Patient and Practitioner Set-up
- The patient should be supine, with head and neck extending beyond the head of the table.
- The table should be as high as possible to reduce the amount of forward bending the therapist must perform to get into position.
- It is recommended that these techniques are done with the therapist standing behind the patient's head.
- Sitting is not recommended. It is very challenging, to achieve the ideal motion and velocity in a seated position.
Passive Motion Assessment
- The therapist may start with one hand cupping the back of the patient's head, and the other hand positioned so the fingertips can feel motion between the spinous process of the mid-cervical spine (some times referred to as "piano key grip").
- Using either rotation or lateral flexion, the therapist should feel for segmental motion, spinous process moving one after the other sequentially.
- Segmental stiffness may be assumed if two or spinous process move simultaneously, relative to the motion of the spinous process above and below.
- It is worth attempting this manual assessment of stiffness from both sides. (with each hand).
Lockout Position:
- Once a stiff segment is located, the next step is to set up the manipulation by finding the "lock out" position. Lock-out occurs by "blocking" the lower vertebrae and taking up all slack in the segments above with a combination of ipsilateral rotation, contralateral flexion, and usually a bit of extension (although in some cases flexion works).
- Note: This sounds complicated, but once the motion is learned is actually fairly simple to replicate.
- Blocking the lower segment is accomplished by pressing into the laminar trough and spinous process of the lower vertebrae, on the side opposite the closed facet, with the second metacarpophalangeal (MCP) joint (the pad at the base of your index finger). It helps to press into the segment obliquely, in a lateral and vertical direction toward the opposite side ceiling.
- Use the other hand to either cup the back of the head firmly with an open hand, or use the head cradle position. The head cradle position is recommended if new to this technique.
- In the head cradle position the back of the crown of the patient's head is placed in the crease of the elbow, the top of the patient's head is often pressed against the upper chest, and the forearm courses behind or over the back of the ear toward the patient's cheekbone. The hand wraps around the bottom of the jaw. The head should be able to be controlled by the pressure between the chest forearm, and the opposite hand blocking the lower segment. Little if any pressure should be necessary on the chin.
- Note: Again, this sounds more complicated than it probably is. Once the position is learned, it is fairly easy to replicate.
- Maintaining pressure with the "blocking hand", gently ipsilaterally flex the neck "over" the blocked segment (generally this takes a slight increase in pressure from the blocking hand as well),
- Contralaterally rotate the neck to end-range rotation.
- Add a little extension and adjust rotation and lateral flexion until you hit a relatively "solid" end feel. This is the lock position.
High-Velocity Thrust
Important Note: 90% of manipulation technique is set-up. If you have not achieved lock-out in the previous steps, having a great "thrust technique" will be rendered useless.
- The motion is mostly contralateral rotation with a little lateral flexion.
- You will need to rapidly twist the head and simultaneously increase pressure with the blocking hand (up and into the laminar trough) to ensure you do not lose the block on the lower segment spinous process.
- Visualize this small motion (maybe 2 - 4".). You are trying to force "one segment" past its resistance barrier.
- Ensure the patient is not guarding.
- Tip: have the patient take a deep breath or wiggle their toes. Your goal is to distract them so that they allow you to passively control their head and neck with as little muscle activity as possible.
- Quickly, thrust the patient into the new position.
- Without letting go of the patient's head, gently return the head to a neutral position and passively test range of motion.
