Patient and Practitioner set-up
- The patient should be side-lying, facing the practitioner, with shoulders stacked, top leg flexed and bottom leg straight.
- The table should be low enough for the practitioner to comfortably reach over the patient and palpate the spinous process, as well as be able to lay their trunk over the trunk of the patient during the manipulation. The ability to use the weight of your trunk during this manipulation is almost mandatory, especially if the patient is considerably larger than you are.
Passive Motion Assessment
- Motion can be assessed using central or unilateral posterior to anterior lumbar mobilizations.
- Note: this usually happens with the patient in prone prior to this technique
- During the set-up of this technique, the therapist may also notice that the spinous processes of two vertebrae move together during flexion, extension, or rotation, indicating stiffness of the facets between those segments.
Lockout Position:
- Place the fingertips of the hand closest to the patient's head over the spinous processes of the segment you wish to target with the manipulation.
- Place the knee of the patient's top leg in the crease under your anterior superior iliac spine (ASIS).
- Use your other hand and your ASIS, to move the patient's leg into hip flexion, to posteriorly tilt the pelvis, and flex the lumbar spine from the bottom up.
- Continue to flex the hip, until the lower vertebrae of the segment you are targeting starts to move. This indicates that you have "locked-up" all of the joints below that segment (ligamentous lock).
- Adjust the patient's bottom leg, top foot, and hip as needed to ensure you maintain ligamentous lock as you set the top knee on the table, turn slightly to face top half of the body and reset your ASIS to pin the top knee to the table and in position.
- Switching hands while successfully completing step 5 may be the trickiest step in this technique; carefully replace the fingers that were monitoring motion of the spinous process with the fingertips of the hand closest to the patient's feet.
- Using the hand closest to the patient's head, gently pull the bottom arm up and behind you to slowly rotate the patient's torso away from you. It may be helpful to cue the patient to allow their top shoulder to roll back as you pull the bottom arm forward and up.
- Continue to rotate the patient's torso until you feel the top vertebrae of the segment you are targeting start to move. This indicates "facet lock" of all the joints above this segment.
- Adjust the forearm of the arm closest to the patient's feet so that they are aligned over the patient's pelvis, and you feel you could use the friction between your forearm and the patient's pelvis to forcefully rotate it toward you.
- Place your other forearm over the patient's lateral pectoralis major , slip your hand under their top arm, and hold your opposite wrist.
- Place your torso over your arms and adjust as needed to feel as though you are pressing and holding the patient in their end-range, i.e lock-out position.
High-Velocity Thrust
Important Note: 90% of the manipulation technique is set-up. If you have not achieved lock-out in the previous steps, having great "thrust technique" will be rendered useless.
- The motion is primarily toward the table, with the intent of rotating the spine. Most of the force is coming from the practitioner's body weight.
- Visualize the small, rapid motion (maybe 4 - 6"".). You are trying to force "one segment" to rotate.
- 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 trunk with as little muscle activity as possible.
- Quickly, thrust the patient into the new position by allowing a large portion of your body weight to depress into their torso while pulling back with the forearm on the pelvis, and pushing a bit forward and toward the table with forearm over the lateral pectoralis major . Again, you are depressing into the table with some intent to rotate. This generally takes a little practice before it can be performed at "high velocity"
- Slowly and gently release pressure, by standing up, tipping the patient back into side-lying, or gently performing physiological rotational mobilizations in side-lying to allow the patient a moment to "catch their breath".
