Patient and Practitioner set-up
- The patient should be prone, with head in face-cut out.
- The table should be at a moderate height so lateral and downward force can be imparted comfortably.
- It is recommended that these techniques are done with the therapist standing at the patient's head.
- It is very challenging to achieve ideal motion or velocity in a seated position.
Passive Motion Assessment
- Motion can be assessed using a unilateral posterior-to-anterior thoracic mobilization
- Rotational stiffness can also be assessed by pressing neighboring spinous processes laterally in opposite directions.
- I have noted that cervicothoracic junction manipulations are often easier to perform and more effective when manipulating to the less restricted side. Although I have no explanation for why this is the case, the study by Karas et al. would seem to support that either direction is effective (136).
Lockout Position:
- The clinician can use a thumb or thenar eminence to block the lower segment by pressing laterally into the spinous process and obliquely into the laminar trough. The size of the patient may dictate what hand position is most useful, with larger patients requiring more force and pressure from a larger surface area (e.g. thenar eminence).
- Upper segment lock-out will be achieved by using the same joint actions as the mid-cervical spine manipulation; (extension, contralateral flexion, ipsilateral rotation); however, with the client in prone in a face cut-out, the easiest way to achieve this is by moving the head so that one cheek is resting on the face cut-out, and can be used as a fulcrum to rock the head back and forth.
- Re-position your blocking hand, place your other hand on the back of the patient's head, and start adjusting the patient until you find lock-out.
- Finding the right place for the cheek on the face cut-out so that rotation quickly results in the lock-out position, will become easier with practice.
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 to ensure you do not lose the block on the lower segment spinous process.
- Visualize the small, rapid motion (maybe 2 - 3".). You are trying to force "one joint" 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.
- For this technique, this occurs by simply pushing the head over the cheekbone into further rotation. The set-up is the hard part, as it can be quite uncomfortable for the patient, so shortening set-up time is beneficial.
- Without letting go of the patient's head, gently return the head to a neutral position and passively test range of motion.
