1596 CHAPTER 73

ity thrust directed specifically at the manipulable lesion (subluxation, osteopathic lesion, etc.). In order to practice these techniques, it is essential that a clinician have some basic understanding of spinal mechanics, have the palpatory skills to diagnose the clinically significant manipulable lesion, and have developed, through experience, the ability to direct the adjustive thrust to one segment in a specific direction.

Once the clinically significant manipulable lesion has been found, the direction in which motion is lost has been determined, and the facet orientation and structural relationship between the vertebrae known, it is possible to work out a technique that will theoretically correct the lesion. The patient is placed in a position which will allow movement of the vertebra in the desired direction. Contact is taken with a relatively small portion of one hand (thumb, finger, pisiform). The spinal segments, either above or below the segment being manipulated, are locked by moving the spine to the limit of their passive range of motion (75,82). A high velocity, small amplitude thrust is then delivered through the contact arm and hand to the short vertebral lever (transverse process or spinous process) in the direction which will correct the segmental fixation.

Once again, it is impossible to list the numerous techniques and variations which have been developed to adjust the lumbar spine and sacroiliac jo.nt. It is possible to perform such adjustments with the patient in the prone, supine, side lying, or sitting position and by using a variety of specially designed adjustment tables, blocks, and traction devices. The following four examples with variations will illustrate a few of the principles of lumbosacral adjusting.

Example !

Adjustment of the sacr ¡iac joint is most frequently carried out with the pati at in the side lying position (43,47). The side to be adjusted is placed up. The inferior leg is straight and the superior leg flexed. This brings the lumbar spine to its neutral position with the shoulders and hips vertically above each other. The inferior arm is drawn rostrally from under the patient with a minimum of spinal rotation and placed across the chest. The clinician's sup or hand is placed on the patient's shoulder and pressure exerted rostrally with only that amount of spinal rotation and lateral flexion necessary to lock the spine down to the segment being manipula.ed. The pisiform eminence of the clinician's inferior hand is used to contact either the posterior superior iliac spine (for a flexion fixation of the sacroiliac joint) or the ischial tuberosity (for an extension fixation). The inferior leg is flexed to the point where resistance is felt in the sacroiliac joint (approximately 75 degrees for flexion fixation, 90 degrees for extension fixations). Traction is applied to the spine as the patient takes a deep breath and then slowly exhales and relaxes. A high velocity, low amplitude thrust is delivered through the clinician's inferior arm and hand while the superior arm simply stabilizes the trunk and spine. The direction of thrust is determined by the "listing" of the pelvis. For example, if the iliac spine is felt to have moved posterior and inferior, the thrust is rostral and anterior toward the patient's shoulder. If the superior ilium is felt to have rotated internally onto the sacrum, the direction of thrust is anterior toward the superior femur in an attempt to open the sacroiliac joint. The thrust on the ischium for an extension fixation is toward the patient's lower shoulder (43) (Fig. 12).

Manipulation of the lumbar spine can be carried out using a very similar technique. The patient is placed in the same position. The spine is locked down to the "6ment being manipulated through traction and slight tation of t.: shoulder. The thrust is de.vered to a tran:verse process or by hooking a spincus process.

With proper placement of the patent, it is seldom necessary to put weight on the femur or to maximally rotate the spine, thus reducing the chance of traumatizing the ris cage, hip joint, or intervertebral disc.

Example 2

The adjustment of the lumbar spine for an extension xation can best be achieved with the patient prone

(47,48,!:4). A fa: couch, however, does not allow for sufficient extension of the lumbar spine to achieve specific localization of the adjustive force. A number of adjusting tables have been developes to overcome this :roblem. The segmental table (Fig. 3) has a pelvic suport that elevates and/or an abdc.ninal support that ops away. This allows the pelvis to be locked while the lumbar spine is hanging in extension.

nother much less costly piece of equipment, the knee posture table, similarly allows for locking of the pelvis (on the femurs) with maximum ext..sion of the lumbar spine. The position of the pelvis locking can be varied by changing the trunk femur angle for a perpendicular 90 degrees to 8 degrees or 100 degrees. This is achieved by moving the i.ees forward or backwa:. Contact is mad

1598 CHAPTER 73

over the transverse processes of the segment being adjusted either unilateral or bilateral (Fig. 14). The clinician may use either his thumbs or pisiform to make the contact. The use of the thenar or hypothenar eminences is less effective since it tends to dissipate the force over a number of segments thus reducing the specificity of the procedure.

The ability to deliver a very sharp, low amplitude thrust is necessary for this procedure. A single "thud" can often be heard and felt over the articulation being adjusted if the procedure is executed properly. Any excessive force or depth to the thrust can be painful. The decision as to whether the thrust should be given unilaterally or bilaterally and the exact direction for the thrust is dependent on the listing, the facet facings, and whether the fixation is unilateral or bilateral.

Example 3

Sitting rotary and lateral flexion manipulations can be quite specific. The clinician has the advantage of being able to maneuver the patient's spine in all three planes of motion prior to delivering the adjustive thrust (65,82). The main drawback is the inability to achieve segmental traction.

The patient straddles the edge of the adjusting table and clasps both hands across the chest on opposite shoulders or behind the neck. The clinician gains control of the trunk by grasping the shoulders or arms with one arm. The clinician's other hand is free to make contact in the lumbar spine. The patient can be maneuvered into flexion, extension, rotation, lateral bending, or any combination of these positions. The thrust is delivered to the transverse or spinous process of the lumbar segment being adjusted (Fig. 15). The position of the patient prior to giving the thrust and the direction of the thrust are once again dependent on the listing and the direction in which the segment is fixated. The thrust is an exaggerated movement of the trunk with localization being directed through the contact point in the lumbar spine.

Example 4

There are a wide variety of specific adjusting procedures that do not utilize a high velocity thrust. These techniques (along with mobilizing procedures) are particularly useful in the management of elderly patients where it may be advantageous not to use heavy force. Kimberly (65) describes a number of so-called "muscle energy" and "respiratory force" procedures. These procedures utilize the patient's own muscles to achieve the correction of a specific fixation. The basic principle of the techniques is to position the patient at the limit of a specific range of motion in the direction of the vertebral fixation. The segment being adjusted is held firm. When

FIG. 15. The rotation-lateral flexion adjustment in the sitting position.

the patient relaxes, the slack created by the isometric contraction is taken up. In this way the passive range of motion of the segment which was held is increased. This process is repeated a number of times until movement is felt in the vertebra being adjusted. Muscle energy techniques have been developed in the sitting, prone, and supine positions for almost every direction of movement fixation. Patient positioning is very similar to that used for the high velocity, low amplitude thrust techniques. It is the use of the patient's own muscles rather than a dynamic thrust which is the distinguishing feature.

A simple example of this technique is that described by Kimberly (65) for a restricted or fixated sacroiliac joining where the posterior superior iliac crest is felt to have moved posterior and inferior (Fig. 16). The patient is placed prone with the clinician standing on the side opposite to that being adjusted. The clinician elevates the leg on the affected side with one hand and places the other hand on the iliac crest slightly above the posterior superior iliac spine. The leg is elevated in extension and pressure exerted on the iliac crest until the restrictive barrier at the limit of passive range of motion is engaged. The patient is then instructed to pull the leg downward

toward the cable against the resistance of the clinician's hand. The patient relaxes and the additiona: slack in the joint motion is taken up until the new restrictive barrier is engaged. The process is repeated two to three times until the ixation is corrected.

Vertebral Mobition or Articulation

The procedures generally included under the term "mobilization" are those where a joint is forced beyond the limits of active muscie contraction and into the passive range of motion. There is no attempt to force the joint beyond its restrictive physiologica. barrier (16,83,95). These tea: niques are extremely valuable in patients with acutely painful joints o: where there is some inherent danger to high velocity adjusting techques (eg, osteoporosis..

Four grades of mobili.ation are classically described (Fig. 17). A Grade I mobilization starts at the neutral position and has only very small excursion. A Grade II mobilization begins at the neutral position and has deeper excursion into the normal range of motion of the joint but do not attempt to reach the limit of passive motion. Grade III mobilizations begin approximately ba. way into the norma! motion of the joint and carry through to the physiological barrier of the joint. A Grade IV mobiliz has a short excursion at the limit of the passive mo...:. of the join:.

Mobilization can be either specific to a single vertebral joint or non-specific to the entire spine or a large seg. ment of the spine. It can be accomplished in flexion, extension, rotation, lateral flexion, or any combination of these movements. The positioning of the patient varie. only slightly from that used in non-specific manipula

tion and the specific spinal adjustment. It is the def.ze of movement and the lack of thrust which distingishes mobilization from these pro dures.

the

In addition, mobilization can be performed neutra. position by springing a joint in a specific cirec tion. These neutral mobilizations are identical to the techniques used for determining neutral join: play. In this case, however, the goal is treatment rather than diagnosis. The springing of a joint is repeated a number of times, often wit, increasing depth (or grades of motilization) until the full range of motion is achieved and is pain free. This may require repeated mobilizations ove: a number of days. Figure 18 illustrates specific rotation mobilization. of a lumbar vertebra in the neutral position by wteral pressure over a spinous process. Figure 19 is an example & technique for specific springing of the lumba: spine in extension.

Manual Traction or Muscle Stretching

The manual application of traction to the legs, arms, head, or trunk falls within the broad definition of spinal manipulative therapy. These techniques are non-specific for any one vertebral level or join:: the traction is applied to the tire spine. The maior advantages over mechanical trion are that the clinician can monitor the amount of traction bein, given, change the direction of traction by altering the position of the ing or arm which is being pulled, and chare the rhyth:. of intermittent traction.

There are two types of manual tr. tion which have been described for the lumber spine. The vertica: traction technique (87,115) begin with the patient and clinician standing back to back. 2.patient grasps his own

shoulders and the clinician reaches behind to grasp the patient's elbows. The clinician then bends forward, holding the patient's elbows rigid and lifts the patient from the ground. The patient is asked to flex his head, and the clinician, after taking up the ligamentous slack in the spine, gives the patient a sharp shake by lifting the patient suddenly higher. This causes straight extension of the spine. It is a clumsy maneuver but can be effective if vertebral traction and extension is required.

The application of traction to one or both legs has been used in an attempt to open the sacroiliac and posterior joints of the lumbar spine and to stretch the para

spinal muscles (6,43,83). This can take the form of sustained traction on the leg, a short tug on the leg, or a movement from the flexed leg position to the extended position followed by traction (Fig. 20). Bourdillon (6) recommends internal rotation of the leg prior to applying the leg tug.

The spray and stretch techniques developed by Travell (118,119) for the treatment of specific trigger points also fall under this heading. In this case, traction is applied to muscles rather than to a joint. Travell describes the myofascial trigger points as palpable tender firm bands of muscle which refer pain in a specific pattern often some