traction

of one of the AAjoints requires the therapist to have both exce llent paJpatory skill s and a sense for fine movement. This is in part why the AA traction techn iq ues are recommended only for the post-professional student.

To contact the atlas , the therapist wi ll sli gh tl y side bend the AA j o int away from the side of contac t and rotate the atlas towards the manipulating hand. Rotating the atlas towards the manipulating hand moves the posterior arch of at las dorsa lly allowing the therapist to ach ieve a better contac t. In addition, the manipulating hand will press the axis slightly ventral to maintain atlanta-denta l contact and to provide for contact of the manipulating hand under the inferior edge of the posterior arch of atlas. Thi s positioning is performed after the the rapi st has contacted the patient with both hands and is a very small motion.

Frequency ofAA manipulation After many years of treating patient ' s w ith upper cervical

movement impairments, it is the opinion of the authors of this text that the AA joint is less commonly restricted than Illany pract itioners of manual therapy think. We attribute the cont inued mobility of the AAjoint to its articular configuration and li gamentous anatomy.

If the CI /2 (AA) segment is clinica lly d iagnosed as hypomobil e and joint restrictions are also found at COi l e~A) and e2/3, we recommend that the two segments immediately above and below C 112 be loosened first. As disc llssed in the opening to thi s chapter, given the ligamentous connection between the occiput and e2, once the COil and/or e2/3 segments are loosened, movement at C I 12 can often be felt. If after the cranial and/o r caudal res trictions 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 restoring AAjoint movement.

38 I Chapter 3 .- Cervical Spine Application

Contacting Atlas

Rotating atlas to the left exposes the posterior edge of the transverse process and posterior arch of atlas.

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AA-Traction EL-0 PP - HV

Indication : To improve movement in all directions (R ight 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 prior to delivering the Im~)UIS,e.

Troubleshooting your technique:

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.

Ifille amplitude o r lhc impul se is too large. the manipu lating hand may s lide cranially result ing in di scomfort and/ or a poor ly local ized and less effective impulse.

Note(s)

Failure to support the head against the therapist's c hest may result in a poorly controlled movcme nt of the head during the manipu lat ion.

By pos itioning in right rota tion, the right posterior arch and transvcrse process o f the Atlas is moved dorsally al lowing bettcr contact ro r the manipu la ting hand. The dorsa l surface of tile index finger o f the manipu lating hand contacts the posterior lateral lamina o f C2. By press ing s lightly ventra l prior to the manipulation and by directing the impulse crania lly and sl ightly ventrally, the odontoid is pressed agai nst the anterior arch of at las the reby pro tecting the transverse ligament. Using a coupled pos it ion at the AA leve l wi ll assi st at taking up the s lac k in the upper cervical region while at the same time placing minima l tens ile stress 0 11 the upper cervica l ligaments.

Translaloric Spinal Manipulalion I 39

AA-Traction Indication: To improve movement in all directions (Right AA Joint) Position: Supine

The therapist's right hand contacts the inferior edge of the patient's transverse process and posterior arch of atlas.

therapist's Jeft hand and are positioned behind

patient's head and against left side of the patient's with the index and middle

cupped around the l o" tio,n!'s ch in.

Troubleshooting your technique:

Note(s)

If the amp litude orlhe impulse is too large, the manipulating hand may slide crania ll y resulting in discomlort and/ or a poorly loca lized and less effective impu lse. Failure to support the head against the therapist 's ches t may result in a poorly contro lled movement of the head during the manipu lat ion.

By posi tioning in right rOlation, the right poste rior arch and transverse process of the atlas is movcd dorsa lly allowing better contact for the mani pu lat ing hand. The dorsa l sur face of the index fin ger 0 11 the man ipu lating hand contacts the pos terior latera l lam ina orC2. By press ing s light ly ventra l prior to the manipu lation and by direc ting the impulse cran iall y and slightly ventra lly. the odonto id is pressed aga inst the anteri or arch of at las thereby protect ing the tra nsverse ligament. In thi s posi tion to gain access to the transverse process and poste rior arch of atlas. the therapist must s light ly tlex the patient's lower cervica l spine.

40 I Chapter 3 : Cervica l Spine Appli cation

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T he Lower Cer vical Spine

The lower cervical (Lie) spine works in conjunction with the upper cervical (U/C) spine to pos ition the head in space . Together the two rotat ional coupling patterns of the 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 the horizonta l plane.

Osseous anatomy The lower cervical spine inc ludes the C2 through C7 spina l segments. Simi lar to the thorac ic and lumbar region, a lower cervica l vertebra consists oftwo fundamenta l parts, an anterior vertebral body and a posterior vertebra l arch. The body of a lower cervica l vertebra is cy lindrica ll y shaped, convex anteriorly and flatt ened posteriorly. The superior surface is concave and the inferior surface is slightly concave in the anterior-posterior d irection and slightly convex transversely.

One of tile n10st un ique charac teristics of tbe LlC vertebra l body are the uncinate processes. These processes ari se from the upper posterolateral borders of each ve rtebra l body. The uncinate processes are concave transverse ly and convex anteroposteriorly. Thcy are directed upward towa rd a conca ve groove in the lateral margin of the inferior surface of the venebral body above. At th is intersection, each process or uncus forms ajoint ca lled the uncovcrtebral joint. Thi sjoint is unique to the cervical SpIllC.

The ve l1ebral arch is form ed by the pedicles and laminae. The pedicles are two short, th ick processes, which project posterolaterally and are attached to the superior pal1 of the vertebral body on each side. Continuing from each of the pedicles, laminae are angled posteromedially to enclose a large tri angular vertebral foram en. The ve rtebral foramen is bounded by lam inae posteri orly, the pedicles la tcrally and thc vertebra l body anteriorly. The vertebral foramen is the largest in the cervica l region measuring approximately 17 111m in the sagitta l direct ion and 18-20111111 transverse ly. Coll ec ti vely, the vertebral foramina form the vertebral canal wh ich houses the thickest part or the spinal cord measuring approximate ly 8- I 0 mm in diameter.

The laminae of the vertebral arch are broad, fl at plates of bone that extcnd posteromedially and slightly interiorly. La minae typica lly overlap from one level to thc next and, as mentioned above, form the posterior wall ort he vertebral foramen. In comparison to the rest of the cervical spine, the lami nae of' C2 are thicker than at lower levels. The laminae come together in the midline to form the spinous process. The spinous process is a si ngle process tha t projects posteriorly and inferiorly from each vel1ebral arch at the junction of the laminae. The spinolls processes of C3 to C6 are short and bifid whil e the spinous process of C7 is long and rou nded at its end point.

Articular surfaces of the lower cervical spine

The cervica l ve rtebral arch has many projections, including four m1icular (the superior and interior facets bilaterally) and th ree non-al1 icular processes. The three non-a rticular processes include the two transverse processes (TPs) and one spinolls process. The TPs arise from the junction of the ped icles and the vertebra l body. Together the TPs divide the arch into an terior and posterior portions. The TPs of C3-C7 are bifid and proj ect laterally and slightl y anteriorly ending in a ll anteri or and a posterior tubercle. Together. the anterior and posterior tubercle form the concave spinal nerve sulcus, which provides a "gutter" for the anterior primary ramus. In addit ion, the lower cervical spine may be distinguished from the lumbar and thoracic spines by the presence or all ova l shaped foramen in each of the TPs called the foral11en transvcrsari ul11 . The fo ramen tra nsversariulll is di rected superiorly and inferiorly and ex ists for the vertebral al1eries and veins to course through . The vertebra l artery enters the transverse fo ramen of the sixth cervica l vertebra. These transverse foramina 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 each pedi cle are known as intervertebral notches. \Vhen the LlC vertebrae are articulated, these two notches (pedicles) form the roof and floor of the in tervertebral foramen (I VF) th rough which spi na l ncrves and blood vessels coursc. The IVF is a small canal approximately 4 111111 in length that is directed anteriorly and inferiorly. It is ovoid in shape with a verti ca l diameter of approx imately 10 Illlll in height and a hori zontal diameter ofapproximate[y 5 mill . Adjacent art icu lar processes, in particular the anteri or aspect of the superior art icular process, form the postero latera l wall of the cervical I VF. The posterolateral portion of the vertebral

Translatoric Spinal Manipulation I 41

bodies and the uncovertebra l joi nts rorm the antero latera l wa ll of the cerv icall VF. Arthrit ic hypert rophy of the structures that constitute the cervicall VF playa ro le inlhe deve lopment of ne rve root compressio ll and irritatioll .

Lower cervical articulations There are five articulations in the lower cerv ical spine: one

interve rtebra l d isc ( IVO)joint , two uncovertebral jo ints and two race t jo ints. In the lower cerv ical spine, the re are six IVDs. Duri ng bending movements, the IYO fac ilitates and res tra ins moti on between the cervica l vertebral segments. Further, the cervica l IVDs dis tribu te weight over a larger surrace area. In other words, wi thout the IYO, we ight would be concentrated eccent rica lly on the vertebral edge, toward the direct ion the spine is bent. Thus, the dcformability of the ccrvica ll VO allows distribution of forces over a grea ter surface a rea . The amount o r movement poss ible for a partic ular region o r the spi ne is large ly determ ined by the rat io o r disc he ight and the corresponding vertebra l bodies of a segment. In the cerv ical spine, th is ratio o f disc thickness to vertebra l body height is 2 to 5. The cerv ica ll YDs are approx imate ly 5mm th ick and a re considered to be the th innest of a ll the in te rvertebral d iscs. The somewhat saddl e-shaped IVOs are responsible for the cervica l lordosis in that the ante rior aspect of the cervica l I V O is th icker than the posterior aspect. The nuclear porti on of the cervica l disc is positioned more anteriorly than in any other port ion o rthe spine. The cervica ll VDs are innervated from a variety of sources. Posteriorl y, the IVOs are innervated from branches ofa posterior longitudinal plexus that is deri ved from the cervical sinuvertebral ne rves. Anter ior ly, the IV Ds are innervated by a sim ilar plex us de rived l1'om the cervica l sympathet ic trunks and the vertebra l nerves. Latera lly, the discs receive penetrating branches from the vertebra l nerve. Nerve fibers penetrate at least the outer 1/3 and up to the outer 1/2 of the annulus fib rosus of the cervica l d iscs.

The cervica l arti cu lar processes ari se from the j uncti on of the

Lower cervical articulations

pedicles and l a mil~ae .. Tl~ e l.·e are two superior art icular pro~esses tl.,at project superiorly an~ ve ~l t r~ l1 y a lld two inferi? r processes that projec t Il1l enorl y and dorsa ll y. At the end o f" the artlCll1ar process, a fl at surface IS formed ca lled the face!. Each facet forms a joint with an adj acent ve rtebra and is ca lled a facet j oint or zygapophysea l j oint. These jo ints are class ifi ed as pl anar diarthrodial joints and li e in an obl ique fro nta l pl ane at approxi mately 45 degrees to the long ax is of the spine. The superior Hlcets of the infra-adj acen t ve rtebra in a segment arc posit ioncd in front of (anterior to) the in ferior facet of the supra-adjacent vertebra. The arti cular surface ofa super ior facet faces dorsa lly and crania lly while the articular surface of an infe rior facet faces vent ra lly and caudally. A practi tioner of translatoric manipU lat ion !TI ust be ab le to see these anatomi ca l rclationships in order to ful ly understand the biomechanics oftranslato ric facet joi nt glid ing and trac tion techniques.

The facet join t's capsular liga ments are attached just beyond the margi ns of the adj acent a l1icular processes of the t~lcet joints. These capsular li gaments arc oriented approx i mate ly perpendi cu lar to the plane of the facet j oi nts. Studies by Panj abi have fo und that these ligaments arc oriented posteriorly at approx imately 45 degrees to the transverse plane in the lower cerv ica l spi ne. They are longer and less taut in the cervica l region as compared to the lumbar and thorac ic regions. The capsula r liga ments provide stab il ity in the lower cerv ical spine during fl ex ion and are onc or the princ ipa l structures stretched during translato ric face t joi nt glidi ng and face t join t di strac tion techniques.

In addition to the facet jo int art iculations, each typica l cervica l vertebral body has two uncovcrtebra l joi nts. Although a synovial membrane has been fou nd in the ul1covertebral jo in t, the re is some debate regarding the class ificat ion of the joint. The presence o f the di sc and fi brous tissue in the joint lead some anatomists to be lieve that it is fibrous in nature. As mentioned earlier, the supe ri or plateau ora LlC vertebra l body is rai sed on each side in the sagi tta l plane form ing the unc inate process. The ac tua l capsul e is located medial to the unc inate process and latera l to the disc. The unci nate processes begin to develop at about 8 years of age and do not fu lly develop un til approximately 18 years or age. The average sizes of the unc inate processes have been invest igated in many anatomi ca l studies. In genera l, it has been shown that the uncinate processes are higher at C4 to C6 levcls as compared to the C3 or C7 levels.

The ro les of the uncovertebra l joints arc both to guide coupl ed motion and to res trict motio l1 . The uncovertebra l joints he lp prevent poste rior translation and postero latera l disc movement , limi t lateral bendi ng and he lp guide flex ion and extension. The unc inate processes themselves ac t to limi t motion, whereas the entire jo int func ti ons to allow motion by ass isting coup led movcment.

42 I Chapter 3 : Cervicat Spine Application

«

Ligamentous anatomy The ligaments of the lower 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 the 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 ligamentous structures. The posterior longitudinal ligament (PLL) is narrower and slightly weaker than the anterior longitudi nal ligament (ALL). It runs over the posterior surfaces of the vertebral bodies from C2 to C7 within the vertebral canal. This ligament has an interwoven connection with the intervertebra l disc. In contrast to the ALL, the PLL narrows over the cervical vertebral bodies and fans laterally over the discs. On either side of the midline of the annu lus 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 longitudinally 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 cranial and dorsal caudal fashion fl'om C2 to C7. There are two ligaments at each vertebra l segment, 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 segmental beginning and endi ng at one vertebral segment. The ligamentum ftava are important in controlling and stabilizing the spine during flexion , a motion that causes the Iigamcnts to stretch. They then regain their original shape when the neck returns to thc neutral position. In extension, the ligaments retract and thicken 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 ligament 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 the IVD joint.

For example, cervical ven tral flexion is accompanied by a slight rocking of the c ranial vertebrae over the caudal 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 cranial vertebra rocks in a dorsal direction with slight dorsal glid ing 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 capsulol igamentous structures of the LlC spine are respons ible for the 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 liding down on the superior articular process oftJle inferior vertebra. During this motion, the facets stabi lize 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

Direction of joint rolling and gliding occuring during lower cervical ventral and dorsal flexion

Ventral Flexion

Dorsal Flexion

44 I Chapter 3 : Cervical Spine Application

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Biomechanics of Lower Cervical TSM

Disc Traction Lower cervica l disc t raction T5M techniques use a coupled position of side bending and rotat ion to the same side and towards the therapist. This position both faci litates contact on the lamina and articular process and insures that the spinal segment ends w ith neutra l sidebending when performing a single handed impulse. The impul se is directed cranially with either the hand on the concave side of the spine or w ith both hands when performing a two handed impul se. Positioning - right side bending right rotation

Facet Distraction

~ Two handed impulse directed cranially

Lower cervica l facet distract ion T5M techniques use a noncoupled position of side bending and rotation to the oppos ite side to compress the facets on one side and gap or di stract the facets on the other side. To fur ther distract a specific facet joint, the therapist then uses either a ventrally, medially and ca uda lly directed force on the lamina and art icu lar process of the cauda l vertebra or he/she uses a med ially directed force on the overlapping articular processes of the ca udal and cran ial vertebrae from the contra lateral side.

Positioning - right side bending left rotation

Facet joint distraction

Facet distraction is facilitated by:

or

Medially directed impulse

the spinal segment sh ifts from the vertebral body to the ove rlapped facet joints.

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 bending and rotation to the same side. This position facilitates gl iding motions in the facet joint. The therapist uses either a ventrally and crania lly directed force or a dorsa lly and ca udally di rected force. Ventral cra nia l gli ding of t he left facet assists in restoring flexion, side bending right and rotat ion to the right. Dorsa l cauda l g liding of th e right facet assists in restoring extension and side bending right and rotation to the right. The ca udal vertebra in the treatm ent segment is stabili zed either with manual stabil izat ion, spi na l locking or some combination thereof.

Positioning - the segment in right side bending right rotation

Ventra! cranial directed impulse

Caudal stabilization for ventral cranial gliding may be achieved by:

Applying a ventral, medial and slightly cranial force to the right lamina and articular process of the caudal vertebra in the treatment segment.

This maintains the axis of motion in the disc

46 I Chapter 3 : Cervical Spine Application

Applying a ventral, medial and slightly caudal force to the right lamina and articular process of the cranial vertebra in the treatment segment.

This shifts the axis of motion to the fight facet joint and generates greater leverage for stretching on the left.

Dorsal caudal directed impulse

Locking below in left side bending, right rotation and slight ventral flexion .

This shifts the axis of motion to the right facet joint and generates greater leverage for stretching on the left.

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C2-7-Disc Traction EL - HV & LV PP - HV & LV

Indication: To improve movement in all directions Position: Supine

A belt may be used to o 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.

Troubleshootin g your tcchnif.lue:

Note(s)

Irthe amplitude oflhe impul se is 100 large, the manipulating hand may slide cranially resulting ill di scomfort and! or a poorly locali zed and less effecti ve impulse. Placing the belt on the therapist's lumbar spine may resuh in d iscomfOJ1 l'or the practitioner.

This tec hnique will effect vertebral segments caudal to the treatment segment. The actual amount of traction in the in fra-adjacent segments is dependent upon the amount of force used, the amplitude of the movement and the amount of motion available at the indi vidual segments. When performing a high velocity TSM, the impul se should be del ivered from the therapist's arms, not the pelvis. When perfo rming a low ve locity tec hnique the pelvis is used to ge nerate the TSM . Attempts to generate a HV impul se from the pelvi s typically results in slow impul ses and large ampl itudes ofmovcment. Thi s techni que may be e l~cc ti ve in reducing cervicogeni c upper extremity pain relcrra1.

Tl'anslatol'ic Spinal Manipulation I 47

EL-0

Traction pp- HV

Indication: To improve movement in all directions Position: Side-lying

The therapist's right hand contacts the right inferior articular process and lamina of C2.

Slack in the disc joint is taken up cranially by the therapist's left hand and chest prior to delivering the

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

Troubleshooting you r techniq ue:

Note(s)

If the amplitude of the impulse is too large, the manipulat ing hand may slide cranially resulting in di scomfort and! or a poorly localized and less effecti ve impu lse. Fa ilure to support the head against the therapist's chest may result in upper cervical fl exion or too much side bending during the manipulation .

Placing the upper cervical and C2 in s light right rotation facil itates contact to the right infe rior articul ar process of C2 . An impulse de li vered to the right s ide ofC2 will cause s light left s ide bend ing and rotat ion resulting in the treatment segment ending in neutra l side bending and ro tat ion. This minimizes stress on the VA and ala r ligament.

An alternative way of performing thi s manipulation is to impul se with both hands. Thi s typically results in a greater sensation of traction for the patient but requ ires exce llent coordination and timing from both hands.

48 I Chapter 3 : Cervica l Spine Appl ication

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Traction El-0 PP-HV I

Indication : To improve movement in all directions Position: Supine

The therapist's right hand contacts 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:

Note(s)

If the amplitude of lhe impulse is too large, the manipulating hand may slide cran ially resulting in discomfort and/ or a poorl y loca lized and less effect ive impu lse. Failure to support the head against the therapist 's chest may result in 100 mllch side bending during the manipulat ion.

Placing the upper cervical and C2 in slight right rotat ion and side bending facili tates contact on the ri ght inferior articular process o f C2 . An impul se del ivered to the right side of C2 will cause slight leli side bcnding and rota tion resu lt ing in the treatment segment end ing in neutral side bending. Thi s min imizes stress on the VA and Alar ligaments. An alternati ve way of performing th is mani pulati on is to impul se with both hands. Thi s req uires excellent coordination and lim ing from both hands. Whil e the patient is still in the supine positi on. va ri ous pass ive segmental movements ca n be re-examined after applicat ion of this TSM.

Translatoric Spinal Manipulation I 49

C2-7-Disc Traction 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

Another contact option for the therapi st's manipulating hand is to hook the fifth

finger around the spinous process of theC:::=::~ cranial vertebra .

When using this contact, the therapist may overlap the ring finger on the fifth finger (see illustration to the right) for additional support of the finger.

Troubleshooting you r tech nique:

stands in of and to the right of,

patient's right side.

therapist's left hand

I C:,~:~:~~ the bilateral It, the caudal

EL - HV & LV PP - HV & LV

Failure to provide an equa l impulse from the chest and hand may result in a s ide bending movement during the manipulation.

Note(s)

If the amplitude of tile impu lse is too large, the right hand may slide crania lly and the left hand may slide cauda lly resu lti ng in discom fo rt and/or a poorly localized and less effective impulse. Ideally, the stabilizing fo rce should be equal to the impu lse. Discomfort may be felt by the patient if the therapist squeezes too much wi th the caudal stab ilizing hand dur ing the manipu lation.

Wh ile it is d ifficu lt to stabilize the infra-adjacent ve rtebra specifically. the lise ofa shon amplitude movcment coupled with the caudal stab ili zing force help to minimi ze the amount of movement occurring in the segmcnts caudal to the impulsed segment. In a symptomatic hypomobile segment , manual intervention often inc ludes a blend ofrSM , translato ric mobi liza tion and fun ctiona l massage. The scated position is particula rly good for the blending of these techniques.

50 I Chapter 3 : Cervical Spine Applica tion

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Traction EL-0 PP -HV

Indication: To improve movement in all directions Position: Side-lying

The therapist's right hand contacts the right inferior articular process and lamina of the cranial vertebra in the treatment

Slack in the disc joint is taken up cranially by the therapist's left hand and chest prior 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 hand contacting the left articular process and lamina the crania l vertebra in the treatment segment.

Troubleshooting your technique:

Nole(s)

If the ampli tude oflhe impulse is too la rge, the man ipulating hand may s lide cranially resulting in discom lorl and/ o r a poorly locali zed and less e fl'ect ive impulse. The medial fo rce applied by both the left and right ha nds should be firm enough to avo id s lid ing crania lly during the impulse but should no t cause any discomfort in the son ti sslles . Irthe soft ti ssues arc sensiti ve, the therap ist shou ld apply the pressure gradua lly unti l e ither the therap ist feel s the underl ying bony surlaces or the patient ex presses mild discomfort . The therapi st should then take up the s lack in the segment in a cranial direc tion. Irthe hands s lide o flthe segme nt o r the d iscomfort increases to the point of intole rance fo r the patie nt, the technique should 11 0 t be performed. Rather, techniq ucs that reducc soft ti ssue sens iti v ity should be used. The techn ique may be attempted aga in upon reduction of soft ti ssue tende rness. Failure to support the head aga inst the therapi st's chesl may result in a nodding motion o rlhe head or too much s ide bending during the manipulation.

The medial force app lied from both hands are necessary to maintain contact to the trea tmcnt scgment. All a lte rnative method of performing thi s mani pulation uses an impu lse de livered from both hands. This requires excell ent coordination and liming from both hands.

Translatoric Spinal Manipulation I 51

EL-0

Traction 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.

Troubleshooting your tec hnique:

Note(s)

Ifill e ampl itude orl he impulse is too large, the manipu lat ing 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 enough medial force from both hands pr ior to the impulse may result in a cranial s liding of the hands during the manipula tion resu lti ng in di scomfort and/or a poorl y loca lized and less e ffec tive impulse. Fai lure to support the head against the therapist 's ches t may result in a nodding motion of the head or too much s ide bending during the manipulat ion .

As with the prev ious technique, both hands may be lIsed to generate the impu lse during this techn ique . It is tile author's experience that impuls ing simultaneoLis ly with both hands typica lly genera tes a greater sensation of trac tion for the patient.

52 I Chapler 3 : Cervical Spine Application

IIC

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 lamina and superior articular process of the caudal vertebra in the treatment segment.

Slack in the facet joint is taken up in a ventral. medial and caudal direction by the therapist's right hand prior to delivering the impulse.

The therapist's right hand impulses ventrally, medially and caudally.

The therapist stands facing the top of the patient's head.

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 crania l vertebra in

• -Troubleshoot ing your technique:

• Failure to sumciently support the side bendi ng and rotat ional positio;li ng of the supra-adjacent spinal segments may result in unwanted cervical moti on dur ing the man ipul at ion.

Notc(s) The treatment segme nt may be placed in ventra l or dorsal flexion based 0 11 the patie nt's speci fi c res triction . Lower cervical facet traction performed in a nOllcoupled posi tion will fac ilita te maximal di stract ion orthe articular sur races. This resu lts in the grea test amount or racet joint capsular stretching. This technique may also be perfofm ed with the pa tient's head/neck resting on a pillow.

Translatoric Spinal Manipulat ion I 53

Distraction EL - LV PP -HV & LV

Indication: To improve movement in all directions (R Facet Joint) Position: Seated

lamina and superior articular process of the caudal vertebra in the treatment

The therapist's right hand impulses ventrally, medially and caudally.

-

patient SUIJoc,rtirlQ the patient's

and neck position i left hand, and abdomen.

therapist's left hand SUIDO(JrtS the left side of

• -Troubleshooting your technique:

Note(s)

Fa ilure to s upport the s ide bending and rotational pos itioning of the supra-adjacent spina l segments may result in unwanted s ide bending du ring the manipu lati on . Pressure aga inst the anterior neck by the stabilizing hand shou ld be avoided and may lead to discomfort during the

manipulation .

During this technique, the OA and AA segments are in a coupled position. The remaining supra-adjacent segments are positioned in a Iloncoupled position. The treatment segment may be placed in ventral or dorsal tlexion based on the specific rest ri ctio ll . Lower cervica l facet traction performed in a noncoupled position wi ll facilitate maximum distrac tion of the

articu lar surfaces. Thi s resu lts in the g reates t amount of t~lcet joint capsu lar st re tchi ng.

Lower cervica l facet traction performed in a noncoupled position is a very specific technique . Thi s techn ique is typica ll y tol e rated well by patients who are experiencing hypermobility caudal to the treatment segment.

54 I Chapter 3 .- Cervical Spine Application

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EL- LV C2-6- Facet Distraction 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, I fore,,,m and chest.

ulnar border of the I th,eralPist's right hand supports the right posterior edge of the

process, articular process and lamina of the crania l vertebra in the treatment segment.

•

In sitting, the patient's cervical spine down through the treatment segment is positioned in left side bending and right rotation.

The impulse is directed ventral , medial and caudal with the therapist's left thumb.

lamina and superior

"--- ..,.-1 articular process of the After the left and i are i contact with the patient, caudal vertebra in the slack is taken up by the therapist applying (1) a gentle cranial , treatment segment. medial and slightly dorsal force with their right hand and forearm and (2) a ventral , medial and caudal force with their left thumb.

Troubleshooting your technique:

-

If the impu lse has 100 largc an amp litude, the manipulating hand may slide cauda lly resulti ng in di scomrort and/o r a poorly localized impulse.

Note(s)

Failure to support the s ide bending and rotational pos iti on ing of the supra-adjacent spinal segments may result in unwanted s ide bending during the man ipulat ion.

During thi s techn ique, the OA and AA segments are in a coup led position. The rema ining supra-adjacent segments are positioned in a noncoLipled position . The race t joint may be placed in neutral , ven tral or dorsa l llex ion based on tile speci fie restri ction. Lower cervica l racet traction performed in a noncouplcd position will rac ilitate maximum distraction orille articular surfaces. Th is res lI It s in the greates t amount or capsu lar stretching in the facet joint. Lower cervica l facet traction performed in a noncollplcd position is a very specific technique. This Icc i1'nique is typica lly tolerated we ll by patients who are experienc ing hypermobil iry caudal to the trea tme nt segment. This form of lower cervica l face t joint tract ion also gives the therapist the latitude to apply the technique while g iving a c ranially directed traction to the di sc joints. Given thi s, hypomobile facet articu lations can be manipu lated or mobilized with this technique in the presence of radicular irritation caudal to the treatment segment.

Translatoric Spinal Manipulation I 55

C2-6- Facet Distraction EL - 121 PP - HV & LV

Indication: To improve movement in all directions (L Facet Joint) Position: Supine

The therapist's right hand impulses medially and slightly cranially and dorsally.

i ii 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.

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.

Troubleshooting your techn ique:

Note(s)

If the manipulating hand is placed too lateral , it may contact the tip of the transverse process result ing in discomfort when taking up the slack and/or during the manipulation . Ifwhen posi tioning the neck, the therap ist positions the side bending prior to add ing rotation, there may not be enough space for the manipulative 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 the cranial vertebra prior to positioning the 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.

The facet joint may be placed in neutral , ventral or dorsa illex ion based on the specific restriction . J f right side bending and dorsal flexion are rest ricted on the right s ide, the thrust must be applied to the right inferior articular process of the caudal vertebra of the segment treated. If the impulse is direc ted too cranially or ventrally, a gl iding 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 distraction occurs on the opposite side of the manual contact making this an excell ent technique if there is soft ti ssue tenderness on the same side as the facet joint restriction.

5 6 I Chapter 3 ." Cervica l Spine A pplication

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C2-6-Facet Glide EL-0 PP - HV & LV

Indication: To improve left rotation (R Facet Joint) Position: Supine

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.

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.

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

The therapist then carefully takes up the remain ing left rotation in the treatment segment by pulling the vertebra into left rotation.

Troubleshooting your tec hnique:

Note(s)

One common mistake made when performing this technique is the loss of right s ide bending cauda l to the treatment segment when the therapi st s ide bends the treatment segment to the len. If thi s occurs, the locking wil l be less efTectivc and the technique less specific. To coun ter this mistake, the therapist shou ld supinate his/her forearm to ma intai n the caudal lock wh ile creat ing coupled motion in (he treatment segme nt. If the pat ien t is unable to re lax or reports di scomfort once the cerv ical spine is positioned for the technique, the therapist should attempt to determine if s light adjustments in posit ion ing improve relaxation and reduce the patient's di scomfort. Techniques such as hold-relax , soft ti ssue massage or fUllct ionalmassage may also be used to facilitate re laxat ion and may be used prior to this technique to enhance pat icnt to lcrance. The use orthe lel't (non-manipu lat ing) hand during the positioning of the trea tment segment reduces the stress placed on the art icular pillar/ lam ina by the man ipulating hand. If the left hand is not used during the posit ion ing, slack may not be taken up eflec ti ve ly and the pati ent may fee l discom fort under the manipulat ing hand.

The ax is ror thi s moveme nt will be in the len racet oflh e treatment segment.

TranslalOric Spinal Manipulation I 57

C2-6-Facet Glide Indication: To improve right rotation (L Facet Joint) Position: Seated

In sitting, the patient's treatment segment is positioned in right side bending and right rotation.

The vertebral segments caudal to the treatment segments are positioned in left side bending and right rotation (locked below).

The fifth finger of the therapist's right hand contacts the left inferior articular process of the cranial vertebra in the treatment segment.

The contact of the manipulating hand may be reinforced by overlapping the ring C::~,.;I. and middle 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.

Troubleshooting your technique:

The therapist's right hand impulses ventrally and cranially.

EL-LV PP - HV & LV

L

The righ t hand must provide a slight ventral and medial force (right s ide bending) to create coupl ing in the \ treatment segment. Fai lure to couple the trea tment segment will red uce the amount of gliding avai labl e during the manipu lation and may result in a less effective technique.

Note(s)

Fai lure to maintain the lock ing be low may resu lt in a poorly localized and ineffective manipulat ion. Using the spinous process as described in the "N ote(s)" below will a id in maintaining the ca udal spi na l lock. The therapi st/student must be sure that they are on C2 and not C l when performing this technique for the C2 spinal segment. This can be checked by palpat ing the spina Li s process of C2 (the first spi naLIs process below the occiput). The the ulnar border of the therapist's ri gh t hand shou ld be placed immediately latera l to the C2 spinous process.

The caudal spinal lock is maintained by the medial fo rce applied by the therapist 's thumb comb incd with thc therapi st's right hand pu lli ng the spinous process of the cranial vertebra in the treatment segment towards the left to further reinforce the caudal locking.

58 I Chapter 3 : Cervical Spine Application

t:

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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:

Note(s)

Maintaining contact to C7 is orten difficult . Irthe amp li tude oflhe impulse is too large, or the medial contact

forces app lied by both hands is 110t forceful enough, the hand may s lide cranially resu lt ing in discom fort o r a poorly loca li zed impulse. Fa ilure to support the head aga inst the therapi st 's chest may result in side bending during the manipulation.

The media l forces app lied from the stabilizi ng and mani pu lat ing hands helps the therapist maintain contact to the impulsed segment. An a lternative method of performing thi s man ipulation uses an impulse de li ve red from both hands. This requires

excellent coord ination and liming from both hands.

Translataric Spinal Manipulation I 59

Glide EL - f2J PP - HV & LV

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/pulling 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.

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 inferior articular process, lamina and spinous process of C7.

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.

Troubleshooting your technique:

Note(s)

O ne common mistake made when perform ing this technique is the loss oflhe cauda l spinal lock, resulting in a less specific technique. The greatest reason for this is dropping of the therapist 's left hand when unlocking the treatment segme nt. To un lock the treatme nt segme nt without los ing the caudal spina l lock, the therapist Illust use both hands to pos it ion the coupling in the treatment segment, moving the supra-adjacen t spina l segments as a unit. I f the therapist 's len hand pulls too mllch from the chin, the patient may experience di scomfort during this technique. To reduce this tendency. the therapi st mllst LIse the 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 spinal segments.

The ax is for thi s movement wil l be in the len nIcet ofC7.

60 I Chapter 3 : Cervical Spine Application

It:

It:

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C7-Facet Glide EL-0 PP - HV & LV

Indication: To improve left rotation (R Facet Joint) Position: Side-lying

The right hand

The patient's C7 segment is positioned in left side bending and left rotation.

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.

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 ulnar side of the hand contacting the left inferior articular process and lamina of 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

Troubleshooting your technique:

Nole(s)

Maintaining contact to C7 is often difficult. If the amplitude of the impul se is too large the direction o rthe impul se too crania l or the medial contact force a pplied by both hands is not forcefu l e nough, the hand may s lide cran ially resulting in discomfort or a poorly loca li zed impul se. Fa ilure to support the head against the therapist's chest may result in additional unnecessary movement in spinal segments crania llO the trcatme nt segmcnt during the manipulation .

The medial force s app lied from the stabili zing and manipulat ing hands he lp the the rap ist ma intain contact to the impul sed scgm~nl. The ax is for this movement will be in the lett facet ofC7 .

Translatoric Spinal Maniplilation I 61

Glide EL-LV PP - HV & LV

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.

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 techniq ue:

cervical spine, excluding 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.

O ne common mi stake whcn perform ing th is techn ique is insufficient contact 011 the C7 spina l segment. To identify where C7 is located, s lide both hands down the latera l surface of the neck until the first rib is contacted. The ve rtebra crania l to this po int is C7.\

NOle(s)

Another common mistake is directing the impulse too medially with the left hand. Th is may cause d iscomfort for the pat ient and may lim it dorsa l cauda l gl iding of the Ic fllacet joint.

By using both hands to position C7, the therap ist may dete rm ine whe re the axi s of movemcnt wi ll bc plnced. The axis for movement at C7 is in the lell facet joint. A belt may be placed across the manubrium to stabili ze against unwanted movement of TI during the

man ipulation.

62 I Chapter 3 : Cervica l Spine Application

Glide EL - HV & LV PP - HV & LV

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 lamina 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:

Note(s)

One comlllon mistake when performing this technique is insufficient contact on the C7 spina l segment. To identify w here C7 is located , slide the manipulating hand down the lateral surface of the neck until the fi rst rib is contacted with the radial border orthe second MCP. The vertebra cranial to this point is C7. In sutlicient stabilization of the shoulder may lead 10 a poorly localized and less effect ive manipulation ofC7. When performed properly, ve ry litLl e movement wi ll occur in the spinal segments cranial to the treatment segment. Failure to contact C7 properly, or to deliver the impulse to C7 through the second MCP, may cause unwanted movement above the treatment segment. T9 assure continued contact to C7 the manipulating hands radial border of the 2nd MCP should maintain contact to the first rib during the TSM .

The therapi st supports his/her index finger w ith their middle finger dorsa ll y. The cervical spine above C7 is contacted by the remainder oflhe therapist 's hand and is moved as a unit with C7. For patients presenting with more thoracic kyphosis , the impulse may need to be directed more ventrally. In c linical practice, comprehensive manual intervention often consists of the application of functional massage, translatoric mobilization and translatoric manipulation all being applied to reduce soft tissue sensi tivity and to enhance symptom free motion. Transitioning from one intervention technique to another can occur quite easily

Translatoric Spinal Manipulation I 63

EL-LV

Glide PP - HV & LV

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.

For restricted dorsal caudal gliding on the left.

The therapist's right hand stabilizes the right facet joint of C7 by pressing ventrally and medially.

The therapist's left hand I and

Troubleshooting your technique:

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 ventral cranial gliding on the right.

The therapist's left hand stabilizes the left facet joint of C7 by pressing ventrally and medially.

The therapist's right hand I I and

For the dorsal caudal version of th is techn ique, if the manipulating force is directed too medially, the patient may experience discomfort during the manipulation.

Note(s)

Slack is taken up in an equa l manner by both hands in order to keep the axis of movewent in the C7 segment. Too large an amplitude or movement Illay resu lt in unwanted Illovemcnt of the thoracic spine and excessive stress in the cranial cervical segments.

A wedge Illay be used to ass ist in stabi li zing the upper thoracic spinc. To allow clearance for movement of the manipulat ing hand, the base of the wedge should be placed under T2 or T3. The thoracic spine may also be stabili zed by placing it in flexion , left rotation and right s ide bending.

64 I Chapter 3 : Cervical Spine Application

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Glide EL - I2J PP - HV & LV

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 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 spinous process of C7.

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.

Troublcshooting your tec hniq uc:

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.

If impulsing with the right hand the impulse is directed mediaUy and dorsally towards the left facet of C7.

If impulsing with the left hand the impulse is directed caudally and medially.

To effectively mobilize C7 using thi s techn ique, the therapist must stand on the ri ght s ide of the patient. The therapist 's right e lbow is supported against the right side ofhis/hcr abdomen and pelvis.

Note(s) A wedge may be used to ass ist in stabil izing the upper thoracic spine. To a llow c learance for movement of the manipulating hand, the base orthe wedge should be placed under T2 or n. The thorac ic spine may also be stabili zed by placing it in t1 ex iol1, left rotat,ion and right side bend ing. During this technique. the emphasis is placed on the dorsa l cauda l glide occurring in the left facet joint.

Translatoric Spinal Manipulation I 65

EL-LV

Glide PP-HV & LV

Indication: To improve left rotation (R Facet Joint) Position: Prone

Troubleshooting your technique:

Nole(s)

As mentioned previously, it is important to be sure the therapi st is properly contacting C7 during this techni que. To avoid any crania l sliding during the manipul ation, the ulnar border of the right hand should maintain contact with the first rib throughout the technique. InsutTicient stabiliza tion of the shoulder may lead to a poorly localized and less effective man ipulati on or C? Irthe manipulati ng hand is located above C7 or i f the impul se is too large or de li vered by the palmar surface instead or lhe ulnar border of the hand, unwanted movement including dorsal ncxiol1 o r the supra-adjacent spinal segments may occur.

TI is stabilized by pulling the shoulder girdle posteriorly thereby approximati ng the clav icle into the first rib and the first rib into T I. A fi fm pillow or sandbag may be placed under the patient 's right shou lder to support the positioning orlhe thoracic spine in right rotation. The therapist may then use the left hand to support the right when deli ve ring the i mpuisc.

66 I Chapter 3 : Cervical Spine Application

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Glide EL -/21 PP - HV & LV

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 shoulders are positioned in approximately 120. 1300

of nexion.

The patient's cervical spine, 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.

Troubleshooting your technique:

Notc(s)

As mentioned previoLisly, it is important to be sure the therapist is properl y contac ting C7 during this techni que. To avoid any cranial sliding dur ing the manipulation, the ulnar border of the righ t hand shoul d maintain contact with the first rib throughout the technique. Insunicicnt stabilizati on of the shoulder may lead to a poorly loca lized and less e ffec tive manipulation of C7. Irthe manipulating hand is located above C7 or irthe amplitude of the impul se is too large or delivered by the palmar surface instead of the ulnar border of the hand , unwanted movement including dorsa l nex ion of the supra­adjacent spinal segments may occur.

T l is stabilized by the posi tioning of the shoulders and shoulder girdle bilatera ll y. For proper stabilization ofTI the patient must relax thei r serratus an terior and allow their 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 therapi st to generate a good deal of force when man ipul at ing C7 with high or low velocity TSM.

Translatoric Spinal Manipulation I 67

Glide Indication: To improve left rotation (R Facet Joint) Position: Prone

The therapist is positioned beside the patient's head , neck and left shoulder.

The 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.

Troubleshooting your technique:

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.

EL -" PP-HV & LV

As mentioned previously, it is important to be sure the therapist is properly contacting C7 dur ing this techni que. To avoid any cran ial sl iding during the manipulation, the ulnar border orthe right hand should maintain contact with the first rib throughout the technique.

NOle(s)

Insufficient stabi liza tion or the shoulder may lead to a poorly loca lized and less effecti ve man ipulation or C7. If the mani pu lating hand is located above C7 or the amplitude orthe impu lse is too large or delivered by the palmar surface instead of the ulnar border of the hand. unwanted movement including dorsa l flexion orthe supra­adjacent spinal segments may occur.

T I is stabil ized by the posi tioni ng orthe shoulders and shou lder girdle bilaterally. For proper stabilization of T I the patient must relax thei r serra tus anter ior and allow their chest to sink ante rior towards the table. This allows the fi rst rib and clavicle to approximate and stabilize T I.

68 1 Chapter 3 : Cervical Spine Appli cation

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Glide EL -LV PP - HV & LV

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,

The impulse may be given in two ways: (1) the therapist's right hand impulses ventrally and cranially and

I e)(CllJdiillg C7, is Posltioned in neutral or slight left side bending.

(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

I tho",cic spine into left rotation.

The thumb presses medially on the left side of the spinous of T1 .

Troubleshooting your technique:

Note(s)

O ne common mistake when performi ng thi s technique is insuffici ent contact on the C7 spinal segment. To identify where C7 is located, s lide the manipulating hand down the lateral surface of the neck until the first rib is contacted. The vertebra cranial to this point is C7. Insuffic ient stabilizat ion orthe shoulder may lead to a poorl y loca lized a nd less dTcctivc manipula tion ofC7 . Undesired and extraneous mid-cerv icalmovemc nt w ill occur if the who le hand contacts cervica 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 the translatoric im pu lse.

The the rapist may a lso take up the last portion o rthe s lack at C7 with a small amount of traction applied by hi s/her chest and manipulating hand. The contact orthe manipulating hands may be reinforced by overlapping the ring and middle finger dorsally over the fifth finger. In cl inica l pract ice, comprehensive manual intervention often consists of the appl icat ion or fun ctional massage, cont ract· re lax manualll1l1sc le stretching, translalOric mobili za tion and translatoric manipulation all being applied to rcduce so n tissue sens iti v ity and to enhance symptom Cree motion .

Tmns/atoric Spina/ Manipu/ation I 69

...

Glide Indication: To improve right rotation Position: Seated

The therapist stands facing the patient.

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.

The ulnar border of the therapist's left hand contacts the patient's right lamina, inferior articular process and right side of the spinous process of C7.

After the left and fight hands are in contact with the patient , slack is taken up by the therapist applying (1) a ventral cranial force ...-___ -. with their right hand and (2) a caudal and medial force with their left hand.

The therapist's right knee is positioned against the patient's left anterior shoulder.

Troubleshooting your tech nique :

, left hand right facet

by pressing vernt",lIv and medially

therapist's right impulses ventrally

and cranially:-

EL -12/ PP - HV & LV

cervical spine, I e,<cllJdir'9 C7 , is positioned in

C7 segment is positioned in right side bending and right rotation .

A number of options are available to improve movement of C7 using this technique; two of the more common movement combinations are de:scriberj I below.

The therapist's right hand stabilizes the left facet joint of C7 by pressing ventrally and medially

The therapist's left hand impulses dorsaUy and caudally.

One common mistake when perform ing this technique is insufi'icient contact on the C7 spinal segment. To identify where C7 is located, sl ide the manipulating hand down the late ral surface of the neck until the first rib is contacted. The vertebra cranial to this point is C7.

Note(s)

Insufficient stabili za tion of the shou lder may lead to a poorly localized and less e fTecti vc manipu lat ion orC7.

This is an cxce llent technique to appl y when the C7 segmcnt is ve ry hypomobilc (Grade I). This technique ca n provide a very strong and safC stretch to the connective tissues tllat may be limit ing movcmcnt

at the C7 segment.

70 I Chapter 3 : Cervical Spine Appl ication

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Distraction EL -" PP - HV & LV

Indication: To improve movement in all directions (R Facet Joint) Position: Seated

The therapist stands facing the back of the patient .

The ulnar border of the therapist's right hand presses medial and in the direction of the anterior surface of the transverse process of C7.

The ulnar border of the therapist's left hand stabi lizes the left side of C7 by pressing the left lamina, inferior articular process and left posterior surface of the transverse process of C7 ventral , medial and caudal.

Troubleshooting you r technique: /

Slack in taken up in a dorsal and Slightly cran ial direction by the therapist's right hand prior to del ivering the impulse.

The patient's cervical spine including C7 is positioned in ventral flexion , left side bending and right rotation.

The patient's thoracic spine is positioned in flexion, left side bending and right rotation (locked below).

i is positioned against the patient's left lateral shou lder.

The therapist 's left leg is used to supportlhe pat ient's trunk posit ion. It should not block the positioning of the thorac ic spine into side bending which is necessary for locking below.

Note(s)

Pressure against the tip of the transverse process ofTI may cause discomfort to the pat ient and should be avoided .

Stab ilization ofTI is generated by the locking occurring below in flexion le ft side bending and right rotation . An alternati ve or supplemental method of stabiliz ing TI can be achieve by placing the therapist's righ t knee behind the patient 's ri ght shoulder thereby manually stabi lizing the thoracic spine and TI.

Translatoric Spinal Manipulation I 71

EL -121 Distraction PP - HV & LV

Indication: To improve movement in all direct i o ns (R Facet Joint) Position: Seated

i j

including C7, is positioned in flexion, left side bend ing and right rotation.

The patient's thoracic spine is positioned in ventral flexion, left side bend ing and right rotation (locked below).

taken up by the ulnar border of the therapist's right hand pressing ventrally and medially to stabilize C7.

Slack in the right facet joint is taken up by the ulnar border of the therapist's left hand pressing dorsally and slightly cranially.

Troubles hooting your techniqu e:

The therapist's right knee is positioned against the patient's left anterior shoulder girdle.

The therapist stands facing the front of the patient.

The ulnar border of the therapist's ' left hand presses medially and in the direction of the anterior surface of the right transverse process of C7.

The ulnar border of the therapist's right hand contacts the patient's left lamina, inferior articular process and posterior surface of the transverse process of C7.

(

The therapi st's ri ght knee must be pressed agains t the pati ent's le n. shoul der girdle to e ffec tive ly stabilize T l .

NOle(s) A towe l may be placed anterior to the the rapist's right knee to reduce any discomfort ex perienced during the stabi lizat ion. Th is technique variation generally provides better stabili zat ion than the one pictured 0 11 the previoLis page, however, it is typica ll y more diflicult to push C7 than pull ii, as pictured on the previous page. The axis of'movcmcnt for this technique is the left fa ce! jo in! orC7.

72 I Chapter 3 : Cervica l Spine Applicat ion

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Distraction EL -" PP-HV & LV

Ind i cation: To improve movement i n all directions (R Facet Joint) Position: Seated

The therapist stands facing the back of the patient.

The ulnar border of the therapist's right hand contacts the patient's right lamina , superior articular surface and right posterior surface of the transverse process efT1.

The ulnar border of the therapist's left hand presses in the direction of the patient's left transverse process and ventral lateral aspect of the vertebra l body of C7.

In addition to the contact described above, the therapist's left hand supports the patient's head and neck position. -----taken up by the ulnar border of the therapist's left hand pressing dorsally and medially to stabi lize C7.

Slack in the right facet joint is taken up by the ulnar border of the therapist's right hand pressing ventra lly, medially and caudally.

Troubles hooting your techniq ue:

The therapist's right hand impulses ventrally, medially and

Discom f'ort in the len side of tile pati en t's neck may be caused by press ing med ially w ith the left hand when support ing thc pat icnt 's neck.

Note(s) Duri ng this techn ique. it is expected and necessary that some min ima l movement occ ur in the thoracic spine ca uda l

10 TI. The axis of movement l'or th is techniq ue is the left facet joint ofC7. The impulse may a lso be given by the radial border of the 2nd Mer and index fi nger of the right hand with the forearm pos it ioned in pronat ion.

Transla/oric Spinal Manipula/ion I 7 3

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Thoracic Spine u@@[}uuuDCQJQJ]@ .

The Thoracic Spine

The stable thoracic segments The twelve thoracic motion segments are the least mobile of the

spinal column. There are a number of factors that contribute to the relative stiffness of this region. The first factor relates to thoracic disc height. The thoracic disc is narrow relative to other regions of the spine. In addition, the nucleus pulposus ofthe thoracic disc is smaller in size reducing the overall water content within the disc. The smaller disc height relative to thoracic vertebral body height reduces overall segmental mobility. A second factor contributing to the overall stiffness of the thoracic spine is the thickness of the ligamentum ftavum. In the thoracic region of the spinal column, the ligamentum ftavum is thicker and well suited to enhance thoracic segmental stability. The third factor contributing to the stiffuess of the thoracic spine is the attachment of the ribs to the spine and sternum. This thoracic cage increases the res istance of the thoracic spine to all movements in the sagittal, frontal and transverse planes. Regarding movements in the transverse plane, the thoracic vertebrae that attach to the sternum via the ribs demonstrate the greatest increase in resistance to motion in the transverse plane. The remainder of the thoracic segments not attaching directly to the sternum show less resistance to torsional motion Lastly, regarding the the overall stabi lity of the thoracic spine, the thoracic facet joint capsular ligaments are thinner when compared to the other regions of the spine. This may be a factor in the relative ease in obtaining joint cavitation with both unilateral and bilateral facet joint distraction manipulations.

Osteological features of the thoracic spine Clinicians providing manual intervention to the thoracic segments

should be aware of the general angle of orientation of the thoracic spinous processes. At the T I through T3 segments, the spinous processes point nearly straight backward. At the T4 through T6 segments, the spinous processes angle downward slightly. This trend continues even more so at the T7 through T9 segments. This osteological characteristic is particularly important when locating and contacting the transverse processes in the thoracic spine for testing and treatment purposes. When contacting thoracic spinal segments in the mid-thoracic spine, the tip of the spinous process is more caudal than the transverse process for a given spinal segment. Due to the normal variation of osseus structures between and within individuals, this principle should be used as a guide for the location of transverse processes. The location of the structures may be further clarified/confirmed through the use of translatoric joint play testing in prone, side-lying or in a seated position.

Thoracic facet joints The thoracic facet joints are principally orientated in the frontal

plane. Given this, the thoracic facets and the thoracic intervertebral discs are the primary stabilizers to anterior/posterior displacement of any given thoracic segment. In the lower portion of the thoracic spine, typically somewhere between the T I 0 and T 12 segments, the general orientation begins to change slightly toward the sagittal plane.

In more specific terms, the thoracic superior articular facet in any given segment lies anterior to the inferior articular facet. The articular surface of a superior thoracic facet is orientated in a cranial, lateral and posterior direction. The inferior thoracic facet lies posterior to the superior facet and its articular surface faces somewhat caudally, medially and anteriorly. On a clinicallbiomechanical note, significant increases in segmental mobility follow the removal of these facets. Loss of the facets due to tumor, trauma or surgery will result in increased segmental motion.

76 I Chapter 4 : Thoracic Spine Application

Articular surfaces of the thoracic spine

~e vertebral body I (

Thoracic spine articulations

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Direction of joint rolling and gliding during thoracic ventral and dorsal flexion

Ventral Flexion Dorsal Flexion

Direction of joint rolling and gliding during thoracic coupled side bending and rotation in ventral flexion

Left Side Bending and Rotation Right Side Bending and Rotation

Translatoric Spinal Manipulation I 77

Biomechanics of Thoracic Spine TSM

Disc Traction

Thoracic disc traction TSM techniques are performed with the patient in a seated or supine postion.The caudal vertebra is stabilized with a wedge or through direct manual stabilization. The impulse is directed cranially through the patient's shoulder girdle and upper trunk.

Position - the actual resting position

Facet Distraction

Thoracic facet distraction TSM techniques can be performed unilaterally or bilaterally. They may also be performed moving the cranial vertebra (typically in supine or sitting) or caudal vertebra (in prone). Stabilization of the cranial or caudal vertebra is achieved through either the use of the hand, the wedge or through spinal locking above or below. Unilateral distraction techniques are performed with sidebending away and rotation towards the treatment side.

Bilateral Facet Distraction Positioning - actual resting position

Caudal stabilization

Cranial stabilization

78 I Chapter 4 : Thoracic Spine Application

Unilateral Facet Distraction Positioning - sidebending away, rotation towards the side of facet distraction

Impulse directed posteriorly towards the left facet joint

Caudal stabilization

Facet joint distraction

Impulse directed ventrally, medially and slightly caudally

Facet joint compression

Cranial stabilization

Facet joint compression

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Thoracic-Disc Traction EL - LV PP - HV & LV

Indication: To improve movement in all directions Position: Supine

The therapist faces the patient's chest.

The therapist supports the patient posteriorly with their left hand and forearm supporting the patient's upper back and neck.

The therapist's right hand is placed on the midline of the patient's crossed forearms.

The patient is positioned in supine with their thoracic spine, including the treatment segment, positioned in the actual resting position.

The patient's arms are positioned across their chest along the ribs connecting to the cranial vertebra in the

Troubleshooting your technique:

Note(s)

Monitor that the patient's cervical region is relaxed, well supported and not hypertlexed or hyperextended when performing this technique.

Translatoric thoracic disc traction is a good initial treatment option if a thoracic segment is very hypomobile (Grade I restriction on the 0-6 KE mobility scale). Once the thoracic segment demonstrates improved mobility, translatoric thoracic unilateral or bilateral facet traction manipulation may be applied. Translatoric thoracic disc traction is a good initial treatment option if there is intercostal pain radiation. In technique variation A pictured above, the therapist uses a "pistol grip" (see illustration on next page) to support the caudal vertebra. A pillow or the movable head section of a manual therapy table may be used to support the position of the treatment segment and the spinal segments cranial to the treatment segment. In technique variation B, a wedge is used to support the caudal vertebra in the treatment segment. The therapist then uses both oftheir hands placed on the patient's overlapping forearms and elbows to generate the manipulative impulse.

Translatoric Spinal Manipulation I 79

Thoracic-Facet Traction EL - HV & LV PP - HV & LV

Indication: To improve movement in all directions Position: Supine

The therapist's right wrist is positioned in ulnar deviation. The fingers are positioned with the index finger straightened and fingers 3-5 flexed. The distal phalanx of fingers 3-5 are positioned perpendicular to the palm.

The spinous process of the caudal vertebra is placed between the flexed fingers and the thenar

Troubleshooting your technique:

Slack in the treatment segment is taken up by pressing dorsally and cranially towards the transverse process of the caudal vertebra in the treatment

The impulse is directed against the therapist's flexed fingers and thenar eminence and slightly cranial to the transverse process of the caudal vertebra in the treatment segment.

The therapist faces the patient's chest.

The therapist contacts the patient posteriorly with their right hand stabilizing the transverse processes of the caudal vertebra in the treatment segment (see box 3).

The therapist's left hand is placed on the midline of the pat.isnt's crossed forearms.

The patient is positioned in supine with their thoracic spine, including the treatment segment, positioned in the actual resting position.

It is important to maintain a light contact with the patient when positioning for this technique.

Note(s)

This may require additional support for the patient's upper body to minimize discomfort prior to and immediately following the manipulation. This may be accomplished by reaching behind the patient's upper back as illustrated on the previous page.

The section of the table located under the thoracic spine may also be elevated to reduce pressure against the stabilizing hand or thoracic wedge. For these pictures, the middle thoracic spine is treated with the patient's head and upper thoracic spine positioned on the head section of the table which is then elevated slightly. The lower thoracic spine is treated with the head and the middle thoracic spine positioned on the foot portion of the table which is then elevated. The patient's anns are positioned across hislher chest cranial to the treatment segment. Note the orientation of the therapist's arm and hand under the patient. The therapist's arm and hand should be placed medial to the inferior angle and medial border of the scapula.

80 I Chapter 4 : Thoracic Spine Application

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Thoracic-Facet Traction EL - HV & LV PP - HV & LV

Indication: To improve movement in all directions Position: Supine

Slack in the treatment segment is taken up by the therapist's chest and hand pressing dorsally and cranially towards the transverse process of the caudal vertebra in

The base of the wedge is placed against the transverse process of the caudal vertebra in the treatment segment.

The therapist supports the patient's upper back and neck

.-.:::::...-, posteriorly with their left hand and forearm.

The therapist's right hand is placed on the midline of the no';onll'. crossed forearms.

The patient is positioned in supine with their thoracic spine, including the treatment segment. positioned in the actual resting position.

The patient's arms are positioned across the chest along the ribs connecting to the cranial vertebra in the

Troubleshooting your technique: ,

Note(s)

As with any of the thoracic facet traction techniques, care should be taken to avoid movement into thoracic dorsal flexion during the impulse.

In cases of significant hypomobi lity, in order to generate the greatest improvement in motion in a given spinal segment, it is necessary to manipulate the treatment segment in the position where the greatest joint play is nonnally felt. Specifically, if the therapist is unable to determine where the joint moves the easiest or greatest, then the manipulation should be performed where the segment's resting position is estimated to be. To achieve this position in the treatment segment, while stabilizing the caudal vertebra, the therapist must test the movement of the treatment segment in varying degrees of ventral and dorsal flexion. The impulse is performed in the position where the movement is felt to be the greatest and the end feel the most firm and nonmuscular. The patient's arms are positioned across hislher chest cranial to the treatment segment. The dorsal cranial movement should occur immediately above the wedge during this technique. In the Haltemative arm position" picture, the patient's arms are not crossed, rather the shoulders and elbows are fl exed and the hands are overlapped behind the neck.

Translatoric Spinal Manipulation I 81

F

Thoracic-Facet Traction EL - 0 PP - HV & LV

Indication: To improve movement in all directions Position: Supine

segment is taken up dorsally and cranially towards the left transverse process of the caudal vertebra in the treatment

placed under the left transverse process of the caudal vertebra in the treatment

The therapist stands on the right side of the patient facing the patient's chest.

The therapist supports the patient posteriorly with their left hand and forearm supporting the patient's upper back and neck. The thenar eminence of the right hand stabilizes the caudal vertebra as described under box 2.

Anteriorly, the therapist contacts the patient's elbows with their chest.

treatment segment, is positioned in ventral flexion , right side bending and left rotation

Troubleshooting your technique,

Note(s)

It is important to be sure that the stabilizing hand is positioned medially and on the spine as described above. If the hand is positioned laterally on the rib and the impulse is directed dorsally, the rib may bend. This may result in pain and potentially a rib injury, including fracture, if treating a patient with osteoporosis.

This technique is often applied when thoracic rotation is restricted and painful. This technique is also good when a therapist with a small stature is treating a patient with a relatively large stature. This technique may be applied prior to bilateral facet traction in a segment that is s lightly more hypomobile. If the arm/hand used to stabilize the caudal vertebra is not long enough to reach around the patient, this technique may be perfonned with tbe therapist using bis/her right hand while standing on the left side of the patient (see next page).

82 I Chapter 4 : Thoracic Spine Application

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Thoracic-Facet Traction EL - I2J PP - HV & LV

Indication: To improve movement in all directions Position: Supine

Slack in the treatment segment is taken up by pressing dorsally and cranially with the therapist's chest and left hand towards the left transverse

The impulse with the chest and left hand is directed slightly cranial to the left transverse process of the caudal vertebra in the treatment segment.

The therapist's right wrist is positioned in the mid­position. The thumb is adducted and placed anteriorly to the second metacarpal and index finger. The thenar eminence is placed under the left transverse process of the caudal vertebra in ,..-_....:::=-.c= '---== '--__ -' the treatment segment.

The therapist stands on the left side of the patient facing the patient's chest.

The therapist contacts the patient posteriorly with their right hand stabilizing the transverse processes of the caudal vertebra in the treatment segment (see box 2).

The therapist's left hand is placed on the midline of the patient's crossed forearms.

spine, down to and ..... ~" ~= __ ~ including the cranial

vertebra in the treatment segment, is positioned in ventral flexion, right side bending and left rotation (locked above).

Troubleshooting your technique:

Note(s)

The patient should feel greater pressure posteriorly on the side of the spine that the therapist's hand is positioned under.

During the impulse, support under the left transverse process of the caudal vertebra will allow the cranial vertebra in the treatment segment to rotate to the left, generating traction in the left facet joint during the manipulation. The spinal positions, therapist contacts and arm placements, all of which have been described in the previous bilateral facet distraction techniques in supine. may be used with this technique to create unilateral facet distraction . When choosing the arm position for this or any other thoracic techniques using pressure through the shoulders, the therapist must confirm that the patient 's shoulders are comfortable throughout the technique. The alternative ann position pictured above uses a cross armed position where the right hand is placed on the left shoulder and the left hand is placed on the right shoulder.

Translatoric Spinal Manipulation I 83

Thoracic-Facet Traction EL - HV & LV PP - HV & LV

Indication: To improve movement in all directions Position: Supine

The right transverse process of the cranial vertebra in the treatment segment is placed on the right side of the base of the wedge.

- __ facet traction. A notch is cut on one side to remove stabilization of one side of the cranial vertebra in the treatment

Troubleshooting your technique:

Note(s)

The patient's treatment segment should be positioned without side bending or rotation prior to the manipulation, however, segments cranial to the treatment segment may be locked in either dorsal or ventral flexion.

During the impulse, the notch in the wedge will allow the cranial vertebra in the treatment segment to rotate to the left, generating traction in the left facet joint during the manipulation. The spinal positions, therapist contacts and arm placements, all of which have been described in the previous bilateral facet distraction techniques in supine, may be used with the modified wedge to create unilateral facet distraction.

84 I Chapter 4 : Thoracic Spine Application

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EL - HV & LV Thoracic-Facet Traction PP - HV & LV

Indication: To improve movement in all directions Position: Prone

The slack and impulse are directed ventrally,

'0:"--__ ventrally caudally and

ventrally cranially depending on where in the thoracic spine the facet traction is performed. See arrows

The therapist stands facing the patient's head.

The base of the wedge is placed on the transverse processes of the caudal vertebra in the treatment segment.

The therapist places both hands on the base of the wedge as illustrated below.

The manubrium is supported on a firm roll when T1 and T2 are treated with

for the general direction of ILIiII..::il1iI movement.

Troubleshooting your technique:

Note(s)

Failure to properly contact the caudal vertebra with the wedge or failure to identify the proper direction of the impulse may lead to a less effective technique.

The direction of the impulse used during this technique must be adjusted to compensate for patients with either extremes of thoracic flattening or kyphosis.

Translatoric Spinal Manipulation I 85

Thoracic-Facet Traction EL - LV PP - HV & LV

Indication: To improve movement in all directions Position: Prone

The therapist stands on the left side of the patient facing the patient's thoracic spine.

The therapist contacts the patient posteriorly with their left pisiform on the right articular process, lamina and transverse process of the caudal vertebra in the treatment segment.

Troubleshooting your technique:

The patient's thoracic ;"" __ .J spine, down to and

including the cranial vertebra in the treatment segment, is positioned in dorsal flexion, right side bending and right rotation (locked above).

The thoracic spine is supported in dorsal flexion , right side bending and right rotation through the use of a firm roll. If the roll is too soft, the locking may not be firm resulting in a less specific and potentially ineffective technique.

Note(s)

To be most effective, the impulse should be directed at a right angle to the articular surface of the facet joint.

Locking in dorsal flexion may not be comfortable for patients who are kyphotic and significantly hypomobile. In these cases, the thoracic spine may be positioned in flexion left side bending and right rotation. This technique may also be performed by pulling the shoulder in a dorsal and caudal direction with the right hand. This is technique variation is illustrated in the lumbar spine on page 119.

86 I Chapter 4 : Thoracic Spine Application

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Thoracic ribs There are different anatomical classifications for the thoracic ribs and rib joint articulations. For example, ribs 2 through 9 can be referred to as the typical ribs. Typical ribs articulate with their vertebral body and the vertebral body one level above. The atypical ribs are numbers I, 10, II and 12. These ribs articulate only with their numerically corresponding vertebrae. The articulation of ribs to the vertebral body is known as the costovertebral joint. These are very stable articulations with strong capsoligamentolls reinforcement. The costovertebral joint are synovial and subject to the development of symptomatic motion restrictions.

The ribs may also be classified based on their attachment to the sternum. For example, ribs I through 6 can be referred to as the vertebrosternal ribs in that they have direct attachment into the sternum. Ribs 7 through 10 can be referred to as the vertebrochondral ribs. The development of symptomatic irritation at these anterior rib articulations can at times be improved by the appl ication ofTSM to hypomobile posterior rib articulations. Regarding the other posterior rib articulations, the recognition of the positional relationship between the ribs to the corresponding thoracic transverse process is of both anatomical interest and clinical importance. Regarding the upper (vertebrosternal) ribs, they articulate both anteriorly and inferiorly to their numerically corresponding thoracic transverse process. The lower (vertebrochondral) ribs lie anteriorly and slightly superiorly to their transverse process. These articulations are known as the costotransverse joints. Similar to the costovertebral joints, these synovial articulations are also subject to the development of symptomatic movement impairments.

Lastly, and very generally, is a brief review of rib movement or kinematics. From an osteokinematic perspective, all ribs can be generally seen to move obliquely upward, outward and forward during inspiration. On an arthrokinematic level, the motion thought to produce this rib cage movement is a long axis rotation through the mechanically combined costovertebral and costostemal articulation.

Position of the ribs relative to the transverse processes

Orientation of the transverse costal facet

Upper thoracic

Middle thoracic

Lower thoracic

Direction ofTSM impulse

Upper thoracic

Middle thoracic

Translatoric Spinal Manipulation I 87

,

Biomechanics of Rib TSM

Costotransverse and Costovertebral glides and distraction

Arthrokinematic movements occurring during rib T5M vary depending on the direction of force used. When the impulse is directed more ventrally, distraction occurs at the costotransverse (CT) jOint and gliding occurs at the costovertebral (CV) joint. When the impulse is directed more laterally, gliding occurs at the costotransverse joint and distraction occurs at the costovertebral joint. During rib T5M, it is difficult to generate much lateral movement of the rib due to lateral sliding of the manipulating hand on the rib. Therefore, ventral forces combined with inferior, superior and lateral forces (dependant on the level of the rib) are most commonly used to treat the costotransverse joints. During rib T5M, the spine may be stabilized (prone and seated techniques) and the rib moved or the rib may be stabilized and the spine moved (supine technique).

Positioning -In prone, the spine and rib are in the actual resting position; in seated and supine, the spine is in flexion, side bending away and rotation towards the treatment rib.

CT and CV joints at rest

88 I Chapter 4 : Thoracic Spine Application

Prone technique with spinal stabilization

Ventrally and slightly laterally directed impulse

Seated and supine technique with rib stabilization

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First Rib-Distraction EL - LV PP - HV & LV

Indication: To improve movement in all directions Position: Supine

costotransverse joints is taken up in a ventral and caudal direction by the therapist's left hand prior

I the

The therapist is positioned the left side of the patient's head.

The therapist's left hand presses ventrally and medially through upper trapezius muscle in the direction of the first rib.

The therapist supports the = =====. position of C7 by (1) stabilizing

against the lamina and tra'1Sv<ers,,1 ~_.., process of C7 with the right

(2) supporting the right side of head with the right forearm and (3) supporting the left side of the patient's head with the right side of the therapist's chest.

Troubleshooting your technique:

Note(s)

In order to lock from above and maintain the lock, right side bending must be maintained when the neck is left rotated.

Tbe therapist may also apply a cranially directed traction to the neck by using the right side ofbislher cbest and right hand. The traction acts as a counterforce to the caudally directed force used during the manipulation. I f the cervical muscles on the left side of the neck are significantly tight, they may hinder the movement of the first rib during this technique wben using locking above. In these cases, stretching of the muscles (i.e. the scalene muscles) should be perfonned prior to and following successive high and low velocity translatoric manipulation. In addition, locking from below may be used to stabilize Tl, ifllsing locking above is contraindicated due to patient discomfort or pathology in the cervical spine.

Translatoric Spinal Manipulation I 89

First EL - LV

Ri b - D i st racti 0 n PP - HV & LV

Indication: To improve movement in all directions Position: Seated

costotransverse joints is taken up in a ventral and caudal direction by the therapist's right hand to delivering the

The therapist's right hand impulses

'-----I ventrally and r caudally.

The therapist stands . patient.

The therapist contacts the patient (1) posteriorly and cranially on first rib with the radial border of their right second MCP and (2) anteriorly and laterally with their left medial forearm and distal arm against the left side of the patient's neck supporting the position.

Troubleshooting your technique:

Note(s)

The therapist's left forearm must be firmly placed against the left side of the patient's cervical spine for proper stabilization of the cranial vertebra in the locked position. Caudal pressure against the shoulder girdle and sternum should be avoided and may cause patient discomfort. If the scalene muscles are tight and are restricting the movement of the first rib, the therapist should perform manual muscle stretching prior to mobilizing the first rib. This principle is typically used in cycles where the muscles are stretched, the joints are mobilized and the muscles are stretched again until the movement is restored.

This technique can also be performed as a facet traction manipulation by moving the right hand medially onto the articular process, lamina and transverse process of the caudal vertebra.

90 I Chapter 4 : Thoracic Spine Application

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First Rib-Distraction EL - 121 PP - HV & LV

Indication: To improve movement in all directions Position: Seated

After the slack in the lock is taken up with the therapist's left arm and body, slack in the costovertebral and costotransverse joints is taken up ventrally. caudally and slightly medially.

Troubleshooting your technique:

The therapist stands behind the patient.

The therapist contacts the patient (1) posterior1y and cranially on the first rib with the radial border of their right second MCP and (2) anterior1y with their left hand and forearm on the patient's crossed arms, supporting thoracic flexion. right side bending and I

The patient's thoracic spine is positioned in ventral flexion, right side bending and left rotation (locked in flexion).

The patient's lumbar spine is positioned in dorsal flexion, left side bending and left rotation (locked in extension).

A roll is placed behind the low back.

A wedge is placed under the left ischial

The position used for locking below must be painfree for the patient. If the patient experiences pain during positioning, the therapist should try to vary the position and lock accordingly to find a position of minimal to no discomfort prior to performing this technique.

Note(s) The movement used during treatment will facilitate greater locking in the thoracic spine. In this position, the right cervical muscles are slackened and will not hinder the movement of the first rib during this technique. When two forms of locking are used during a technique it is called "double locking".

Translatoric Spinal Manipulation I 91

Ri bS2-12- Distraction EL - I2J PP - HV & LV

Indication: To improve movement in all directions Position: Supine

The therapist contacts the patient posteriorly with their left hand and forearm supporting the patient's upper back and neck. The thenar eminence of the right hand stabilizes the rib being treated as described under box 2. The right side of the therapist's chest contacts the patient's right lateral humerus and left distal forearm and hand.

The i directed across the body in the direction of the tip of the thumb to maximize vertebral movement on the rib, while minimizing rib compression.

Slack in the costotrans­verse and costorvertebral joints is taken up during the positioning of the thoracic spine in flexion , right side bending and left rotation . The thumb is adducted and placed anterior

to the second metacarpal and index finger.

The thumb and thenar eminence are placed under the rib, with the tip of the thumb placed immediately lateral to the left transverse process of the adjacent vertebra.

Troubleshooting your technique: A direct dorsal pressure may "bend" and injure the rib.

Note(s)

In supine, the patient's thoracic spine is positioned in ventral flexion , right side bending and left rotation .

The patient's arms are positioned across their chest above the level of the rib

Ifthe therapist is having difficulty generating the impulse using the chest alone, the right hand may additionally apply a quick, short lateral impulse along the the rib.

92 I Chapter 4 : Thoracic Spine Application

Ri bS2-12- Distraction EL - LV PP - HV & LV

Indication: To improve movement in all directions Position: Prone

The therapist stands either at the head of the patient (upper-middle ribs) or beside the patient (lower ribs).

The therapist contacts the patient with the ulnar border of their left hand placed next to the spinous process. pressing in the direction of the patient's left transverse processes and ~~1)'I'l ribs and the pisiform of their right hand on the rib slightly lateral to the corresponding thoracic vertebra's transverse process.

transverse and costo­vertebral joints is taken up in a ventral and slightly lateral direction with the right hand.

Troubleshooting your technique:

Note(s)

During this technique. failure to properly stabilize against the transverse processes can lead to movement of the vertebral segment. In order to properly stabilize the vertebra, the stabilization pressure should increase during the impulse.

Jfthe stabi1ization force is reduced, this technique can be used to begin small rotational movements in the thoracic spme. The stabilization force should be gradually increased as the slack in the costovertebral and costotransverse joints is taken up prior to the manipulation. When giving the impulse, the right hand may slide in the direction of the arrow which will help generate a quicker impulse.

Translatoric Spinal Manipulation I 93

Ri bS2-12- Distraction EL - 121 PP - HV & LV

Indication: To improve movement in all directions Position: Prone

side of the patient.

The therapist contacts the patient (1) with their right hand on the patient's right shoulder girdle pulling the shoulder posterior1y to rotate the thoracic spine to the right and (2) with the ulnar border of their left hand on the rib. The pisiform is placed lateral to the transverse process of the vertebra adjacent to the treated rib.

Slack in the treatment segment is taken up during the positioning of the thoracic spine in dorsal flexion, right side bending and right rmatlc,n.'

A roll. pillow or other support may be placed under the patient's right arm, shoulder girdle and torso to assist in positioning the patient in right rotation.

The therapist may then use their right hand to support their left wrist and hand the

Troubleshooting your technique:

The left hand impulses ventral, ventral caudal or ventral cranial depending on which rib is being treated. See the

The therapist should confirm that the patient tolerates the contact to the anterior shoulder when positioning for this technique. If the contact is not tolerated, the therapist may ( I) try diffusing his/her contact pressure throughout the hand or (2) try positioning the patient by pull ing from the anterior/superior chest instead of the shoulder.

Note(s) If the force used during th is technique is directed too ventral, the rib may be bent and potentially injured.

The superior ribs are suspended below the transverse process, so the direction of the impulse is ventral and slightly caudal. The middle ribs are positioned in front of the transverse process, so the direction of the impulse is ventral. The inferior ribs are positioned slight ly above the transverse process, so the direction of the impulse is ventral and slightly cranial. The direction of the impulse will also further reinforce the locking above.

94 I Chapter 4 : Thoracic Spine Application

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Ri bS2-12- Distraction Indication: To improve movement in all directions Position: Seated

The therapist contacts the patient (1) posteriorly and laterally with the left side of their lower chest and abdomen (supporting the locked noncoupled ventral flexion position of the thoracic spine), (2) anterior with their left hand and arm holding the patient's right shoulder and controlling the patient's ventral flexion, left side bending and right rotation and (3) posteriorly on the rib, lateral to the thoracic transverse process with the radial border of the right hand and index I

The right hand impulses ventrally, ventrally cauda lly or ventrally cranially. See the

I "n"tel's)" section below I In" I"rth,,, detail.

take up the slack, the rib is stalbiilized the thoracic spine above is moved into

right rotation (while the ventral flexion and side bending are maintained). Next, the right hand takes up the slack in the costotransverse and costovertebral

by pressing the rib in a ventral, ventral caudal or ventral cranial direction dependant on which rib is treated.

Troubleshooting your technique:

EL - LV PP - HV & LV

Failure to adequately lock through the adjacent vertebral segments may lead to motion in the spine in addition to the rib.

Note(s)

The patient's arms must not be pressed against the rib cage as this may block movement of the rib undergoing treatment.

The seated position is potentially less aggressive than the supine position because the patient's trunk weight is not being used to generate the stretch. The superior ribs are suspended below the transverse process, so the direction of the impulse is ventral and slightly caudal. The middle ribs are positioned in front of the transverse process, so the direction of the impulse is ventral. The inferior ribs are positioned slightly above the transverse process, so the direction of the impulse is ventral and slightly cranial.

Translatoric Spinal Manipulation I 95

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Lumbar Spine u@©W ITiJ 0 CQ] OJ]@

The Lumbar Spine

Osseous anatomy The smallest functional unit of the spinal column is the motion segment. The motion segment consists of two adjacent vertebrae and all of their interconnecting structures. Vertebrae can also be divided into other anatomical or functional components such as the vertebral body, the pedicles and the posterior elements. What follows is a brief review of these components in the lumbar region.

The lumbar vertebral body is clearly larger than both thoracic and cervical vertebral bodies. It is flat on its superior and inferior surfaces and slightly concave on the anterior and lateral surfaces. The vertebral body has a greater transverse diameter as compared to its anterior diameter and height. The shape of the lumbar vertebral body reflects its responsibilities in terms of supporting longitudinally applied loads. While stable for these longitudinal loads, the lumbar segments are dependent on the posterior structures for stability in other planes. The body of the vertebra and the intervertebral disc support 85% of the weight-bearing requirements of the movement segment.

The pedicles attach to the upper posterior portion of the vertebral body. They are the only connection between the posterior elements and the vertebral bodies. All forces sustained by any of the posterior elements are ultimately channeled to the pedicles which then transmit these forces to the bodies.

The posterior elements provide attachment sites for many of the lumbar ligaments and muscles. They provide rigid levers for the restriction and enhancement of movement. The laminae project from each pedicle towards the midline and serve to protect the contents of the spinal canal. Forces that act on the spinous and articular processes are transmitted to the laminae. The part of the lamina that is found between the superior

Articular surfaces of the lumbar spine

and inferior articular process on each side is the pars interarticularis. Lumbar spine articulations The pars is thicker than other portions of the lamina and is typically able to withstand large bending forces. Individuals with insufficient bone structure in this area are susceptible to fractures (spondylolysis) as a result of excessive or sudden forces applied to the interarticularis region. The posterior extension of the lamina is the spinous process. This structure represents the uniting of the two laminae in the midline. The spinous processes are broad and thick and extend horizontally. Another structure considered a part of the posterior elements is the transverse process (TP). The TPs extend from the junction of the pedicle and lamina. The TPs are flat and rectangular and extend in a posterior and lateral direction.

The facet joints are also an important component of the lumbar posterior elements. In the most basic sense, the facet joints are formed by the articulation of the inferior art icular process of the cranial lumbar vertebra and the superior articular process of the caudal vertebra in the spinal motion segment. The facet joints support 15% of the weightbearing requirements of the lumbar motion segment. Viewed from behind, the articular facets appear as straight surfaces, suggesting that they are planar. When viewed from above, it can be seen that the lumbar facets vary in the shape of their articular surfaces and in the general direction they face. In the transverse plane, the articular facets may be flat, planar, slight ly curved or curved in a "C" or "J" shape. The class ic C-shaped orientations are particularly well suited to resist and constrain against excessive motion in two principal directions. The sagittal portion of a C-shaped facet will limit excessive rotation in the transverse plane while the more frontal portion of the facet surface wi ll limit excessive anterior translation. Certain developmental and degenerative changes reduce the ability of the facet joint to resist loading. When these joints develop with an asymmetrical unilateral variation it is ca lled facettropism.

Articular cartilage covers the superior and inferior articular 98 I Chapter 5 : Lumbar Spin. Application

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processes and assumes the same concave or convex curvature of the underlying facet. The cartilage is generally thickest over the center of each facet. Around its dorsal, superior and in ferior margins, each lumbar facet joint is enclosed by a fibrous capsule . The anterior capsule is reinforced by the ligamentum flavom. The posterior portion of the lumbar facet joint capsule blends with fibers of the deep lumbar extensor muscles. Situated around the borders and within each facet joint are meniscoid bodies composed of fat and surrounded by fibrous ti ssue. These meniscoids move into and out of the facet joints during movement to enhance the articular congruency.

The vertebral foramen is formed anteriorly by the vertebral body, the intervertebral disc and the posterior longitudinal ligament. The posterior aspect of the vertebral foramen is formed by the lamina and ligamentum flava. The lumbar vertebral foramen shows three typical shapes, oval, triangular and trefoil. Genera lly, the upper lumbar region foramen are oval in shape and the lower lumbar region are more triangular or trefoil in shape. When articulated together, the five lumbar vertebrae form the lumbar canal. The size and shape of the lumbar cana l will vary based on a number of potential factors, including the size and shape of the pedicles and facets.

Ligamentous anatomy There are three principal ligamentous structures that interconnect the lumbar vertebral bodies. These structures

include the annulus fibrosus, the anterior longitudinal ligament (ALL) and the posterior longitudinal ligament (PLL). Based on its size and strength, the peripheral portions of the annulus fibrosus are arguably the princ ipal stabilizing structure that unites the lumbar vertebrae at the intervertebral disc joint.

The ALL consists of muhiple sets of both long and short collagen fibers. The most superficial fibers are the longest and may traverse four to five vertebral segments. The deep sets of fibers connect adjacent segments. The principal function of the ALL is to res ist excessive separation of the anterior aspects of the lumbar vertebral bodies.

The PLL runs along the dorsal surfaces of the vertebral bodies and widens laterally over the posterior surface ofthe intervetebral discs where it blends with the annulus fibrosus. This ligament runs inside of the vertebral canal and anterior to the spinal cord and cauda equina. Its princ ipal biomechanical function is to resist separation of the posterior aspects of the lumbar vertebral bodies.

Similar to the PLL, the ligamentum flavum is an intracanalligament. This structure is primarily composed of elastin fibers. It is short, fa irly thick and connects successive lumbar laminae. The ligamentum flavum primarily resists excessive separation of the laminae.

The intervertebral disc (lVD) The IVD consists of three principal components, the nuc leus pulposus, the annulus fibrosus and the vertebral end­

plates and form s the principa l connection between the vertebral bodies. The nucleus pulposus is a semi-fluid substance that is subjected to muhi-directionalloads. Given its structu re and anatomical constituents, the nucleus will deform, aher its shape and subsequently transmit or distribute loads equally in all di rections.

The annulus fibrosus consists of 6 to 20 sheets or rings , also known as lamellae. The annular rings are arranged in a concentric fashion around the nucleus. Centrally, the annular fibers become more loosely arranged and blend wi th the nucleus pulposus. Similar to other ligamentous structures, the princ ipal function of the annulus fibrosus is to constrain motion. The annulus not only binds the two vertebral end plates together, but also functions as the principa l stabilizing structure between the two vertebral bodies at the lVD joint. Examination, evaluation and biomechanical intervention for the IYD joint is paramount to the practice of TSM. Joint play testing examines the translatoric mobility at the IYD joint and various translatoric disc traction manipulation techniques seek to improve mobil ity and reduce load at this same articulation.

The vertebra l end plates are found between each IYD and adjacent vertebral bodies. The end plates consist of both fibrocartilage and hyaline cartilage. This structure covers the nucleus pulposus, allows fluid diffusion into the IYD and further serves to protect the vertebral body by transmitting a portion of the weight-bearing requirement.

Vascular anatomy In brief, the principa l blood supply for the lumbar spine comes from the lumbar arteries. Pa ired lumbar arteries arise

from the aorta and descend along the anterior and lateral aspect of the lumbar vertebra l bodies. Dorsally directed branches of the lumbar arteries pass under the transverse processes and supply the deep lumbar extensor/rotator muscles as well as the facet joints. Further branching of this artery occurs opposite the lumbar intervertebra l foram en. These branches supply important anatomical structures within the vertebral canal.

Translatoric Spinal Manipulation I 99

i

Direction of joint rolling and gliding during lumbar ventral and dorsal flexion

Ventral Flexion Dorsal Flexion

Direction of joint rolling and gliding during lumbar coupled side bending and rotation in ventral flexion

Left Side Bending and Rotation Right Side Bending and Rotation

100 I Chapter 5 : Lumbar Spine Application

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Biomechanics of Lumbar Spine TSM

Disc Traction

T5M techniques generate lumbar disc traction by either (1) lifting the thoracic spine off the lumbar spine in sitting, (2) moving the pelvis and sacrum caudally in side-lying or prone or (3) moving the pelvis away from the thoracic cage by performing a body drop into the side of the patient while simultaneously pressing the pelvis and sacrum caudally. In effect, these techniques elongate the lumbar spine, reducing the lumbar lordosis. Traction provides a uniform stretch to the discal tissues and surrounding segmental structures in addition to facilitating intervertebral foraminal decompression.

In side-lying

i generated by the supoort roll and treatment table.

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Translatoric Spinal Manipulation 1101

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Biomechanics of Lumbar TSM

Side Bending

Lumbar side bending techniques are used to restore side bending while minimizing associated coupled rotation. Side bending techniques are performed in side-lying with the spine side bent towards or away from the surface of the table. When performing a right side bending technique in ventral fiexion, the thoracic and lumbar spines are positioned in right side bending and left rotation prior to the TSM, thereby locking the spine, to minimize coupled right rotation. When performing a right sidebending technique in dorsal fiexion, the thoracic and lumbar spines are positioned in right side bending and right rotation prior to the TSM, thereby restricting the coupled left rotation that w ill occur w ith right side bending. When performing side bending towards the table, a towel roll or bolster is used to position the spine. Side bending may then be applied to one or more spinal segments. When treating a specific spinal segment, the TSM impulse is directed over the cranial portion of the roll (when positioned in ventral flexion) or over the caudal portion of the roll (when positioned in dorsal fiexion).

L1-4 Side Bending

Right side bending TSM in ventral flexion

Side bending towards the table

Side bending away from the table

The patient is positioned in side-lying with their lumbar and thoracic spine in ventral flexion, right side bending and left rotation.

L5 Side Bending

Right side bending TSM in dorsal flexion

Side bending towards the table

Side bending away from the table

The patient is positioned in sidENying with their lumbar and thoracic spine in dorsal flexion, right side bending and right rotation.

Right side bending TSM in ventral and dorsal flexion

102 I Chapter 5 : lumbar Spine Application

Side bending TSM for the L5 segment can be performed in both ventral and dorsal flexion, the same as when treating L 1-4. However. when side bending lS, the sacrum is stable. Therefore. the direction that L5 is moved is relative to the pelvis. To improve right side bending at LS, L5 is translated to the right. To improve left side bending at LS. L5 is translated to the left. Noncouplingllocking is used as described above to stabilize against coupled rotation at L5.

Biomechanics of Lumbar TSM

Facet Distraction As discussed previously, the lumbar facet joints are typically (- or J-shaped. Therefore, facet distraction TSM techniques in the lumbar spine generate different amounts of facet distraction between the anterior, middle and lateral surfaces of the facet joint depending on how they are performed. To emphasize distraction at the anterior aspect of the joint, a bilateral ventral force is applied to the caudal vertebra in the treatment segment. To emphase distraction of the lateral aspect of the right facet joint, a unilateral ventral, lateral and slightly caudal force is applied to the right lamina and posterior aspect of the transverse process. The thoracic and lumbar spine, down to and including the treatment segment, is positioned in extension, right side bending and right rotation (locked in extension). This position causes compression of the facet joint on the left and assists in generating facet distraction of the right facet.

In prone

Bilateral facet distraction Unilateral facet distraction

fStiiliiiii :afu~ i above in extension, right sidebending and right rotation.

i ventrally. laterally and slightly caudally against the caudal vertebra in the treatment segment.

Translatoric Spinal Manipulation 1103

Biomechanics of Lumbar TSM

Facet Glide

Lumbar glide techniques may be performed unilaterally, with the therapist's hands, or bilaterally with a firm wedge.

Ventral cranial glide to improve ventral flexion

Bilateral technique To improve flexion the patient is positioned in ventral flexion, the caudal vertebra is stabilized and the cranial vertebra is moved in a ventral, cranial direction with a bilateral force.

Unilateral technique When applying a unilateral force to improve ventral flexion in the right facet joint, the patient is positioned in coupled ventral flexion, left side bending and left rotation. The caudal vertebra is stabilized and a unilateral ventral cranial force is applied in the direction of the right lamina and posterior edge of the transverse process of the cranial vertebra.

i is directed the lamina, articular ~-...!~~

and posterior edge transverse process of

caudal vertebra.

1041 Chapter 5 : Lumbar Spine Application

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Biomechanics of Lumbar TSM

Facet Glide Lumbar glide techniques may be performed unilaterally, with the therapist 's hands, or bilaterally with a firm wedge.

Ventral cranial glide (relative dorsal caudal glide) to improve dorsal flexion

Bilateral technique To improve extension, the patient is positioned in dorsal flexion, the cranial vertebra is stabilized anteriorly with a cuff weight and the caudal vertebra is moved in a ventral and cranial direction.

Anterior stabilization

Unilateral technique When applying a unilateral force to improve dorsal flexion in the right facet joint the patient is positioned in non coupled extension, right side bending and right rotation (locked above in extension). The T5M is applied in the direction of the right lamina and posterior edge of the transverse process of the caudal vertebra.

The thoracic and lumbar _---"1 spine, down to the cranial vertebra. are positioned in noncoupled extension (locked in extension).

is directed

Translatoric Spinal Manipulation 1105

Lumbar-Traction EL - HV & LV PP - HV & LV

Indication: To improve movement in all directions Position: Side-lying

Slack in the lumbar spine is taken up caudally by the therapist's right arm and torso.

The therapist stands facing the patient's abdomen and pelvis.

The therapist contacts the patient posteriorly on the sacrum with their right forearm and anteriorly on the pelvis with the side of their torso.

The patient is positioned in side-lying with their lumbar spine in a resting or actual resting position (see ~note(sr seclion below for further information regarding positioning).

arm. A sandbag or a towel roll may be used to support the resting position for narrow waisted individuals or to accommodate an antalgic position.

Troubleshooting your technique:

Note(s)

Do not let your proximal medial forearm slide over the skin of the sacrum. The impulse remains very short.

This technique is most effective if performed on a table with a sliding foot section. If a sliding foot section is not avai lable, the patient's lumbar spine must be positioned in slight left side bending prior to the impulse to avoid ending in an right side bent position. When providing a sustained or intermittent low ve loc ity traction using this technique, the therapist uses his/her arm and body to generate the traction. When performing a high velocity traction, the therapist uses bis/her arm to generate the quickest impulse. A painful lumbar shift or list can be accommodated and supported using the moveable head section of a mobilization table. This wi ll allow the translatoric traction technique to be delivered in the patient's actual resting position .

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Lu m ba r-Traction EL - HV & LV PP - HV & LV

Indication: To improve movement in all directions Position: Side-lying

To provide an impulse using a body drop, the therapist must maintain the same pressure the patient anteriorly, laterally and posteriorly.

The therapist then lifts their head, neck and upper thorax slightly while maintaining the tension in the slack described in box 3.

The impulse is directed medially by dropping the chest and head towards the patient, in combination with a caudal impulse delivered by the right forearm.

Troubleshooting your technique:

Slack in the lumbar spine is taken up caudally by leaning fOlWard and pressing the therapist's body between the patient's thorax and pelvis.

It is necessary to take up a small amount of slack with the right forearm avoid extending the lumbar spine when taking up the slack with the body.

Slack is taken up prior to delivering the impulse.

The therapist stands facing the patient's abdomen.

The therapist contacts the patient (1) with the flexor surface of the right forearm on the dorsal midsurface of the patient's sacrum, (2) with the left arm and forearm on the left side and dorsal surface of the rib cage and (3) with the abdomen between the lower ribs and pelvis.

The patient is positioned in side-lying with their lumbar spine in a resting or actual resting position (see "note(sr section below for further information regarding positioning).

A sandbag or a towel roll may be used to support the resting position for narrow waisted individuals or to accommodate an antalgic

During the body drop, avoid excessive pressure on the lateral aspect of the patient's pelvis or lower ribs.

Note(s) This technique is most effective ifperfonned on a table with a sliding foot section. If a sliding foot section is not available, the patient's lumbar spine must be positioned in slight left side bending prior to the impulse to avoid ending in a right side bent position . When treating a unilateral radicular condition, the therapist must determine which position improves the patient's signs and symptoms the most. This can be assessed in side-lying by examining key signs such as muscle strength and nerve tension sensitivity. In addition, the therapist may monitor dural tension symptoms after taking up the slack in the spine prior to the impulse. If dural symptoms are worsened after taking up the slack, the impulse should not be delivered. Rather, the therapist should attempt to find a position which relieves dural symptoms. L5 translatoric disc traction may assist in reducing patient symptoms by subtly moving the L4, L5 or S I nerve root(s) away from an anatomical source of irritation such as a degenerated and/or hypertrophic structure.

Translatoric Spinal Manipulation 1107

Lu m ba r-Traction EL - LV PP - HV & LV

Indication: To improve movement in all directions Position: Seated

The therapist contacts the patient posteriorly by placing a mobilization wedge, base down, against the transverse processes of the cranial vertebra in the treatment segment.

The therapist places both hands anteriorly on the patient's abdomen or crossed arms.

The therapist then pulls the patient posteriorly against the

and the torso.

taken up cranially by the slight straightening of the therapist's knees.

The impulse is directed cranially and is generated by a quick straightening of the therapist's knees.

belt may be placed around the table and the proximal anterior portion of the patient's thighs to stabilize the lower extremities/pelvis to the table.

The patient is seated with their lumbar spine positioned in a resting or actual resting position.

Troubleshooting your technique:

Note(s)

If the table is positioned too high, it may be difficult/impossible for the therapist to generate enough cranial movement to effectively traction the lumbar spine.

The picture above illustrates a lower rib cage and abdominal contact by the therapist. This technique may also be perfonned by contacting the patient's foreanns and elbows. With this second contact, the therapist must pull the anns against the rib cage prior to taking up the slack. The actual resting position of the lumbar spine can be found by making slight adjustments in lumbar ventral flexion, dorsal flexion, side bending and/or rotation. This position may be used in the treatment of acute conditions when it may be necessary to maintain the patient's antalgic position during treatment.

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Lumbar-Traction EL - HV & LV PP - HV & LV

Indication: To improve movement in all directions Position: Seated

Slack in the lumbar spine is taken up cranially by slightly elevating and retracting the shoulder girdle bilaterally and slightly adducting and extend­ing both shoulders.

When taking up the slack, the therapist flexes their knees as they pull up on the patient's

The impulse is directed cranially and is generated by quickly elevating and retracting the shoulder girdle bilaterally while slightly adducting and extending both

A belt may be placed around the table and the proximal anterior portion of the patient's thighs to stabilize the lower

I i to the table.

The therapist stands behind the patient.

The therapist contacts the patient posteriorly by placing a mobilization wedge, base up, against the caudal vertebra in the treatment segment.

The therapist places both hands anteriorly and inferiorly on the patient's crossed arms.

The therapist then pulls the patient posteriorly against the wedge and the therapist's torso.

The patient is seated with their lumbar spine positioned in a resting or actual resting position.

Troubleshooting your technique:

Note(s)

The therapist must make sure that all the slack in the patient's shoulder girdle is taken up in a cranial direction prior to the impulse. Tfthe table is positioned too high it may be difficult/impossible for the therapist to generate enough cranial movement to effectively traction tbe lumbar spine. The therapist should avoid leaning back prior to delivering the impulse as this may lead to spinal dorsal flexion over the wedge during the manipulation. The therapist must not straighten hislher knees when taking up the slack or delivering the impulse.

Further slack can be taken up in a caudal direction by lowering the treatment table immediately prior to delivering the impulse. The actual resting position of the lumbar spine can be found by making slight adjustments in lumbar ventral flexion, dorsal flexion, side bending and rotation. This technique can be very effective for unloading, providing traction and assisting in the correction of a lumbar lateral list (antalgic position/sciatic scoliosis). The antalgic position can be supported by the therapist while the lumbar spine is unloaded (tractioned) by lowering the treatment table.

Translatoric Spinal Manipulation 1109

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EL - HV & LV

L1-4-Side Bending PP - HV & LV

Indication: To improve right side bending Position: Right side-lying & ventral flexion

The impulse is directed medially with the fingers, caudally with the right forearm and cranially with the left forearm and is gener­ated by quickly flexing the elbows, extending the shoulders and retracting the shoulder girdle bilaterally.

The therapist stands facing the patient's abdomen.

The therapist contacts the patient posteriorly with both hands pressing medially on the right side of the spinous processes of the lumbar vertebra.

The right forearm contacts the left side of the pelvis posteriorly and laterally.

The left forearm contacts the left side of the rib cage posteriorly and laterally.

The therapist supports the patient anteriorly by contacting the patient's abdomen with their torso.

In side-lying, the patient is positioned with their lumbar and thoracic spine in ventral flexion, right side bending and left rotation down to and the treatment

Troubleshooting your technique:

Note(s)

This TSM uses a very short amplitude movement. Do not let your fingers slide laterally to the left side of the spinous processes.

The therapist can also change his/her contact to the left side of the spinous processes and provide functional massage to the left lateral paraspinal muscles. In clinical practice, it is common to blend various intervention techniques such as translatoric manipulation, translatoric mobilization and functional massage. All three fonns of intervention can be readily applied in this position. By virtue of this contact on the lumbar spinous processes, this technique is less forceful then the manual contact used for the specific translatoric lumbar side bending. As such, this is an excellent first manipulative maneuver to apply as a therapist begins to integrate quick movements into his or her treatment session. Choosing to perform this or any lumbar side bending techniques in either lumbar ventral or dorsal flexion is based on the position of greatest side bending restriction. When the onset of restricted side bending is recent and the disc or facet joint is suspected as the cause of the restriction, it is often beneficial to treat by side bending away from the direction of greatest restriction. As movement improves, the patient position can be progressed towards the midline.

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Ll-4-Side Bending EL - LV PP - HV & LV

Indication: To improve right side bending Position: Left side-lying & ventral flexion

To provide an impulse using a body drop, the therapist takes up the slack medially (described in step 3).

The therapist then lifts their head, neck and upper thorax slightly while maintaining the same end slack tension within the segment (described in step 3).

The impulse is directed medially through the dropping of the chest and head towards the patient.

The patient is posiUoned in left side-lying with their lumbar and thoracic spine in ventral flexion, right side bending and left rotation.

The therapist kneels on the table facing the patient.

The therapist's right thigh is pressed gently but firmly against the patient's lower abdomen.

The therapist presses in the direction of the right articular sulfaces of the cranial and caudal vertebrae with the ulnar border of the right hand.

The therapist's right wrist is slighUy extended and radially deviated.

The therapist uses their left hand to reinforce the position of the right wrist.

Troubleshooting your technique:

Note(s)

The manual contact will be uncomfortable if it is too lateral and on the lumbar transverse process.

The entire lumbar spine is locked in noncoupled ventral flexion. This allows for much of the nonnal soft tissue slack to be taken up prior to application of the translatoric impulse. Utilizing noncoupled spinal locking and straight-line impulses will minimize rotational movement that may occur in the treatment segment. Subtle adjustments in the amount of dorsal flexion, side bending and rotation can be made if the set-up position causes discomfort.

Translatoric Spinal Manipulation 1111

L1-4-Side EL - HV & LV

Bending PP - HV & LV

Indication: To improve right side bending Position: Right side-lying & ventral flexion

i

The therapist kneels on the table facing the patient.

The therapist's left knee is pressed gently but firmly against the abdomen to support lumbar ventral flexion .

The therapist presses in the direction of the left articular surface and spinous process of the cranial vertebra with the ulnar border of either the left or right hand (lett hand pictured on the lett, right hand pictured below).

The hand contacting the patient's spine is slightly extended and radially deviated.

The therapist uses their other hand to reinforce the position of their wrist.

drop, the therapist takes up the slack mediaUy (described in step 3).

The therapist then lifts their head, neck and upper thorax slightly while maintaining the same end slack tension within the segment (described in step 3).

The patient is posiboned in right side-lying with their lumbar and thoracic spine in ventral flexion, right side bending and left rotation. The impulse is directed medially

through the dropping of the chest and head towards the patient. A roll is used to support the caudal vertebra in the treatment s""m,mt.

Troubleshooting your technique:

Note(s)

In addition to the medial direction, lumbar side bending impulses using this manual contact should also be applied in a slightly ventral direction. The therapist must lean over the patient and roll the patient toward him or herself in order to facilitate a translatoric impulse that is in a slightly ventral direction.

This is a very specific technique and can be applied to the adjacent segments of a bypennobile and sensitive lower lumbar segment. As noted previously, specific side bending impulses are applied in a medial and ventral direction. In comparison to a rotational movement, this ventraVrnedial translational movement promotes greater arthrokinematic motion of one facet joint in relation to another, given the common saginal and frontal plane development/orientation of a mid-lumbar facet joint. Furthennore, emphasis on the creation ofa side bending motion during the application of these techniques will more effectively elongate the connective tissue of the intervertebral disc joint.

112 I Chapter 5 : Lumbar Spine Application

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Ls-Side Bending EL - HV & LV PP - HV & LV

Indication: To improve right side bending Position: Right side-lying & ventral flexion

To provide an impulse using a body the therapist takes up the slack medially (described in step 3).

The therapist then lifts their head, neck and upper thorax slightly while maintaining the same end slack tension within the segment (described in step 3).

The impulse is directed medially through the dropping of the chest and head towards the patient.

Troubleshooting your technique:

The therapist kneels on the table facing the patient.

The therapist presses in the direction of the left side of the spinous process of L5 with the ulnar border of either the left or right hand (right hand pictured).

The therapist's right thigh is placed anteriorly against the lower abdomen to support lumbar ventral flexion. The therapist's right thigh also contacts the patient's left thigh and is used to control the pelvic position and subsequently the right side bending at L5.

The hand contacting the patient's spine is slightly extended and radially deviated.

The therapist uses their other hand to reinforce the position of their wrist.

The patient is positioned in right side-lying 1_"";;;;"'';'';''==''1 with their lumbar spine, including L5, in slight

ventral flexion.

The patient's left hip is flexed approximately 90°.

If the impulse is directed dorsally, the therapist's hand may slide off of the lumbar spinous process resulting in a less effective technique.

Note(s)

Given the anatomy of the L5 segment, the therapist must finnly press the ulnar aspect of his or her manipulating hand in a ventral direction in order to achieve solid contact on the L5 spinous process.

Pre-positioning the L5 segment in noncoupled dorsal flexion will constrain rotational movement during the application of this technique. To pre-position L5 into further right side bending prior to this manipulation, a roll may be placed under the patient's ilium to right side bend the lumbar spine down through L5. To further restrict rotation from occurring at L5, the patient may be positioned in further left rotation from above down through the L5 segment.

Translatoric Spinal Manipulation 1113

Ll-4-Side Bending EL - HV & LV PP-HV&LV

Indication: To improve right side bending Position: Right side-lying & dorsal flexion

The therapist stands facing the patient's abdomen.

The therapist contacts the patient posteriorly with both hands pressing medially on the right side of the spinous processes of the lumbar vertebra.

The right forearm contacts the left side of the pelvis posteriorly and laterally.

The left forearm contacts the left side of the rib cage posteriorly and laterally.

The therapist supports the patient anteriorly by contacting the patient's abdomen with their torso.

The impulse is directed medially with the fingers, caudally with the right forearm and cranially with the left forearm and is generated by quickly flexing the elbows, extending the shoulders and retracting the shoulder girdle bilaterally.

In side-lying, the patient is positioned with their lumbar and thoracic spine, down to and including the treatment segment, in dorsal flexion, right side bending and right rotation.

Troubleshooting your technique:

Note(s)

This TSM uses a very short amplitude movement. Do not let your fingers slide laterally to the left side of the SplllOUS processes.

The therapist can also change his/her contact to the left side of the spinous processes and provide functional massage to the left lateral paraspinal muscles. In clinical practice, it is common to blend various intervention techniques such as translatoric manipulation, translatoric mobilization and functional massage. ~11 three forms of intervention can be readily applied in this position. By virtue of this contact on the lumbar spinous processes, this technique is less forceful then the manual contact used for the specific translatoric lumbar side bending. As such, this is an excellent first manipulative maneuver to apply as a therapist begins to integrate quick movements into his or her treatment session. Choosing to perform this or any lumbar side bending techniques in either ventral or dorsal flexion is often based on where the side bending restriction is the greatest.

1141 Chapter 5: Lumbar Spine Application

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L1-4-Side Bending EL - LV PP - HV & LV

Indication: To improve right side bending Position: Left side-lying & dorsal flexion

Slack in the lumbar spine is taken up medially by leaning the body weight onto the right hand.

To provide an impulse using a body drop, the therapist takes up the slack medially (described in step 3).

The therapist then lifts their head, neck and upper thorax slightly while maintaining the same end slack tension within the segment (described in step 3).

The impulse is directed medially through the dropping of the chest and head towards the patient.

The patient is positioned in side-lying with their lumbar thoracic spine in dorsal i right side bending and right rotation.

The therapist kneels on the table facing the patient.

The patient's right knee is pressed gently but firmly against the patient's lower ribs anteriorly.

The therapist presses in the direction of the right articular surface of the cranial and caudal vertebrae with the ulnar border of the right hand.

The therapist's right wrist is slightly extended and radially deviated.

The therapist uses their left hand to reinforce the position of the right wrist.

Troubleshooting your technique:

Note(s)

The manual contact will be uncomfortable if it is too lateral and on the lumbar transverse process.

The entire lumbar spine is locked in noncoupled dorsal flexion. This allows for much of the nonnal soft tissue slack to be taken up prior to application of the translatoric impulse. Utilizing non coupled spinal locking and straight-line impulses will minimize rotational movement occurring in the treatment segment. Subtle adjustments in the amount of dorsal flexion, side bending and rotation can be made if the set up position causes discomfort.

Translatoric Spinal Manipulation 1115

EL - HV & LV

Ll-4-Side Bending PP - HV & LV

Indication: To improve right side bending Position: Right side-lying & dorsal flexion

provide an impulse using a body drop, the therapist takes up the slack medially (described in step 3).

The therapist then lifts their head, neck and upper thorax slightly while maintaining the same end slack tension within the segment (described in step 3).

The impulse is directed medially through the dropping of the chest and head towards the patient.

Troubleshooting your technique:

The therapist kneels on the table facing the patient. The therapist's right thigh presses gently but firmly against the lower abdomen.

The therapist presses in the direction of the left posterior surface of the transverse process, the left articular surface and left side of the spinous process of the caudal vertebra with the ulnar border of either the left or right hand (right hand pictured).

The therapist's wrist, for the hand contacting the patient's spine, is slightly extended and radially deviated.

The therapist uses their other hand to reinforce the of their wrist. ..:........;,.,..,,...:..:;

The patient is positioned in right side-lying with their lumbar and thoracic spine in dorsal flexion, right side bending and right rotation.

A roll is used to support the cranial vertebra in the treatment segment.

In addition to the medial direction, a lumbar side bending impulse using this manual contact should also be applied in a slightly ventral direction.

Note(s)

The therapist must lean over the patient and roll the patient toward him or herself in order to facilitate a translatoric impulse that is in a slightly ventral direction.

This is a very specific technique and can be applied immediately adjacent to a hypermobile and sensitive lower lumbar segment. As noted previously, specific side bending impulses are applied in a medial and ventral direction. In comparison to a rotational movement, this ventral/medial translational movement promotes greater arthrokinematic motion of one facet joint in relation to another given the common sagittal and frontal plane development/orientation of a mid-lumbar facet joint. Further, emphasis on the creation ofa side bending motion during the application of these techniques will more effectively elongate the connective tissue of the intervertebral disc joint.

1161 Chapter 5 : Lumbar Spine Application

-= -=

Ls-Side Bending EL - HV & LV PP - HV & LV

Indication: To improve right side bending Position: Right side-lying & dorsal flexion

i the therapist takes up the slack medially (described in step 3).

The therapist then lifts their head, neck and upper thorax slightly while maintaining the same end slack tension within the segment (described in step 3).

The impulse is directed medially through the dropping of the chest and head towards the patient.

Troubleshooting your technique:

The therapist kneels on the table facing the patient. The therapist's right thigh is placed anteriorly against the lower abdomen.

The therapist presses in the direction of the left side of the spinous process of LS with the ulnar border of either the left or right hand (right hand pictured).

The therapist's wrist. for the hand contacting the patient's spine, is slightly extended and radially deviated.

The therapist uses their other hand to reinforce the position of their wrist.

The patient is positioned in right side-lying with their thoracic and lumbar spine, including L5. in dorsal flexion , right side bending and right rotation (locked above).

A roll is used to support the position of right side

If the impulse is directed dorsally, the therapist's hand may slide off of the lumbar spinous process resulting in a less effective technique.

Note(s)

Given the anatomy of the L5 segment, the therapist must firmly press the ulnar aspect of hislher manipulating hand in a ventral direction in order to achieve solid contact on the L5 spinous process.

Pre-positioning the L5 segment in noncoupled dorsal flexion will constrain rotational movement during the application of this technique.

Translatoric Spinal Manipulation 1117

L1-S-Facet Distraction EL - HV & LV PP - HV & LV

Indication: To improve movement in all directions (bilateral facets) Position: Prone

segment.

The therapist places their hands, one over the other, on the base of the wedge.

A cuff weight or sand bag is placed anteriorly and in the midline to stabilize the cranial vertebra of the treatment

Troubleshooting your technique:

Slack in the treatment segment is taken up in a ventral and slightly caudal direction by the therapist leaning their body weight over the wedge.

Prior to the application oftranslatoric mobilization in the prone position, correct placement of the mobilization wedge may be confirmed by palpating at the interspinous space as the caudal vertebra of the treatment segment is translated with a ventral/caudal test pressure.

Note(s) By moving the caudal joint partner, a hypomobile LS/S I segment can be loosened even when the L4/S segment is hypermobile and sensitive.

11 B I Chapter 5 : Lumbar Spine Apptication

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L1-S- Facet Distraction EL - LV PP - HV & LV

Indication: To improve movement in all directions (right facet)

Position: Prone

The therapist places their left hand next to the spinous process of the caudal vertebra in the treatment segment and presses in the direction of the lamina and transverse

Once both hands are in contact with the patient, slack in the treatment segment is taken up by pulling the right shoulder towards the treatment segment and subsequently right side bending, right rotating and dorsiflexing the thoracic spine down to and induding the treatment segment.

The caudal vertebra in the treatment segment is stabilized with the manipulating hand when the slack is taken up.

The therapist contacts the patient's right anterior-lateral shoulder with their right hand. The therapist pulls the shoulder in the direction of the treatment segment, thereby moving the cranial segments into right side bending, right rotation and dorsal flexion.

The patient is positioned in prone with their thoracic and lumbar spine, down to and including the treatment segment, in right side bending, right rotation and dorsal flexion (locked in extension).

Troubleshooting your technique:

Note(s)

A common mistake occurs when the therapist does not take up enough slack when pulling dorsally with the non­manipulating hand. To ensure complete locking above, the therapist must pull the patient's shoulder caudally as well as dorsally.

The moveable head or foot section on a mobilization table may be elevated to support and hold the thoracic spine dorsal flexion portion of this locking pattern. This technique may be applied to specifically loosen the upper and mid lumbar spine when L415 and L5/S I are hypermobile and sensitive.

Translatoric Spinal Manipulation 1119

Ll-S- Facet Glide EL - HV & LV PP - HV & LV

Indication: To improve dorsal flexion (bilateral facet joints) Position: Prone

The therapist stands beside the patient's thigh.

A wedge is placed against the caudal vertebra in the treatment segment.

The therapist places their left hand over their right on the base of the wedge.

A cuff weight or sand bag is placed in the midline anteriorly to stabilize the cranial vertebra in the treatment

Troubleshooting your technique:

Note(s)

Pressure on the wedge should be placed evenly so the patient does not feel more on one side of the spine verses the other.

The weight may be moved cranially when the treatment segment is higher in the lumbar spine. Pressure on the xyphoid process may be uncomfortable for the patient and may require additional padding to increase patient comfort.

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Ll-S- Facet Glide EL - HV & LV PP - HV & LV

Indication: To improve ventral flexion (bilateral facet joints) Position: Prone

Slack in the treatment segment by pressing the wedge in a ventral and cranial direction.

i i hand on the base of the wedge.

The therapist stabilizes the caudal vertebra (the sacrum in this illustration) with the ulnar border and palmer surface of their left hand.

~-

Troubleshooting your technique:

Note(s)

An additional folded towel or soft cushion may reduce pressure from the edge of the table. Too much hip flexion may cause the pelvis to move off the table resulting in a less specific and ineffective technique.

This is a recommended treatment position if the lower lumbar segments are hyperrnobile and sensitive in dorsal flexion. Patients with movement restrictions and severe degenerative changes (stenosis) often find this treatment position comfortable. Ventral/cranial impulses promote improved dorsal flexion at mid and upper lumbar segments and may reduce mechanical stress and symptoms coming from L4/S and LS/S I.

Translatoric Spinal Manipulation 1121

L1-S- Facet Glide EL - HV & LV PP - HV & LV

Indication: To improve ventral flexion (right facet joint) Position: Prone

The therapist places the ulnar border of their right hand next to the spinous process of the cranial vertebra in the treatment segment and presses in the direction of the lamina and transverse process (L5 illustrated).

The therapist stabilizes the caudal vertebra

(the sacrum in this illustration) with the ulnar r====------.:=..l of their left hand.

Troubleshooting your technique:

Note(s)

The L5 transverse process is a deeply located structure. Therefore, the manipulating hand must attempt to "catch" the tip of the L5 spinous process and move it ventrally and laterally during the translatoric impulse. Too much hip flexion may cause the pelvis to move off the table resulting in a less specific and ineffective technique.

This technique is used to loosen a hypomobile L5/S I segment. It can be applied even when the adjacent L4/5 segment is hypermobile.

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TS The 51 Joint u@cg[}u UU 0 CQJ Ql]@

SI Joint The SI joint is included in this text because of its proximity to

the lumbar spine and because of the common tendency for patients with lumbar pathology to experience pain that is referred over the SI joint. This is due in part to the fact that the SI joint is innervated by multiple spinal segments (anteriorly by the L2-S2 spinal levels and posteriorly by L4-S2 levels).

While it is the author's experience that pain in the SI region is seldom caused by SI dysfunction, there are situations where primary SI joint dysfunctions occur. Primary SI joint dysfunctions typically result from either trauma or ligamentous laxity. Two common traumas that may result in SI joint dysfunction (i.e. positional fault) include MVAs where the passenger's knee strikes the dashboard or walking injuries where the lower extremity is forced in a cranial direction. Trauma not withstanding, SI joint positional faults may occur as a result of ligamentous laxity. During pregnancy or other times (such as when breast feeding or during menstruation) when there is a higher circulating amount of the female hormone relaxin, it is possible for the sacrum to become slightly displaced in relation to the ilium(s) when an individual bends fully forward. This can potentially result in a symptomatic positional fault where the sacrum is nutated in relation to the ilium.

The purpose of SI joint translatoric manipulation (TM) is to reducefcorrect painful positional faults. These faults are diagnosed using symptom localization techniques and joint play techniques described by Evjenth and Kaltenbom in their respective texts. Upon reduction! correction of these positional faults, the movement of the SI joint must be retested. Ifhypermobility is present, it is often necessary to use an SI belt to stabilize the joint until the ligaments have healed or the hormone levels of relaxin have decreased.

Osseous anatomy The sacrum is a fused block of five bones that is situated at the

base of the lumbar spine. The sacrum supports the weight of the vertebral column and transmits loads from the trunk into the lower extremities and from the lower extremities into the trunk. The SI joint is classified as part synovial and part syndesmosis. The size, shape and roughness of the articular surface varies greatly among individuals. In a chi ld, these surfaces are relatively smooth. In an adult, they develop irregular depressions and elevations that interlock. The sacral articular surface consists of hyaline cartilage that is approximately 1-3 mm in thickness. The iliac articular surface is composed of approximately I mm of fibrocartilage.

Ligamentous anatomy The SI joints are supported by several strong ligaments. The

posterior sacroiliac ligament limits anterior rotation of the innominate

Fitting the 51 joint together

1241 Chapter 6 : 5t Joint Application

Articular surfaces of the sacrum

Articular surfaces of the iIIium

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or sacral countemutation. The short posterior sacroiliac ligament limits all pelvic and sacral movements. The posterior interosseous ligament forms part of the sacroiliac articulation (the syndesmosis). The sacrotuberous and sacrospinous ligaments limit nutation and posterior rotation of the innominate. The anterior sacroiliac ligament stabilizes the Sf joint anteriorly. Lastly, the iliolumbar ligament stabilizes L5 to the ilium.

Muscular support of the SI joint The sacroiliac joints and symphysis pubis joint have no muscles that control their movement directly. although

there are muscles that provide pelvic stability. These joints are influenced by the action of muscles that move the hip and lumbar spine because many of these muscles attach to the pelvis. The muscles that support the pelvic girdle, as well as the lumbar spine and hips, can be divided into two groups. The inner group consists of deep muscles including the transverse abdominus, diaphragm, multifidus and pelvic floor muscles. The outer group consists of four groupings that act primarily in crossing or oblique patterns of force couples to stabilize the pelvis. The superficial posterior oblique system includes the latissimus dorsi, gluteus maximus and the intervening thoracolumbar fascia. The deep longitudinal system consists of the erector spinae, thoracolumbar fascia and the biceps femorus muscle along with the sacotuberous ligament. The lateral system consists of gluteus medius and minimus and the contralateral hip adductors. The anterior oblique system consists of the internal and external obliques, the contralateral hip adductors and the abdominal fascia in between. The muscle systems help to actively stabilize the pelvic joints and contribute significantly to the load transferred during gait and pelvic rotational activities.

Kinematics of the SI Joint In terms of joint kinematics, the principal SI joint axis is in the transverse plane at the S2 level. The SI joint is

unique in that its range of movement is extremely small and there are no muscles that directly produce active motion at this joint. In effect, SI joint movements are passive and occur in response to the loads it must transmit and the stresses it must relieve. The SI joint has two principle motions, nutation and counter nutation. During nutation, the sacral promontory moves anteriorly and inferiorly and the coccyx moves posteriorly. During counter nutation, the sacrum moves in an opposite direction with the sacral promontory moving posteriorly and superiorly and the coccyx moving anteriorly. The movements that occur in the SI joint and symphisis pubis are small compared with the movements occurring in the spinal joints.

51 joint kinematics

Movements of the ilium in relation to the sacrum involve movement of the entire innominate bone. This means that a posi tional fault of the ilium in relation to the sacrum would have to involve movement through the pubic symphysis joint. Clinical evaluation of the pubic symphysis joint is required if a positional fault of the ilium in relation to the innominate is suspected. Although these joints are relatively mobile in young people, they become stiffer with age. In some cases, ankylosis occurs. The pubic symphysis

The symphysis pubis The symphisis pubis is a cartilaginous joint. A fibrocartilage disc, called the

interpubic disc, separates the two joint surfaces. The joint is supported by the inferior and superior pubic ligaments. The inferior pubic ligament is thought to provide the primary stability to this articulation. The superior pubic ligament is more easily palpated and may be tender if there is displacement or hypermobility affecting the joint.

Translatoric Spinal Manipulation 1125

Mechanisms of injury at the 51 joint

The stepping injury

The dashboard injury

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The ground reaction forces are transmitted through the hip creating a dorsal and cranial force on the right innominate relative to the sacrum.

If the force is great enough. the resultant positional fault would be a ventra l caudal position of the sacrum relative to the ilium.

i are i through the left femur and hip joint located inferior to the transverse axis of motion for the SI joint.

This results in an anterior rotation of the inominate and a counter nutation of the left 81 joint.

The resultant positional fault for this injury is a dorsal cranial position of the sacrum relative to the ilium on the

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Biomechanics of 51 joint Translatoric Manipulation Translatoric manipulation (TM) techniques are used to reduce/correct SI joint positional faults. The

principle directions of intervention with TM techniques include moving the sacrum in a cranial direction relative to the ilium and moving the base of the sacrum ventral or dorsal relative to the ilium subsequent to the traumas discussed on the previous page.

To correct a caudal positional fault of the sacrum TM techniques to correct a caudal positional fault of the SI may be performed by either gliding the sacrum cranially on a stable innominate or gliding the innominate caudally on a stable sacrum.

The therapist's left hand contacts the right iliac crest.

Innominate caudal"

'The authors do not recommend this technique unless there is an associated malposition of the pubic symphysis joint.

Translatoric Spinal Manipulation 1127

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Biomechanics of 51 Joint Translatoric Manipulation

To correct a ventral positional fault of the sacrum TM techniques to correct a ventral positional fault of the 51 are performed by stabilizing the sacrum and gliding the illium ventrally.

To correct a dorsal positional fault of the sacrum TM techniques to correct a dorsal positional fault of the 51 are performed by stabilizing the sacrum and gliding the illium dorsally.

1281 Chapter 6 : SI Joint Application

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Sacrum Cranial EL· HV & LV pp. HV & LV

Indication: Pain reduction and correction of caudal positional fault of sacrum (R side) Position: Prone

The therapist stands to the left of the patient's left thigh and pelvis.

The ulnar border of the therapist's right hand contacts the right lateral angle of the

The therapist's lett hand contacts and stabilizes the patient's right innominate by placing the radial border of their left index finger, hand and ulnar border ot their thumb

the right iliac crest. ,..-------

Troubleshooting your technique:

Note(s)

One common mistake made during this technique is failure to properly contact the sacrum, either by positioning the hand too caudally or too medially. When properly positioned, the therapist's ann should be roughly parallel to the table. Another common mistake is failure to properly stabilize the pelvis resulting in a right side bending of the lumbar spine.

The lumbar spine may be side bent slightly to the left , if discomfort is felt in the lumbar spine during this technique. Note how the therapist uses the right side of his chest to support his right hand. This will facilitate greater force generation during the technique.

Translatoric Spinal Manipulation 1129

Illium Caudal EL - HV & LV PP - HV & LV

Indication: Pain reduction and correction of caudal positional fault of sacrum (R side) Position: Prone

The therapist stands to the left of the patient's left thigh and pelvis.

The therapist's left hand contacts and stabilizes the patient's right innominate by placing the radial border of their left index finger, hand and ulnar border of their thumb along the patient's right iliac crest.

The ulnar border of the therapist's right hand contacts the right lateral angle of the sacrum.

Troubleshooting your technique:

Note(s)

In addition to the stabilization comments made on the previous page, the most difficult aspect of this technique is properly timing the impulse and the stabilization between the two therapists. Failure to properly stabilize may result in lumbar side bending to the left. This technique should not be used ifthere is pathology that is intolerant to traction at the ankle, knee or hip.

This technique allows for the generation of a greater amount offorce at the SI joint but may also stress the lower extremity joints and soft tissues.

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EL - HV & LV

Sacrum Cranial PP - HV & LV

Indication: Pain reduction and correction of caudal positional fault of sacrum (R side) Position: Side-lying

The therapist stands in front of the patient.

The therapist's left arm and forearm stabilize the patient's left leg against the left side of the therapist's chest and waist.

A belt is used to stabilize the patient's rtght thigh to the table.

Troubleshooting your technique:

Note(s)

Care must be taken to assure that the therapist is properly contacting the sacrum.

While this technique is particularly awkward in appearance, for pregnant patients with SI pain there is little recourse other than trying to reduce the positional fault in side-lying. Taking up slack in hip flexion with the therapist's left shoulder, ann, foreann and hand may assist in reducing a positional fault where the sacrum is in a ventral and caudal (nutated) position. The therapist may try reducing the patient's discomfort in supine by pulling from the distal leg as illustrated on the previous page. However, the movement of the sacrum will be less direct and potentially less effective than this technique.

Translatoric Spinal Manipulation 1131

Illium EL - HV & LV

Ventral PP - HV & LV

Indication: Pain reduction and correction of ventral positional fault of sacrum (R side) Position: Prone

The therapist stands to the left of the patient's pelvis.

The heel of the therapist's right hand contacts and stabilizes the left lateral angle of the patient's sacrum.

The ulnar border of the therapist's left hand and fifth finger contact the patient's right iliac crest.

Troubleshooting your technique:

Note(s)

Care must be taken to assure that the stabilization of the sacrum is equal in magnitude to the TM force. This can be achieved by the therapist leaning his/her torso over his/her hands to take up the slack in the joint. Failure 10

stabilize with equal force will result in a less specific and potentially less effective technique. Another common mistake when perfonning this technique is failure to contact the sacrum properly resulting in ineffective stabilization.

The patient may be positioned in slight right side bending to slacken the right iliolumbar ligament and minimize movement at L5 during this technique.

132 I Chapter 6 : 51 Joint Application

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Illium EL - HV & LV

Dorsal PP - HV & LV

Indication: Pain reduction and correction of dorsal positional fault of sacrum (L side) Position: Supine

The therapist's left anterior thigh supports the patient's left thigh.

The therapist's right thenar eminence contacts the patient's left ASIS.

Troubleshooting your technique:

patient's sacrum is positioned at the edge of the table.

The patient's left hip is flexed approximately 80' .

Care should be taken to avoid pressing medially when using this TM. Medial pressure may provoke symptoms from an irritated SI joint secondary to joint compression.

Note(s) One challenging aspect of this technique is controlling the patient's left thigh and body position. To reduce any perception by the patient that he/she is not well supported on the table, the patient should be instructed to lay at a slight angle with hislher trunk fully supported.

Translatoric Spinal Manipulation 1133

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References Boden, S.D., The Aging spine: essentials of pathophysiology, diagnosis, and treatment. 1991 , Philadelphia: W.B. Saunders. xiii, 347 p. Bogduk, N. and L.T. Twomey, Clinical anatomy of the lumbar spine. 1987, Melbourne ; New York: Churchill Livingstone. vi, 166 p. Bohlman, H.H. and S.E. Emery, The pathophysiology of cervical spondylosis and myelopathy. Spine, 1988. 13(7): p. 843-6. Bullough, P.G. and V.J. Vigorita, Atlas of orthopaedic pathology with clinical and radiologic correlations. 1984, Baltimore New York: University Park Press; Gower Medical Pub. 1 v. (various pagings). Clausen, J.D., et aI., Uncinate processes and Luschkajoints influence the biomechanics of the cervical spine: quantification using afinite element model of the C5-C6 segment. J Orthop Res, 1997. 15(3): p . 342-7. Connell, M.D. and S.w. Wiesel, Natural history and pathogenesis of cervical disk disease. Orthop Clin North Am, 1992. 23(3): p. 369-80. Creighton, D., Arthrology Course Notes. 2000, Oakland University. Evjenth, O. and C. Gloeck Spinal Mobilization Translatory Thrust Technique 2nd Edition. 2nd ed. 2002, Minneapolis: OPTP. Evjenth, O. and F. Kaltenborn, Spinal Mobilization Translatoric Thrust Techniquefor Physical Therapists. 1991 : Oslo. Grant, R., Physical therapy of the cervical and thoracic spine. 3rd ed. 2002, New York: Churchill Livingstone. x, 449 p. Grieve, G.P., Common vertebraljoint problems. 2nd ed. 1988, Edinburgh ; New York: Churchill Livingstone. xvi, 787 p. Hartman, L., An Osteopathic Approach to Manipulation , in Orthopedic Physical Therapy Clinics of North America, R. Erhard, Editor. 1998, w.b. Saunders: Philadelphia. p. 565-580. Johnson, G.M., M. Zhang, and D.G. Jones, Thefine connective tissue architecture of the human ligamentum nuchae. Spine, 2000. 25(1): p. 5-9. Kaltenborn, F., Manual Mobilization of the Joints, Volume II, The Spine. 4th ed. 2003, Oslo: Norli . Kapandji, LA., The physiology of the joints: annotated diagrams of the mechanics of the human joints. 2nd ed. 1970, London,: E. & S. Livingstone. 3 v. Kirkaldy-Willis, W.H. and T.N. Bernard, Managing low back pain. 4th ed. 1999, New York: Churchill Livingstone. xiii, 434 p. Levangie, P.K. and C.C. Norkin, Joint structure andfunction : a comprehensive analysis. 4th ed. 2005, Philadelphia, PA: FA Davis Co. xix, 588 p. Lu, J., et aI., Cervical uncinate process: an anatomic study for anterior decompression of the cervical spine. Surg Radiol Anat, 1998.20(4): p. 249-52. McCulloch, J. and E. Transfeldt, McNab's Bachache. 3rd ed. 1997, Baltimore: Williams & Wilkins. Mercer, S. and N. Bogduk, The ligaments and annulus fibrosus of human adult cervical intervertebral discs. Spine, 1999.24(7): p. 619-26; discussion 627-8. Moore, K.L., A.F. Dalley, and A.M.R. Agur, Clinically oriented anatomy. 5th ed. 2006, Philadelphia: Lippincott Williams & Wilkins. xxxiii, 1209 p. Panjabi, M.M. , et aI. , Articular facets of the human spine. Quantitative three-dimensional anatomy. Spine, 1993. 18(10): p. 1298-310. Paris, S. and P. Loubert, Foundations of Clinical Orthopedics Seminar Manual. 1999: St. Augustine. White, A.A. and M.M. Panjabi, Clinical biomechanics of the spine. 2nd ed. 1990, Philadelphia: Lippincott. xxiii , 722 p.

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